Symptoms
Enuresis: symptoms and progression in children
Children develop at different rates. This applies not only to walking and talking, but also to toilet training. Bladder control is a maturation and learning process that takes time and lasts until about the age of 5.
Not every child has completed this maturation process by this age. There are also other influencing factors that contribute to a delay in toilet training in children. From a psychological point of view, the term "enuresis" is only used when a child wets twice a month after the age of 5.
Depending on when the child wets himself during the day, it is necessary to distinguish between
- Night symptoms (bedwetting, medical term: nocturnal enuresis): 15-20 percent of all 5-year-old children suffer from it. Boys are affected twice as often as girls.
- Enuresis during the day (medical term: enuresis diurana or paediatric urinary incontinence): affects about 5 percent of 5-year-old children. With each passing year, spontaneous healing occurs in around 15 percent of those affected.
It is not always easy to tell the difference between bedwetting and daytime enuresis, as daytime symptoms such as frequent urination and a sudden urge to urinate are often hidden by children and not immediately noticed by parents. Combinations also occur frequently.
All you need to know about bedwetting
Doctors also differentiate between primary and secondary enuresis (urinary incontinence):
- Primary urinary incontinence: the child has not achieved urinary continence for more than 6 months.
- Secondary urinary incontinence: the child has already achieved urinary continence for more than 6 months, but starts wetting at night or during the day again. This can also be due to psychological causes in children, such as increased stress caused by settling into nursery or school, parental separation or moving house
The topic of child wetting must be discussed with a doctor in the following situations:
If your child is over 3 years old and wets regularly both during the day and at night. | If your child is over 5 years old and still wets at least twice a month. | If, regardless of age, your child experiences pain when urinating. |
Trigger
Causes and risk factors of child wetting
The causes of enuresis are different from those of bedwetting alone. There can be both organic and functional reasons for incontinence in children during the day.
The cause is often bladder dysfunction, such as the lack of bladder control. However, there are a number of other reasons for incontinence in children during the day.
Overactive bladder and small bladder capacity
On the other hand, it is possible that the bladder is too small for the age. In this case, even small amounts of urine can cause the urge to urinate. Affected children have to go to the toilet very frequently and often do not get there in time.
Bladder emptying disorder
If the interaction between the bladder sphincter and the relaxation or contraction of the pelvic floor is not working properly in your child, your child may experience "stuttering" or squeezing during urination. On the other hand, if the urethra or urethral outlet is narrowed, a weakened urine stream may be observed when going to the toilet. The bladder is often not emptied completely.
Infrequent visits to the toilet
Girls in particular often delay going to the toilet or avoid using other people's toilets altogether. Due to constant overexpansion of the bladder muscle, one is no longer able to feel that the bladder is full and the bladder muscle loses strength. This can lead to enuresis with large amounts of urine. Here too, the bladder is often not emptied completely during normal visits to the toilet, resulting in large amounts of residual urine.

