Many children and adults know the humiliation and embarrassment of waking up in a urine-soaked bed. The stigma attached to a "bed-wetter" is something which, often times, follows a child throughout his adolescent/teen years and sometimes, even into adulthood. The fear and anguish that awaits with the rising of the sun is a certainty in many lives.
The majority of children and adults with this problem, known as nocturnal enuresis, tend to be withdrawn and possess very low self-esteem. This negative effect touches many aspects of their lives. They generally make few friends and do not do well in school. A bedwetter will decline offers to sleep over at a friends house or go on camping trips. The very real fear of being "discovered" by their peers would be too devastating to risk the attempt. Their academic performance may suffer as a direct result of the stress, tension, and lack of self confidence associated with this condition. All of this negativity can and will affect a child's psychological development.
Many studies and surveys have been conducted producing the following profile:*
- The average bedwetter is between 4 and 14 years old
- About 15% of children wet the bed after the age of 3
- Two out of three bedwetters are boys
- It is common for the child to wet within 2 1/2 hours of going to sleep
- A bedwetter will do so 1-4 times a night, 5-7 nights a week
- Bedwetting may be inherited
- Normally, bedwetting ceases by puberty
In most cases, bed-wetting is considered as just an unfortunate childhood problem, and no outside treatment is sought. The parents are frequently prepared to simply wait until the child grows out of it, and in most cases these problems go untreated.
The traditional chiropractic approach to treating the child who is a bed-wetter is to adjust the spine, usually in the area of the lumbar spine or sacrum. A review of the anatomy and physiology of the bladder may help us understand why these areas are chosen as the prime target.
The bladder:Emptying of the urinary bladder is controlled by the detrusor and trigone muscles. The nerve supply to these muscles is via the sacral parasympathetic nerves from S2 to S4.
Appropriate bladder function is also controlled by the urogenital diaphragm which derives its nerve supply from the L2 spinal nerve.
Development of the SacrumThe sacrum (or tailbone) develops as five separate segments. These segments remain separated until a child reaches puberty, at which time fusion of one sacral segment to another commences. Eventually, the sacrum will be one single bone with all five segments fused together, but this does not occur until the mid-20s.
Because the sacrum consists of separate segments during the early years of life, it is possible that misalignment of these segments can cause nerve irritation or facilitation. This nerve facilitation, especially to the area of the bladder, may be the cause of the inappropriate bladder function associated with bed-wetting.
As we have seen, the developing sacrum in the early childhood years remains highly mobile, existing as separate spinal segments. During this period, the sacrum can be subjected to repeated trauma from childhood falls and the early attempts at walking. This early trauma to the sacrum may be the major reason why bed-wetting in some patients ceases after the spine is adjusted.
Is the Spine the Cause of all Enuresis?
Adjustment of the sacral segments in the bed-wetter has an anecdotal history of effectiveness throughout the years. Recent studies, however, would appear to disagree with such claims. One such study from Australia concluded that spinal adjusting offered little help for enuresis, while another study suggested that good results could be obtained. This apparent disagreement may suggest nothing more than bed-wetting is due to several causes, one of which is spine related. Children with a spinal cause respond while those with other causes of bed-wetting do not.
The conclusion would therefore appear to be to have all children who are bed-wetters evaluated for the possibility of spinal problems as the underlying cause.
The following studies are provided by International Chiropractic Pediatric Association
Peer Reviewed Publications:
Chiropractic management of primary nocturnal enuresis. Reed WR, Beavers S, Reddy SK, Kern G. J Manipulative Physiol Ther. 1994 (Nov-Dec);17 (9): 596-600
This was a controlled clinical trial of 46 enuretic children that were placed under chiropractic care. The children were under care for a 10 week period preceded by and followed by a 2 week nontreatment period.
- Participants: Forty-six nocturnal enuretic children (31 treatment and 15 control group), from a group of 57 children initially included in the study, participated in the trial.
- Results:...25% of the treatment-group children had 50% or more reduction in the wet night frequency from baseline to post-treatment while none among the control group had such reduction.
Nocturnal enuresis: treatment implication for the chiropractor. Kreitz, B.G. Aker, P.D., J Manipulative Physiol Ther. 1994 (Sep);17 (7): 465-473
A comprehensive review of the literature concerning the etiology, diagnosis, and the natural history of primary nocturnal enuresis is presented. Contemporary treatment options are discussed in light of the documented annual remission rate of this disorder.
