The medical term for bedwetting is NOCTURNAL ENURESIS. This article will help you and your child better understand what this condition is and some of the ways to work toward dryness. 

Bedwetting, also known as PRIMARY ENURESIS or NIGHTTIME INCONTINENCE, is a common condition in which a child empties his or her bladder during sleep without being aware of it. Bedwetting can be a stressful and embarrassing condition that begins in early childhood and, for some children, extends into the preteen and teenage years. Although most children remain dry through the night be age 5, about 15% of 6-year-olds wet the bed. Boys are twice as likely as girls to wet the bed. Although we don’t really know why bedwetting occurs, it is likely due to multiple factors. Heredity plays a large role; most children who wet the bed have close relatives who suffered from bedwetting as children. Small bladder capacity, too much urine production, and an inability of the body to sense that the bladder is full or emptying during sleep can contribute to bedwetting. 

Children who experience primary enuresis should be reassured that wetting the bed is not their fault and will eventually stop on its own. However, an older child’s bedwetting may bring parents to the child’s health care provider to learn ways to cope with the condition/situation. Several lifestyle changes may make bedwetting less likely, such as using the bathroom at bedtime (twice) and limiting fluid intake in the hours just before sleeping. Some children benefit from the use of moisture sensors, which make a noise or vibrate when the nightclothes are first wet. The use of medications to treat bedwetting is somewhat controversial. Although there are effective drugs to treat bedwetting, the condition may return when the drugs are stopped.  

In most cases, bedwetting is a natural part of childhood and does not signal a serious problem. Therefore, it is important for parents to support and reassure their child that the situation is not their fault and that it will someday stop on its own. Children should be allowed (encouraged) to change wet sheets so that they feel they are helping in some way and sharing responsibility. The mattress should be protected by plastic sheets or pads to prevent the odour of urine from remaining in the room. Siblings should be strictly forbidden to make fun of the child’s bedwetting. 

It is important to discuss bedwetting with a health care provider. Although only about 1% of all bedwetting is related to a physical problem or disease, it is important to determine if your child is part of that 1%. Sometimes tests are done with older children whose bedwetting continues, to rule out physical conditions as a cause. A consultation with a paediatric urology team is most appropriate if it appears the bedwetting is due to a treatable medical condition.

Sometimes bladder and bowel retraining exercises during the day are helpful with night wetting episodes. These usually include bladder emptying every 2 hours from morning until night, along with time set aside each day for complete and adequate bowel evacuation. This is called a BLADDER AND BOWEL REGIMEN (BBR). Older children (age 7 or 8 and up) and teens respond well to moisture alarms, which wake them so that they can empty their bladder on the toilet. This program requires adult participation for the first few weeks in order to insure full awakening of the child. Continued nightly use of such an alarm will eventually train most children to sense when their bladder is beginning to empty and wake them up before they begin to urinate. After a number of weeks of dry nights, the child is usually able to discontinue the use of the alarm altogether.  

When bedwetting begins suddenly after a long period of dry nights (many years), an investigation is needed since this can be a sign of infection, diabetes, bladder disorders or a reaction to a significant stressful event. 

Drugs to treat bedwetting include desmopressin acetate, or DDAVP, which works by reducing the amount of urine produced during the night. It is available as a pill or nasal spray. It is given before bedtime and begins to work quickly. Although it has few side effects, DDAVP can cause water intoxication and seizures in children who drink excess water before bedtime. It is important that children who take DDAVP drink no more than the amount of fluid indicated in the prescribing instructions before they go to sleep. 

Imipramine is an antidepressant that has been used for years in the treatment of bedwetting. It isn’t known exactly how it works, but it is thought to reduce the amount of urine produced, help the bladder to hold urine longer, and change the sleep cycle itself. It works best in older children and must be carefully controlled by an adult, as an accidental overdose can be fatal. 

Anticholinergic drugs, such as oxybutynin and tolterodine, are used mostly in children who have daytime and night time wetting. These medications work by increasing the amount of urine the bladder can hold and reducing the bladder contractions that lead to urination. The primary side effects are facial flushing (especially in hot weather), dry mouth and constipation. When treatment of bedwetting is unsuccessful using DDAVP alone, it may be helpful to add and anticholinergic drug, since both medications work in different ways.

Ureteropelvic junction obstruction

One in 1,500 children are born with a urinary tract blockage call Ureteropelvic Junction Obstruction or UPJ. This congenital obstruction occurs where the ureter joins the renal pelvis. This malformation of a muscle develops as the kidney forms in the fetus. It can be commonly diagnosed with a prenatal ultrasound test.

