Bed-Wetting aka Enuresis

Many times parents actually blame their child for urinating in bed. They believe this is a behavior intended to get back at them for something. Nothing could be farther from the truth. Children do not willfully wet their beds. The anguish of the young child who wets the bed at night is a personal nightmare! He cannot go to camp, stay over night at his friend's house, or go on trips without the constant fear of the wet bed in the morning. Psychologically the bed wetting child bears a burden, but so does the mother. The constant changing of bed linens is certainly a chore she would like to put behind her.

Is there anything that can be done for bed-wetting? This is a question parents sometimes ask of the chiropractor. Usually, this question is asked when other methods of treatment have been tried and found ineffective.

Bed-wetting (enuresis) is another of the many reasons why parents bring their children to see the chiropractor. What can the doctor of chiropractic do for this problem? The phrenic nerve and the sacral nerves must be addressed.

The phrenic nerves come out from between the 3rd, 4th and 5th cervical (neck) vertebra. Subluxation of these vertebrae can cause nerve interference, which can disturb the proper function of the phrenic reflex and cause bed wetting. Chiropractors correct vertebral subluxations, and thus influence the return of proper nerve function.

Most children wet the bed for the first few years of life, but by the age of 4 to 5 years old, most children should be able to establish proper bladder control. Enuresis refers to the inability of a child to establish this proper bladder control resulting in either daytime or nocturnal involuntary urination.

Just what causes Nocturnal Enuresis (bed wetting) and is there any help for this problem? Yes, there is and to explain why children wet the bed we must understand a spinal reflex called the phrenic reflex. You see, when a baby sleeps, its respiration (breathing) gets slower and slower until a mother might bend over the crib and be concerned, Eventually the breathing normalizes.

This pattern of breathing goes on throughout the night. As the infant sleeps respiration continues to slow down until the carbon dioxide in the body gets high enough to trigger a breathing mechanism called the phrenic reflex. This mechanism stimulates the large muscle of breathing, the diaphragm, to increased activity and the normal rhythm of breathing returns. If this mechanism is not working correctly, the carbon dioxide continues to increase and when it gets too high, “smooth” muscles begin to relax. Smooth muscles are the involuntary muscles of the body, those that function without our conscious control. The valve at the bottom of the urinary bladder is a smooth muscle, and when it relaxes the bladder simply does not retain its fluid, you might say it leaks throughout the night.

This is normal for infants, as the phrenic reflex is not fully developed at birth, but as the child grows, the reflex matures and soon most children can sleep all night and retain their urine. This reflex develops more slowly in boys, in the same way that boys mature sexually later than girls, and thus boys are more frequent bed wetters.

Primary enuresis occurs in a child over five years of age, who has never been able to establish proper bladder control. Secondary enuresis is the diagnosis for the child who has been able to establish proper bladder control, but who has since lapsed back to wetting the bed. Occasionally a pathological mechanism such as neurogenic bladder may be responsible, but usually no such cause can be identified.

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. A bed wetting child is typically a very active child, often playing to exhaustion and when at sleep, sleeping in a very deep slumber with slow respiration. The child's sluggish, or immature phrenic reflex allows too much carbon dioxide to build up in the system. The bladder valve (sphincter)relaxes, and the bladder leaks throughout the night. No, the child does not voluntarily urinate in bed. The urine simply runs out involuntarily while he sleeps.

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.

Bladder Anatomy and Physiology
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 Sacrum
The 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. 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.