This pack has been produced with by Frimley Health NHS Trust in partnership with Healthier Together This pack is aimed at children and young people who have long lasting abdominal (tummy) pain. When a physical cause cannot be seen on a test or a scan, it is called ‘Functional pain’, because it affects your functioning (what you are able to do).
The urinary system, also known as the renal system or excretory system. Its purpose is to eliminate waste from the body, regulate blood volume and blood pressure, control levels of electrolytes and metabolites, and regulate blood pH. The urinary tract is the body's drainage system for the eventual removal of urine. It consists of the following:
The medical term for the inability to control urine in individuals who are already toilet trained. Such accidents commonly occur at night, when the individual is sleeping, but wetting can occur during the daytime as well. Daytime wetting occurs in roughly 3.5% of healthy children, with 67% of these children experiencing night time wetting. Enuresis Signs/Symptoms Include…Damp underwear, urine accidents during the day and irritation and/or redness around the genitals.
A child who experiences daytime wetting may feel the urge to urinate at the last minute and may ‘curtsey’ using their heel to stop the flow of urine. When the child/young person does go to the toilet, the outlet valve may not relax fully. This means that the bladder does not empty fully. When the child returns to what they were doing, the outlet valve will relax, and urine can leak out. The child becomes at risk of urinary tract infections (UTI) when the bladder does not empty fully. The bladder can continue to fill and become overstretched. This results in a loss of sensitivity and confusion of the signals between the brain and bladder.
The medical term for the involuntary wetting during sleep. Bedwetting is considered as a medical difficulty when a child older than seven years of age has one or more episodes per month. Whilst the causes are not fully understood, help with this has a positive effect on the self-esteem of children and young people. Nocturnal Enuresis Signs/Symptoms Include…Many parents/carers observe wet bedding or nightclothes in children and young people with bedwetting.
Sometimes a child may not drink enough during the day, and then drink more in the evening, filling the bladder before bed. The sleeping child may then not feel the urge to urinate resulting in bedwetting. Some children do not produce enough of the hormone that stops urine production overnight, therefore too much urine is produced. For other children the signals from the bladder to brain are not working as they should. This means the bladder overfills and stretches, and the signals between the brain and bladder become more confused. Finally, a child may withhold urination due to a fear of using the toilet, or because they do not like using the toilet in certain environments.
Dysfunctional Voiding Many children who experience daytime wetting feel the urge to urinate at the last minute and may ‘curtsey’ using their heel to stop the flow of urine. When the child/young person does go to the toilet, the outlet valve may not relax fully. This means that the bladder does not empty fully. This means that when the child returns back to what they were doing, the outlet valve will relax, and urine leaks out. The child becomes at risk of urinary tract infections (UTI) when the bladder does not empty fully. UTI’s also increase the risk of bedwetting; indicators of UTIs include smelly and cloudy urine, pain or burning during urination, and stomach aches.
Weak Outlet Valve The outlet valve opens and closes to control the flow of urine. A weak outlet valve may lead to a child/young person wetting themselves when they laugh, cough, or strain.
Structural Abnormalities Structural abnormalities in the bladder or the kidney tubes can also cause daytime wetting. This can result in pain while weeing, a poor wee stream or continuous trickling wee.
Nerves The brain and bladder are connected by nerves; messages are sent from the bladder to the brain via these nerves. Sometimes these messages get confused and the warning of urgency, sent from the bladder, is not received by the brain. The child then may not realise they need a wee.
Functional Causes Enuresis can also be described as a functional disorder, meaning that it has a physical impact of the body without any apparent visible, organic, biological cause. Psychological factors contribute in the progress of functional disorders.
Constipation A bowel that is full of stools presses against the bladder. The bladder then becomes squashed and struggles to expand to hold large amounts of urine. As a result, the child/young person feels the urge to urinate frequently, and has to do lots of little wees.
Bladder Size
Some bladders do not stretch enough to hold all of the urine made during the night.
Urine Production
Some people produce too much urine at night, the bladder cannot hold this extra urine.
Sleep
Some children/young people do not wake up when their bladder signals to their brain that it is full.
Constipation
A bowel that is full of stools presses against the bladder. The bladder then becomes squashed and struggles to expand to hold large amounts of urine. As a result, the child/young person feels the urge to urinate frequently and has to do lots of little wees.