The obstruction blocks adequate flow of urine produced by the kidney to pass from the renal pelvis into the ureter. The excess urine builds up in the kidney and causes a hydronephrosis which is visible on the ultrasound. This observation is the red flag that the child has a UPJ obstruction. This obstruction may be severe (high grade), minimal (low grade) or intermittent. 

Unless treated, children may have pain (related to the blockage), urinary tract infection (due to stagnation of urine caused by the UPJ blockage), or kidney stones. The kidney may become damaged if subjected to prolonged blockage and infection. 

Most UPJ obstructions are identified before birth because of the widespread use of fetal ultrasound screening. After birth, symptoms of UPJ obstruction may be an abdominal mass, a urinary tract infection with fever, flank pain especially with increased fluid intake, kidney stones and bloody urine. It is possible to have pain without an infection. UPJ obstructions may be irregular. Urine may pass normally for awhile and then completely stop, producing sporadic pain. 

An ultrasound is helpful in screening for problems, it does not diagnose UPJ.  A test called a lasix (furosemide) renal scan is used. With this nuclear test, dye is injected and absorbed, and once the diuretic is given, scans are used to view passage of the dye.  The material is viewed with a special camera as it passes though the kidney to the ureter and gives the physician even more accuracy in diagnosing a UPJ. 

Surgery (pyeloplasty) involves removing the UPJ blockage and reconnecting the ureter to the renal pelvis. A tube may be placed across the pyeloplasty (stent) or may be left above the surgery to decompress the kidney (nephrostomy).

Sometimes the UPJ in infants and young children less than 18 months may be temporary. Many infants with good kidney function and poor drainage will have a dramatic improvement of drainage over the first few months of life. Others may not improve or worsen. Because there is a chance of improved drainage without surgery, some infants with hydronephrosis (fluid-filled enlargement of the kidney) are watched with repeat ultrasounds and office visits. Once the diagnosis of UPJ obstruction is established and after 18 months of age, if there is no further reasonable chance of improvement, the condition requires surgical treatment. 

The surgery lasts a couple of hours and has a success rate in excess of 95 percent. Post-surgical hospitalization may be required. The incision on the patient is two to three inches long just below the ribs and behind a line that would pass from the patient’s arm to their leg on the affected side. 

Newer treatment of UPJ obstruction involves minimally invasive surgery. There are two options, a laparoscopic pyeloplasty and an internal incision of the UPJ. Laparoscopic surgery is done by placing several instruments through the abdominal wall and performing the surgical procedure. This procedure is most often done through the abdominal cavity and has the disadvantage of potentially causing scarring or adhesions within the abdomen. Surgeons also cannot use techniques that are as delicate in a laparoscopic as in an open procedure. The clear advantages of laparoscopic surgery are less pain and nausea especially in older children and adults. Success rates of laparoscopic pyeloplasty approach the effectiveness of open surgery. The second option is to insert a wire through the ureter and use it to cut the tight and narrow UPJ from the inside. A special ureteral drain is left in place for several weeks and then removed. The UPJ heals in a more open manner in most patients but the treatment may need to be repeated and success rates are clearly less than those of open surgery. The advantages of this procedure are less pain and nausea. 

After surgery, there is usually swelling of the ureter and continued poor drainage of the kidney for awhile. A functional test is performed a few weeks after the procedure, to evaluate how well the kidney is working. Patients usually recover quickly but some have pain for a few days. A drainage tube may be left in place to help drain the kidney while it heals.

The appearance of the kidney improves over the years, but usually it never looks normal on ultrasound or other studies. A UPJ obstruction almost never recurs. Patients may have a slightly increased risk of developing stones and infection throughout their lives. A child should be monitored for several years after a UPJ surgery to evaluate kidney function and any potential infection.

Vesicoureteric reflux

What is Normal?

Your child has two kidneys that make urine. The urine travels down the ureters into the bladder where it is stored until he urinates out the urethra. This urine flow should only be one way: from kidney to ureter to bladder to urethra and out. 

What is Reflux?

In patients who have reflux, urine washes back up from the bladder to the kidney. The usual cause is a weakness or deficiency of muscle at the point where the ureter connects to the bladder. This muscle normally acts to close the ureter and prevent backwash of urine up to the kidneys. The reflux of clean urine poses no problem to the child and no threat of damage to the kidneys. However, if the urine becomes infected, the infection can travel back up to the kidneys and cause a kidney infection-pyelonephritis. Kidney infections can cause damage or scarring to the kidney. Reflux can occur on one side (unilateral) or both sides (bilateral). Reflux also occurs in different degrees or grades from mild (grade 1) to severe (grade 5). 