Congenital malformations and neurological diseases
Congenital malformations of the ureter or a malformation of the urethra may be present if there is constant dribbling of urine.
Neurological diseases that affect the nerves that control the bladder can also cause enuresis. However, both these causes are rare.
Urinary tract infections
Acute and chronic urinary tract infections can also cause enuresis. While an acute urinary tract infection is accompanied by pain and burning when urinating and fever, these signs are not always present in a chronic urinary tract infection. However, foul-smelling urine is an important indication of a urinary tract infection.
Stress incontinence and laughter incontinence
This happens when children involuntarily leak urine when they cough, sneeze or laugh. The reason: the sphincter or pelvic floor is not strong enough to withstand the pressure on the bladder.
Children need to have a number of important skills that are subject to different maturation processes in order to be able to control their bladder:
- Bladder sphincter: the child needs to learn to control the bladder sphincter.
- Recognise and react: the child needs to recognise when the bladder is full and react quickly by going to the toilet.
- Sleeping and waking up: the child needs to learn the cues to wake up and go to the toilet.
Diagnosis
How is incontinence diagnosed in children?
Anamnesis: these are the questions that the doctor asks
It is best to think about the following questionsbefore you visit the doctor. Every detail is important:
- When does the child wet and how often?
- Does the child go to the toilet frequently during the day, or rarely and then often too late?
- Is there frequently an urge to urinate, and is it irrepressible?
- Is the urine stream interrupted or even sputtering?
- How large are the individual urine volumes?
- Has anyone in the family had a similar problem?
It is also very helpful if you have already kept a so-called micturition diary, also known as a pee diary. This records your child's drinking and toilet behaviour and wetting symptoms. This is an important part of the diagnosis and helps the doctor find the causes of enuresis.
To maintain the diary, you should observe and record the following aspects over a period of 3 days together with your child:
- Urination times
- Urine volumes
- Feeling of a full bladder
- Times/situations of wetting
- Drinking times and quantities
- Stool behaviour
To determine the exact amount of urine during night-time wetting, we recommend using a nappy that you weigh dry and wet.
Use the micturition diary to easily record the data. This enables the doctor to gain many important insights, for example:
- Does your child drink too much at inappropriate times, for example before going to bed?
- Is the capacity of the bladder developed according to age?
- Does the nocturnal urine production exceed the bladder volume?
Simply download the PDF file, print it out, fill it up and take it with you to your next appointment with the doctor.
Or use "Hoppla" - more than an online bladder diary - for documentation.
Physical examinations
A physical examination follows after the doctor, with your help, has gained an insight into your child's drinking and toilet habits. The doctor palpates the child's abdomen and back and examines the genital area. The focus here is on ruling out urological or neurological diseases or congenital malformations as causes of enuresis.
The doctor will run a urine test to rule out a urinary tract infection as the cause of your child’s symptoms. You just need to fill a small amount of urine into a clean cup.
Urinalysis gives the doctor important information about the child's metabolic balance, possible kidney diseases and the presence of bacteria.

An ultrasound examination (sonography) can rule out abnormalities in the kidneys, bladder and urinary tract. By measuring the residual urine and the thickness of the bladder wall, the consulting doctor can draw conclusions about an overactive bladder, bladder emptying disorders or chronic illnesses. This examination is mostly carried out by specialists.

Further investigations
In most cases, the treatment of enuresis can begin once the above examinations have been carried out. However, if these examinations, known as basic diagnosis, are inconclusive, the doctor could ask for urine flow and bladder pressure measurement. This is done by urologists or in specialised centres.
Urine flow measurement is carried out to rule out the possibility of a urinary flow disorder.

Bladder pressure measurement is only carried out if treatment has been unsuccessful over a long period of time and no other causes of enuresis can be found.
Bladder pressure measurement measures the activity of the bladder muscle and, occasionally, also of the pelvic floor. In this way, the consulting doctor can get definitive clarity about the cause of enuresis.

The doctor may also order a blood test or a cystoscopy.
If psychological causes are suspected as the reason for child wetting during the day, psychological tests are also carried out. They can be used to determine whether there is any psychological stress that could have triggered the incontinence.
Tips for parents
What can parents do if their child has incontinence?
Taking away the child's fear
Wetting is usually very distressing for the affected child. Children who wet themselves feel "different" and ashamed of their problem. As parents, you should be even more empathetic and understanding towards your child. Take away your child's fear of being "different" and show them a way out.
One of the most important steps at the start of the treatment is to get the child interested in toilet training. The child should understand what the problem is and enjoy influencing their own bladder. Explain to your child that they are not yet fully in control of their bladder.
A micturition diary and a colouring calendar can help the child understand better. The colouring calendar deals with wetting in a playful manner and motivates your child to stay dry.
How to deal with friends at nursery and school
The affected child may be afraid to visit friends for fear that something will go wrong. Talking openly with the friends’ parents and giving them a change of clothes will help. Other parents are usually aware of the condition from their own experience.
It is also important to make sure that your child’s nursery or schoolis calm and understanding in dealing with enuresis. Talk to your child's nursery or school teachers. Most of them are already familiar with enuresis, as many children are affected by it.
Perhaps the nursery or school can address the issue of enuresis playfully to provide information about the causes.
Observing holding manoeuvres
So-called holding manoeuvres are attempts to suppress the urge to urinate. Children use them to avoid wetting themselves. For example, they press their legs together, jump back and forth, become fidgety, squat or sit on their heels.
If you observe such behaviour in your child, remind him or her to go to the toilet. Children often intentionally suppress the urge to urinate while playing or forget to go to the toilet because they are so absorbed.