The author states: "Spinal manipulative therapy has been shown to possess an efficacy comparable to the natural history."
Functional nocturnal enuresis. Blomerth PRJ Manipulative Physiol Ther 1994; 17:335-8
To discuss a patient with primary nocturnal enuresis whose symptoms resolved following manipulation.
CLINICAL FEATURES: An 8-yr-old boy with a history of primary functional nocturnal enuresis was under care at this office. The patient's clinical examination was benign. He had several areas of lumbar segmental dysfunction. The patient's medical history was unremarkable except for childhood asthma.
INTERVENTION AND OUTCOME: The patient's lumbar spine was manipulated once, and at a 1 month follow-up there was complete resolution of enuresis. The patient had several recurrences of bed-wetting, all of which were associated with minor injury to the lower back. The patient responded positively to subsequent manipulation.
CONCLUSION: This patient's enuresis resolved with the use of manipulation. This happened in a manner that could not be attributed to time or placebo effect.
Chiropractic care of children with nocturnal enuresis: a prospective outcome study. LeBouf C, Brown P, Herman A et al. J Manipulative Physiol Ther. 1991 (Feb);14 (2): 110-115
- Children with a history of persistent bed-wetting at night received eight chiropractic adjustments. Number of wet nights fell from 7/week to 4. At the end of the study, 25% of the children were classified as successes.
Functional nocturnal enuresis. Blomerth PR. J Manipulative Physiol Ther. 1994 (Jun);17 (5): 335-338
- Eight-year-old male bed wetter. Lumbar spine was manipulated once and at 1 month follow-up there was complete resolution of enuresis. "This happened in a manner that could not be attributed to time or placebo effect.
"Neurogenic bladder and spina bifida occulta: a case report Borregard PE. J Manipulative Physiol Ther. 1987 (Jun);10 (3): 122-123
- Examination found fixation in L3 and both SI joints, following the restoration of SI function the patient's mother reported the patient was now aware of bladder distention approximately 30 minutes before it was necessary to void. A slight of bladder sensitivity occurred 4 months after the release from treatment and responded immediately to manipulation.
Chiropractic management of enuresis: time series descriptive design. Gemmell HA, Jacobson, BH J Manipulative Physiol Ther. 1989 (Oct);12 (5): 386-389
- Case of a 14-year-old male with a long history of continuous bed-wetting that was alleviated (not completely cured) by adjustments.
Characteristics of 217 children attending a chiropractic college teaching clinic. Nyiendo J. Olsen E. J Manipulative Physiol Ther. 1988 (Apr);11 (2): 78-84
- The authors found that pediatric patients at Western States Chiropractic College public clinic commonly had ordinary complaints of ear-infection, sinus problems, allergy, bedwetting, respiratory problems, and gastro-intestinal problems. Complete or substantial improvement had been noted in 61.6% of pediatric patients of their chief complaint, 60.6% received "maximum" level of improvement while only 56.7% of adult patients received "maximum" level of improvement.
Epileptic seizures, Nocturnal enuresis, ADD. Langley C. Chiropractic Pediatrics Vol 1 No. 1, April, 1994.
- This is an eight year old female with a history of epilepsy, heart murmur, hypoglycemia, nocturnal enuresis and attention deficit disorder. The child had been to five pediatricians, three neurologists, six psychiatrists and ten hospitalizations and had been on Depakote, Depakene, Tofranil and Tegretol. Birth was difficult including a cesarean under general anesthesia. Mother was told the baby was allergic to breast milk and formulas and stayed on prescription feeding. The doctors told the mother the girl would never ride a bike or do things like normal children do. The child was wetting the bed every night and experiencing 10-12 seizures/day, with frequent mood swings, stomach pains, diarrhea and special education classes for learning disabilities.
- Chiropractic adjustments: C1 and C2 approximately three times/week. After two weeks of care the bed-wetting began to resolve and was completely resolved after six months. She was also leaving special education classes to enter regular fifth grade classes. Seizures were much milder and diminished to 8-10 per week after one year of care. Patient was also released from psychiatric care as "self managing." Her resistance to disease in-creased and she can now ride a bike, roller skate and ice skate like a normal child. After medical examinations, she is expected to be off all medication within a month.