How is Reflux Diagnosed? 

A VCUG – X-ray of the bladder is used to diagnose reflux. A thin tube, catheter, is inserted into the urethra- the opening where the urine comes out. Fluid containing dye is injected through the tube until the bladder is full. The child urinates and pictures are taken to see if the dye goes backward up to one or both kidneys. 


Mild to moderate reflux is treated with long-term, low-dose antibiotic therapy to prevent infections. In many cases, as the child grows and the bladder muscles develop, the reflux cures itself. Your child will need to have an X-ray study to determine the amount of reflux still present. One sign that these muscles may be maturing is the development of urine control in a child who was previously a day or night wetter.

In more severe forms of reflux or if antibiotic therapy does not control the infections, surgery may be needed. Traditional techniques move the ureter to a place on the bladder where there is more muscular support.

Endoscopic treatment means that a cystoscope- a miniature viewing device- is inserted into the bladder through the urethra. A material is then injected into the bladder at the locations where the ureters enter the bladder. A little bulge is formed which makes it harder for the urine to flow backwards. The bulge also makes the openings from the ureters into the bladder smaller, which again makes it harder for the urine to flow back. The openings are still large enough for the urine to flow down into the bladder without any problem. 

Special Tips

1. Any time your child has a fever of 101 degrees F or more, he will need to have his urine checked, not just his ears and throat. (Your family doctor can do this.)

2. Since reflux tends to run in families, it is a good idea to have your other children evaluated by a urologist. (The office staff can set that up for you.) 

Follow-up Appointments

Be sure to keep the appointments with the doctor as scheduled. 


It is important to give antibiotics once a day, usually at bedtime, to prevent infection. 

When to call the office

1. If your child has a urinary tract infection

2. If your child has any unexplained fever or belly pain

Why is Surgery Necessary for Children with Reflux

Reflux is the backward flow of urine from the bladder to the kidney. Surgery stops this backward flow. This backward flow poses a treat to the kidneys’ health when the urine is infected. The main reasons for performing surgery are:

1. Inability to control infection

2. Persistent reflux

3. Severe degree of reflux that has little chance of stopping on its own 

What is Anti-reflux Surgery?

Anti-reflux surgery is done to stop the flow of urine up into the kidneys. There are two possible types of surgery your child may have if diagnosed with reflux. 

“Reimplantation” Surgery

The surgery consists of moving (“reimplanting”) the ureter (tube which carries urine from the kidneys to the bladder) to a place on the bladder where there is more muscular support so the urine can not wash back u the ureters to the kidney. The incision for the surgery will be in a curved line just above the pubic area, or a small incision in the groin.  

Endoscopic Surgery

Endoscopic treatment means that a cystoscope (a miniature viewing device) is inserted into the bladder through the urethra. A material is then injected into the mucosa of the bladder at the locations where the ureters enter the bladder. A little bulge is formed which keeps the urine from flowing backwards. The bulge also makes the openings from the ureters into the bladder smaller, which again keeps urine from flowing back. The openings are still large enough for the urine to flow down into the bladder without any problem. 

During Surgery

After your child is taken into surgery, you can wait in the Outpatient Surgery Lobby at Children’s Hospital. The “reimplantation” surgery takes 2-3 hours, and the endoscopic surgery takes 30 minutes. Your doctor will talk to you as soon as he is finished. Your child will then be in the Post Anesthesia Care Unit (Recovery Room) for 1-2 hours before you can see him in his room. The staff will call you when you can see your child. 

What to Expect after “Reimplant” Surgery

When you see your child after surgery, he will have: 

  • IV- A plastic tube into his arm for the first day following surgery. This will be removed as your child eats and drinks without problems 
  • Foley Catheter- a tube that drains the bladder of urine. This tube is connected to a urine bag. While the bladder is draining, the urine may look dark red or pink and may contain some blood clots. This is normal. Your child may go home with the catheter in place for several days from the day of surgery. He may pass some clots in his urine and may feel burning when urinating for several days after the catheter is removed. This is also normal. Be sure your child drinks plenty of fluids. 
  • Dressing- A small gauze dressing or “Steri-Strips” will cover the incision. 
  • Medication- Your child will be given pain medication as needed. It will be given in the IV until he/she is eating and then can be given in oral form. Your child will also receive antibiotics through the IV and then by mouth. He/She will continue on the antibiotics at home. 
  • Pain- Some children may have bladder spasms which give them an intense feeling of having to urinate even though their bladder is empty. These spasms happen because the bladder has been opened for surgery. Constipation may make bladder spasms worse, so you must ensure that your child has at least one soft bowel movement per day. You may use an over the counter stool softener if necessary (milk of magnesia,, etc.).
  • Activity- Early activity should be encouraged. Hen he is out of bed, a special leg bag may be used for the catheter so it is easier for him to move around. 