Work with your child to set specific times when he or she should empty the bladder in a relaxed way. You and your child need to internalise and stick to these times.
Over time, this responsibility should be increasingly transferred to your child. Your child should feel bladder pressure early and go to the toilet in time. By the time the bladder "sounds the alarm", it is usually too late and there is little time to get to the toilet. In this way, the child learns to consciously induce emptying of the bladder.
Consistent toilet training enables the necessary exchange of information between the bladder and the brain and promotes the normal maturation of the nerve pathways that run between them. In addition to controlling urination, it is also important to have regular bowel movements.
Change in drinking and toilet habits
Changing your child's drinking and toilet habits can often make a big difference.
- The child should drink majority of fluids during the first half of the day.
- Ensure regular toilet visits.
- Do not give your child any caffeinated or carbonated drinks in the evening.
- Before going to bed, the bladder should be emptied completely.
- In the so-called coachman's seat position, your child can relax the pelvic floor muscles and completely empty the bladder.
- Make sure your child has regular bowel movements.
In the coachman's seat position, the feet are on a stool. The legs are bent at 90 degrees. The upper body is bent forward slightly relaxed and the arms are supported on the thighs. Show your child this relaxed sitting posture on the toilet and practise it a few times together.

If your child continues to wet themselves despite following these tips, it is advisable to see a doctor to discuss further treatment.
Treatment
Child wetting: treatment options
Good news first: enuresis can be treated. There are various treatment methods that can make your child’s everyday life fun again. Enuresis can be very stressful for both the child and the parents. Therefore, it should be treated actively.
The treatment of paediatric incontinence varies depending on the diagnosis. Urotherapy usually comes first. If this is not successful, there is the option of taking medication or using biofeedback methods.
What is urotherapy?
During urotherapy, the child and parents are informed about how the kidneys and bladder work and what the young patient’s problem is. This increases the child's understanding and willingness to cooperate.
Your child should become aware of the processes in his or her body and learn to empty the bladder voluntarily. Changing incorrect drinking or toilet habits, as described above, often leads to significant improvement and no further treatment is necessary.
It is also important to pay attention to your child's bowel movements. The elimination of constipation usually also relieves the symptoms of enuresis.
What to do if your child delays going to the toilet (delayed micturition)?
At the beginning of treatment, you as parents must initiate dialogue with your child. Use a relaxed situation in a home environment to find out why your child is holding back urine.
The aim of the treatment is for your child to go to the toilet at least 7 times a day. Note down the number of toilet visits in a diary and analyse it together with your child. Small rewards also reinforce success and motivate you to keep going.
Medication
In the case of urge incontinence and an overactive bladder, it may sometimes be necessary to take medication (so-called bladder spasmolytics). These have a relaxing effect on the bladder muscle. They calm the bladder and enable it to store more urine again. The frequency with which your child feels the urge to urinate is also reduced.
The duration of treatment varies greatly. Some children get toilet trained quickly; others need a little more time. Important: don’t end the treatment abruptly and immediately after achieving success. Continue to motivate and guide your child to avoid relapse.
Biofeedback methods
Special biofeedback devices are used to visually and acoustically show the children the relaxation and contraction of their pelvic floor muscles. The goal is for your child to learn how to consciously relax and contract their pelvic floor.
This is helpful for children who have incorrect toilet habits such as "stuttering" urination. Biofeedback training should take place over several weeks under the supervision of a specially trained physiotherapist.