Type 1 Diabetes & Diabetes Insipidus
Symptoms of Type 1 Diabetes include more than typical urination, fatigue, weight loss, and thirst. People with Diabetes Insipidus experience excessive urination and increased thirst. If you are concerned, you/your child may have diabetes please see your GP urgently.
Bedwetting is nobody’s fault, it does not happen because of laziness or bad behaviour. It is an accident! Children/young people should not be punished for accidents.
You can see if you are drinking enough water-based fluid by looking at the colour of your wee. Hydrated, healthy wee is a light yellow colour (almost like water). Dehydrated, unhealthy wee is a dark yellow colour, and means you need to drink more water!
Water
Drink the recommended amount of water (information provided in the table below) based fluid throughout the day to help your bladder fill and stretch. This helps the bladder to hold more urine and stay healthy. Drinking also helps to keep your bowels moving too! By drinking lots of water and keeping your bowels moving healthily, there is less pressure on the bladder, increasing its capacity. Drinking less fluid is more likely to result in constipation, worsening day and nighttime wetting. Drinks with caffeine in them can make an overactive bladder misbehave. These drinks include some fizzy-pop, coffee, tea, and hot chocolate. Try to do most of your drinking in the daytime and just drink a small cup of water an hour before bed, if you are thirsty.
Age (years)
Total drink Intake per day
1 - 3
1 litre
4 - 8
1.2 litre
9 - 13
1.5 litre
14 - 16
2 litre
Diet
One of the causes of enuresis is constipation. It is important to eat a diet high in fibre, fruit, and vegetables (e.g. whole wheat products, peas, broccoli, carrots, sweetcorn and oranges, apples) to enable healthy bowel movements. During episodes of constipation, the bowel presses against the bladder, limiting its capacity, meaning the child/young person urinates much more frequently. By having healthy bowel movements, the bladder has a larger capacity meaning urination will be less frequent. Tip: Add more vegetables to soups and stews, have baked and boiled potatoes and keep the skins on, swap white bread for brown bread.
Toilet Routine
Try to have a regular toileting routine. Go to the toilet every 1.5 – 2 hours, even when you are busy doing something, it is important to listen to your bladder. Setting alarms might remind you to use the toilet. Try doing a wee before brushing your teeth and then another one just before you get into bed, so that your bladder is fully emptied before going to sleep. When you do use the toilet, try to empty all of the wee out of your bladder. Sit down, relax, and take your time. Wee doesn’t need the same amount of force to push out like poo.
Bedwetting Alarms
Bedwetting alarms are attached to a sensor on the young person’s underpants, if the sensor gets wet the alarm goes off. This then wakes the young person up. Over time this should help the young person learn when they need to wee and wake up to go to the toilet. A key element in the success of bedwetting alarms is the young person’s motivation and understanding that waking to the sound of the alarm is the treatment that will help to eliminate their night-time wetting. It is also important to start the treatment with realistic expectations. It can take an average of 2-3 months for a young person to be consistently dry at night, others can take longer. Furthermore, it is important that the child knows what to do when the alarm goes off (go to the bathroom, change their pjs, and strip the wet bedding). More information about bedwetting alarms can be found at: https://www.eric.org.uk/guide-to-bedwetting
Bladder Training
The aim of bladder training is to help your bladder get bigger and stronger. During this process you should drink a water-based drink every 1-2 hours and try and wee 10 minutes after every drink. It will help if you are sitting on the toilet properly; girls should have their feet supported on a step, and boys might find it better to sit down to wee once or twice a day to help make sure the bladder is emptied properly. It is important to not rush when trying to wee, take time to empty your bladder completely. Try sitting on the toilet for 10-20 seconds when trying to wee; when finished, wait for 20-30 seconds, and attempt to wee again to ensure the bladder is empty. For more information on Bladder Training and to read The Wendy Wee Comic, click here.
Advice for Parents and Children Using Toilet Charts…
Understand What Enuresis Is
To understand the young person, you must first need to know what enuresis is, and what causes it. There are many potential causes of enuresis and nocturnal enuresis as described on pages 5 and 6 in this pack.
Normalise The Toilet
It is important to talk openly and honestly about going to the toilet. This allows those close to the child to intervene at an early stage with simple measures to help them use the toilet. Allowing your child to observe normal toileting behaviour, such as seeing parents use the toilet frequently, shows the child that the toilet does not need to be feared.