Home going Instructions for “Reimplant” Surgery 

1. No heavy physical activities (such as gym, bike riding, swimming) for 3 weeks.

2. Continue giving the antibiotics and other medications as directed.

3. You may begin giving baths the day after hospital discharge.

4. Your child may return to school 10 days after surgery. 

Follow-up Care for “Reimplant” Surgery

Your child will need to be followed up for at least a year. At the first appointment after surgery (1 month), your child will be scheduled for an ultrasound exam of the kidneys and bladder. The ultrasound is then repeated at 4 months and 12 months after the operation. 

What to Expect after Endoscopic Surgery

  • Medication- Your child will need to continue taking a daily antibiotic until a bladder X-ray shows reflux is no longer present. 
  • Pain- There may be some pain after your child has endoscopic surgery, including pain with urination. Your child may use Tylenol for this pain.
  • Activity- Your child will go home the next day of surgery. He will be able to go to school the in 2-3 days, and to participate in activities as he can tolerate.

 Home going Instructions for Endoscopic Surgery 

1. Continue giving the antibiotics and other medications as directed.

2. You can begin giving baths the day that you go home.

Follow-up Care for Endoscopic Surgery

Your child will need to be followed up for at least a year. At the first appointment after surgery (1 month), your child will be scheduled for an ultrasound exam of the kidneys and bladder. At 4 months as well as 12 months after the surgery, your child will have a voiding cystourethrogram (VCUG), as well as another ultrasound. 

When to Call the Office 

1. If your child has a fever of more than 101 degrees F

2. If your child is having severe pain

3. If your child has significant vomiting or is dehydrated

Hypospadias- An Abnormality of the Penis

Hypospadias (hi-po-SPAY-dee-us) is a very common birth abnormality among male infants. In general, of every 200 baby boys born, one baby will have the condition. If you have one son with hypospadias, the chance of having another baby boy with the same problem is about 10%. In other words, you would have a 90% chance that it would NOT happen again. 

What is Hypospadias?

Hypospadias is an abnormality of the penis. To understand it, one must examine the normal penis anatomy. The urine tube (urethra) travels through the shaft of a normal penis. The urine tube (urethra) has an opening (meatus) at the head of the penis. This opening is usually in the center of the head of the penis (glans). 

What is Different about the Penis when the Condition of Hypospadias is Present?

In boys with hypospadias the urine tube (urethra) is short and does not come out to the end of the penis. The opening (meatus) could be anywhere along the shaft of the penis or even in the scrotum. In addition, the foreskin is not evenly distributed around the end of the penis. Instead there is often scant foreskin on the underside of the penis and extra foreskin on the top. This makes the end of the penis look hooded. When hypospadias occurs, usually the penis shaft is also bent downward toward the scrotum. This curving is called CHORDEE (chord-ee). You can see it easily when the penis is erect. 

Why is Hypospadias a Problem?

The position of the urinary opening (meatus) may make it difficult for your son to control the direction of urine flow. Urination may be straight down and in some cases the boy must sit down in order to urinate and hit the commode. Also, if the penis is curved (chordee), your son’s sexual activity may be altered when he is an adult. 

What causes Hypospadias?

There is not single known cause of hypospadias. Some things that we know about possible causes of hypospadias are:

  • The formation of the penis, which is completed by the 12th week of pregnancy, is affected by hormones given off by the mother’s placenta and the baby’s testes.
  • During the development of the penis in the second month of pregnancy, if the movement of the opening of the urine tube (urethra) toward the head of the penis is blocked, hypospadias will occur.

What can be done to correct the Problem?

Circumcision is the removal of the foreskin to expose the head of the penis. We ask doctors not to circumcise boys with hypospadias. This tissue is used in the surgical repair. If a circumcision is desired, it is done at the time of the surgery to correct the hypospadias. We usually leave a small amount of extra skin in case further surgery is required for the hypospadias.

The surgery for hypospadias is often performed near the first birthday. The goals of the surgery are to:

  • Straighten the penis 
  • Move the opening (meatus) of the urine tube (urethra) to a normal position at the top of the penis (glans)
  • Have the penis look as normal as possible

If the hypospadias is quite severe, there may be a need to do the operation in stages, separated by a six to eight month waiting period. At times, more than one surgery may be required to correct the hypospadias. If the repair fails to heal correctly, leaking of urine along the area of repair may occur. Scar tissue may narrow the reconstructed tube. Great care is taken to provide the most normal penis that is possible. At times, irregularities require further surgery. 