My son, 6 years old, is a very bright boy. When cycling and playing football, he's constantly on the go. He also knows a lot about lizards and fish. Before going to sleep, we always read books about them together. But, for some time now, a certain tenseness has been creeping into our evening ritual – because my son sometimes wets himself at night. He also hasn't wanted to sleep over at his grandparents’ place any more, because they put pressure on him because of this.
![[Translate to English:] Lachende Kinder auf einer Schaukel freuen sich, dass sie das Einnässen überwunden haben.](/fileadmin/_processed_/c/f/csm_Einnaessen-beim-Kind_Illustrationen-3_4d36e4b506.png)
He'll be starting school soon, so we visited our paediatrician. First of all, the paediatrician gave my son the all-clear that there was no physical damage and sent us to a urologist. After an extensive physical examination, he asked many questions and had my son keep a bladder diary.
6 weeks later, we had the next appointment. When evaluating the bladder diary, the doctor noticed that my son also goes to the toilet frequently during the day (up to 13 times) and that the amount of urine stored in the bladder was too small for his age. I also noticed that he often runs very fast to the toilet. In addition to many behavioural tips, the doctor suggested urotherapy and, on the next visit, recommended taking a medicine that increases bladder capacity.
My son has been taking this medicine for 8 weeks now and we notice that he doesn't have to go to the toilet so often during the day, and especially that he doesn't have to rush so much any more. We've just finished the bladder diary, which we have to take to the doctor next week. Now my son goes to the toilet only 8 times a day and can already store 30 ml more urine in his bladder.
And we haven't had a night-time "incident" in four weeks. I'm glad we got help from a doctor. Now we can relax and read the books before we go to sleep and my son can enjoy staying over with his grandparents again.
Specialist groups
Information for specialist medical groups
Would you like to know more about the treatment of enuresis and the appropriate medication? Click here to go to the specialist group area:
Services
Free downloads and services
APOGEPHA Arzneimittel GmbH offers a downloadable bedtime story and child-friendly service material to ensure that your child doesn’t lose out on fun during the often lengthy treatment of enuresis.
Bedtime story
To prevent the problem of enuresis from dominating your everyday family life and your child from going to bed with the fear of wetting during sleep, we offer you a downloadable bedtime story.
You can listen to it together with your child before bedtime to create a relaxed atmosphere.
![[Translate to English:] Hilfe bei Einnässen bei Kindern: Zeichnung eines Jungen im Bett.](/fileadmin/apogepha/werbung-ausserhalb-homepage/csm_einnaessen-beim-kind-gutenachtgeschichten_f3efdc3c92.png)
Download the fairytale "The Steadfast Tin Soldier" by Hans Christian Andersen as an mp3 file from here:
The fairytale "The Steadfast Tin Soldier" has been made available by www.vorleser.net.
Downloads
More downloads
FAQ
Enuresis: FAQs on incontinence in children
There are various approaches to treating enuresis. These include behavioural therapy, reward systems, medication and biofeedback. It is important to be patient and support the child. Scolding or punishing usually worsens the situation.
There can be many reasons for enuresis in children. It is often caused by delayed development of bladder control. However, urinary tract infections, congenital malformations, psychological stress factors or hormonal imbalances are also possible causes.
Children can wet themselves again even after being toilet trained. Possible reasons for this are stress, changes in everyday life, infections, constipation or other medical conditions. Relapses are not uncommon and are usually temporary.
A child is considered to be incontinent if, at the age of 5 years or older, he or she urinates uncontrollably at least twice a month, either during the day or at night, and for a prolonged period of time.
Incontinence during the day is normal in children up to the age of about 4 to 5 years. If it persists beyond this, a doctor should be consulted to investigate possible causes.
A child should have full bladder control by the age of 5. Treatment is recommended if a child over the age of 5 is still wetting. Give your child a little more time and consult a paediatrician if problems persist after the age of 5.