‘Toilet Area’
Sometimes it is necessary to build up confidence to sit on the toilet and relax before the child can comfortably pass urine on the toilet. Suggest that children who insist on using a nappy to urinate do so in the toilet area. Adopt a gradual exposure approach; encourage the child to sit on the toilet with the nappy on, and over time gradually remove it. It is important to create an environment without anxiety and pressure.
Teacher Support
Education settings should be aware of bladder and bowel conditions in their role in supporting affected young people. Education settings should also be aware of how to promote healthy bladders and bowels by encouraging students to remain hydrated, and ensuring all young people have access to clean, well stocked toilets at intervals appropriate to the need of the individual child. Parents/carers should also not be expected to come to school to change the young person, a care plan should be in place to ensure their individual needs are met in school. For younger children, it might be helpful for the teacher to have a spare change of their clothes available incase of any accidents during the school day. Older children may prefer to carry their own spare clothes, and clean themselves up.
Be Positive, Encouraging, Patient, and Understanding.
Evidence of your support, encouragement, and understanding will help your child to relax and eventually move forward in their journey to overcoming enuresis. Your support and understanding is VITAL – they can do it if you think they can. It is important to understand bedwetting is a medical condition, and is not the young persons fault.
Supporting Those With Autism and Development Disabilities
Many children with autism are visual learners: they understand and learn more easily if pictures are used to help explain what is required. Social Stories and Picture Exchange Communication Systems can be used to give the child an understanding of the toileting process.
Enuresis can cause a lot of emotional distress for children and young adults. Muscle tension is commonly associated with stress and anxiety, it is the bodies natural response to potentially dangerous situations. Even when there is no danger, our bodies can still respond in the same way. You may not always realise that your muscles are tense, it may be as subtle as your jaw clenching, or as obvious as your shoulders feeling really tight and hunched. PMR is a deep relaxation technique which is based upon the simple practice of tensing one muscle group at a time . This is followed by a relaxation phase with release of tension. This is very useful before bedtime.
Deep Breathing
During deep breathing your blood is oxygenated, triggering the release of endorphins, whilst also decreasing the release of stress hormones, and slowing down your heart rate.
Visualisation
Help yourself to feel more relaxed by thinking about things that make you feel calm and rested. For example, picturing your favourite place. This can be either independent, or you can take a guided visualisation approach. A guided visual imagery relaxation task has been provided in this pack. Safe Place Visualisation
A powerful stress reduction and relaxation tool, that can be applied at any time, in any location.
The Ladder Hierarchy
Help yourself to change how you cope with toileting difficulties, by gradually exposing yourself to different toileting scenarios over time.
Developing Coping-Self Talk
These are phrases that you can say to yourself that are supportive. For example “Just because it has happened before it does not mean it will happen again”
⦁ Mindfulness and Sleep:https://www.smilingmind.com.au/ ⦁ Meditation and Sleep:https://www.calm.com/ ⦁ Meditation: https://www.headspace.com/kids ⦁ Progressive Muscle Relaxation: https://www.thinkpacifica.com/
Websites:
ERIC, the Bladder and Bowel Charity website: https://www.eric.org.uk/ There is a free downloadable Guide to Children’s Toileting Problems. ERIC have also created Poo and Wee characters and a range of videos for children and parents. Bladder and Bowel UK website : https://www.bbuk.org.uk/children-young-people/ National Institute for Health and Care Excellence (NICE) Guidelines: www.nice.org.uk/guidance/CG111
Books:
Bedwetting In Children and Young People: A Simple Guide For Parents – Dr C Yemula
General Resources: ⦁ Free Online Counselling for Young People: https://www.kooth.com/ ⦁ Stress and Anxiety: https://www.moodcafe.co.uk/for-children-and-young-people/feeling-worried,-frightened⦁ ,-stressed-or-anxious.aspx ⦁ Relaxation Techniques: www.getselfhelp.co.uk/relax.htm ⦁ Relaxing Imagery: www.getselfhelp.co.uk/imagery.htm ⦁ Thought Distancing: www.getselfhelp.co.uk/cbtsetp6.htm When accessing online resources and communities, it is important that children and young adults are supervised, and are aware of online safety.