Remember that your son is an individual and will have his own special needs. Now that you have a general idea about hypospadias, your son’s physician will answer your further questions and will attend to his individual needs.


What is a urinary tract infection (UTI)?

An infection caused by germs or bacteria getting into the urinary tract is called a urinary tract infection or UTI. The urinary tract include the kidneys, ureters, bladder and urethra, the parts of the body that create or transport urine. The infection becomes more serious when it is located further up into the urinary tract.Both men and women at any age can get a UTI. It becomes more difficult to diagnose in children because they not always exhibit the symptoms.

How to recognize a UTI in Children

It is important to contact our office or your primary care provider is your child displays:

  • A persistent fever of unknown cause
  • Burning or pain when urinating
  • Frequent of urgent urination
  • Strong-smelling, cloudy or bloody urine
  • Abdominal, back or side pain

Young children and babies cannot tell you how they feel. Infants who show irritability, poor feeding, listlessness, fever or below normal temperature may have a UTI. If the kidneys become infected, the child will feel very ill and will usually run a fever. 

UTI treatment

A simple urine test will tell if your child has a UTI. Antibiotics are normally prescribed and the bacteria is quickly killed. More tests may be required to examine the urinary tract if any abnormalities are suspected or if the infection reached the kidneys. 

Prevention of UTI’s in children

You can reduce the risk of an infection reaching the urinary tract by:

  • Frequently changing diapers
  • Wiping front to back after going to the bathroom
  • Wearing cotton underwear
  • Urinating often
  • Avoiding and treating constipation.

Repeating UTI’s

A child who gets a UTI is prone to get additional infections in the future. It is important to tell your doctor if your child has had a UTI in the past. Sometimes there is an underlying problem causing the susceptibility to infection for the child. Additional tests can reveal any serious conditions that require treatment. Or, for less serious causes, behavior modification outlines can direct the parent proper practices to reduce UTI risks.

Hernias And Hydrocele

As a child develops in the womb, testicles grow near the kidneys in the abdomen.  During the last three months of pregnancy, the testicles move toward their normal place in the scrotum.  To begin their descent, a muscle ring in each side of the groin opens to allow their travel.  The lining of the abdomen accompanies the testicles to line the scrotum and may carry fluid with it. This causes the scrotum to appear enlarged.  Usually this channel closes in most boys and the fluid is absorbed.  This is called a noncommunicating hydrocele.  If it remains open, or reopens, the fluid causes a sac and remains around the testicle(s) in the scrotum.  This is called a communicating hydrocele.  If it opens (or reopens) widely, a part of the intestine can descend through this channel toward the scrotum, ending up as an inguinal hernia.

Injury or inflammation within the scrotum can also produce a hydrocele.  Usually this resolves itself within a few months.  If it remains, medical attention may be required.  Hernias can also develop from straining during bowel movements, coughing, sneezing, heavy lifting or obesity.  These cause pressure on the intestines and can push a section of intestine through a weak spot in the abdomen.

Surgery is recommended for a hydrocele if it is still present in one-year-olds.  Surgery may be required before one year if the scrotum continues to enlarge from fluid build-up.  If the hydrocele is uncomplicated, a simple incision is made to the scrotum so the sac and fluid can be removed.  If it is complicated, such as accompanied by a hernia, a small incision to the groin is made to treat both conditions at the same time.

Hernias should be treated as soon as they are identified.They do not go away on their own. Hernias require suturing (or sewing) of the channel and repair of the muscle ring by a urological surgeon.

Undescended testicles

Undescended testes (cryptorchidism) refers to abnormal descent of the testes into the scrotum. Normally the testes will descend into the scrotum during the third trimester of the pregnancy.This condition often self-corrects by six (6) months of age. Cryptorchidism (undescended testes) is influenced by age. The incidence in premature boys is about 9% to 30%; the incidence in male infants delivered at term is 3% to 6%.

“Retractile testes” are fully descended,but move freely between the scrotum and groin.Undescended testes must be surgically placed in the scrotum to maximize fertility and reduce the risk of testicular malignancy.

As the parent of a boy with undescended testes, regular exams with your Primary Care Provider or a Pediatric Urologist are important. Sometimes hormones are given to stimulate descent into the scrotum. Testes should be in the scrotum by 6 to 12 months of age to avoid the risk of decreased fertility or malignancy.