Bed-wetting; two case studies. Marko, RB Chiropractic Pediatrics Vol. 1 No. 1 April 1994.
- Case #0991: Five year old female who had been wetting her bed for six months. She was prescribed antibiotics for what MDs diagnosed as a bladder infection. After the second chiropractic adjustment, she stopped wetting her bed for three weeks. She had a bad fall and began to wet her bed again. After her next adjustment, she has remained dry.
- Case #0419: Nine year old male who wet his bed almost every day of his life. After the first six months of chiropractic, he would be dry for the next day or two. A change in adjustments to the sacrum resulted in greater improvement. He is now dry for one-half to two-thirds of the nights between the adjustments.
ADD, Enuresis, Toe Walking. International Chiropractic Pediatric Association Newsletter May/June 1997. From the records of Rejeana Crystal, D.C., Hendersonville, TN.
- A six year old boy with nightly nocturnal enuresis (bedwetting), attention deficit disorder and toe walking. He walked with his heels 4 inches above the ground. The medical specialist recommended that both Achilles' tendons be cut and both ankles be broken to achieve normal posture and gait. Chiropractic findings included subluxation of atlas, occiput, sacrum and pelvis.after 4 weeks of care both heels dropped 2 inches and the bedwetting frequency decreased to 2-3 times per week. His doctor could not believe how chiropractic care made such a change.
Management of pediatric asthma and enuresis with probable traumatic etiology. Bachman TR, Lantz CA Proceedings of the National Conference on Chiropractic and Pediatrics (ICA), 1991: 14-22.
- A 34-month-old boy with asthma and enuresis had not responded to medical care. More than 20 emergency hospital visits had taken place for the asthma attacks during a 12 month history. Three chiropractic adjustments were administered over an 11 day period and the asthma symptoms and enuresis ceased for more than 8 weeks. The asthma and enuresis reoccurred following a minor fall from a step ladder but disappeared after adjustments. After a two year follow-up, the mother reports no reoccurrence of the asthma or the enuresis.
Rosenfeld, J. & Jerkins, G.R. The bed-wetting child. Post Grad Med, 1991, 89, pp. 63-70.
Lynch, D. Nocturnal enuresis: an evaluation and management with an illustrated case. J Osteopath Med, 1991, June 10-9.
- Young, D.E. & Young, R.R. Nocturnal enuresis: A review of treatment approaches. Am Fam Physician, 1985, 31, pp. 141-44.
- Spitzer RL, Chairperson. Diagnostic and statistical manual of mental disorders. 3rd ed. American Psychiatric Association Task Force on Nomenclature and Statistics, Phila., 1980.
- Forsythe, W.I. & Redmond, A. Enuresis and spontaneous cure rate: study of 1129 enuretics. Arch Dis Child, 1974, 49, pp. 259-63.
- Bachman, T.R. & Lantz, C.A. Management of pediatric asthma and enuresis with probable traumatic etiology. Proceedings of the National Conference on Chiropractic and Pediatrics (ICA), 1991, pp. 14-22.
- Blomerth, P.R. Functional nocturnal enuresis. JMPT, 1994, 17 (9), pp. 335-338.
- Gemmell, H.A. & Jacobson, B.H. Chiropractic management of enuresis: Time-series descriptive design. JMPT, 1989, 12(5), pp. 386-389.
- Reed, R.R., Scott, B., Reddy, S.K., & Kern, G. Chiropractic management of primary nocturnal enuresis. JMPT, 1994, 17(9), pp. 596-600.
- LeBoeuf, C., Brown, P., Herman, A. et al. Chiropractic care of children with nocturnal enuresis: A prospective outcome study. JMPT, 1991, 14 (2), pp. 110-115. San Francisco Chronicles, March 5, 1992.
- Moser, R. Bed-wetting: The wee hours of the night. Medical SelfCare, Jan/Feb 1990, p. 21.
Nocturnal Enuresis by Claudia Anrig, DC Two Cases
..What I enjoy the most when the boys come in for their adjustments is being aware that their quality of life has improved.
Chiropractic Management of Enuresis by Peter Fysh, DC
...The conclusion would therefore appear to be to have all children who are bed-wetters evaluated for the possibility of spinal problems as the underlying cause...