The potty line
Doctors meeting in the bay area posit bed-wetting as something remedied with behavioral modification, rather than waiting it out.
By JOHN BARRY
Published March 13, 2006
CLEARWATER -- In all, they numbered nearly 200: pediatricians, urologists, psychiatrists, family doctors, psychologists, surgeons, nephrologists, RNs, distinguished leaders in their fields. They hailed from far-flung practices in Hong Kong, Belgium, Germany, Britain, Canada and Colombia as well as the United States.
For two crowded days this month at the Sheraton Sand Key, they plowed through eye-glazing uroflow measurements, pressure flow studies, biofeedback and ultrasound therapies, exotic sacral nerve stimulation surgeries and simple daily "bladder diaries." They toted gift boxes of bran cereal and taped electrodes to themselves during lunch to test their "pelvic floors."
They did so with open brio, a desire to leave nothing out. They even turned down the lights and hypnotized themselves.
This was an event many people who care about children had been waiting for: a focusing of medicine's best minds on an affliction that tortures one of every 10 6-year-olds but doesn't get talked about much.
"Until recently, bed-wetting has been in the closet. That's why this is so fantastic," said Naida Kalloo, a pediatric urologist from Children's National Medical Center in Washington, D.C. "It's always been a dirty little secret."
So much so that in one study of children ages 5 to 11, two-thirds didn't know they have bladders.
The International Children's Continence Society and the University of South Florida rounded up the doctors. Getting all the different specialists in one room has long been a mission for the conference's co-chairman, Yves Homsy, a pediatric urologist with the Children's Urology Group in St. Petersburg and Tampa.
"Unfortunately, one problem with one treatment is not the reality," he said. "There are many treatments, and a tug of war between many specialties, each with its own approach. We had to find a way to address all these approaches and put them together."
Bed-wetting has been around as long as beds, though the term is a misnomer. Children who wet the bed at night often wet themselves during the day at school, in minimal amounts, and their clothes usually dry without anyone noticing. Both night and day miseries must be addressed as one.
The affliction is usually hereditary, and prevalence is the same worldwide. No race is spared. Neither gender is spared. It has often been treated as more of a phase than a medical problem. Most kids grow out of it. Many general practitioners tell parents that.
But simply growing out of it can take six years or more. Baseball Hall of Famer Mickey Mantle wet the bed until he was 16.
For decades, the "Michael Landon story" typified the kind of emotional damage that can beset children whose parents try to shame them out of bed-wetting. The late actor had made the issue a personal cause and directed a TV movie on the subject. He had been a bed-wetting child whose mother made him wear parts of the wet sheets to school.
Abusive stories like Landon's are far less common today. But many other everyday conditions in children's lives make bed-wetting as resistant an affliction as ever.
Speaking during a lunch break at the Sheraton, Kalloo painted a typical scenario:
"A child goes to a school where the bathrooms have open stalls or they're filthy, or the teacher discourages children from using the bathroom. It may be that the child needs a hall pass, or a buddy to go with him, or he has to write his name on the blackboard every time he goes.
"So the child doesn't drink anything while he's at school. When he gets home, he's dehydrated. He guzzles. But he doesn't drink water, he guzzles sugary drinks like Coke. His mother keeps buying sugary drinks because that's what she drinks, too. You can have a 300-pound mother, and a 200-pound kid. Everything they eat or drink comes out of a package or a bottle.''
Packed with sugar, caffeine and sodium, soft drinks can throw children's metabolisms out of whack and increase their need to urinate in the middle of the night. Junk food diets, Kalloo also said, can lead to other complications.
"Constipation is a big part of it,'' she said, "but the parent is probably constipated, too, and thinks going once a week is normal.
"But by the time that kid goes to bed every night, he's loaded. I tell the parent, 'You have to change, too.' Sometimes, they say, 'I'm not going to make the whole family suffer.' "
She tells parents to start with the basics: Make sure their children are drinking water and using the bathroom at school, so they won't have a problem later that night. Most times, unless there's a physical or emotional complication, it's as simple as that.
About 70 percent of bed-wetting cases are resolved by using an alarm that wakes the child in the middle of the night.
But failure occurs if the wakings are discontinued too soon by tired parents, who must also get up to walk the child to the bathroom doctors suggest 16 weeks. If the child is never fully awakened, but merely carried sleeping to the toilet, it's a waste of time. Bed-wetters tend to be deep sleepers. It takes 120 decibels, the sound volume of a chain saw, to wake them. Or there may be physical problems like bladder infection, or complications like emotional trauma or attention deficit.
One failure compounds more failures.
"We've done studies about self-esteem and bed-wetting," said Johan Vande Walle, a professor of pediatric nephrology at Ghent University Hospital in Belgium. "The self-esteem problems are more related to treatment failures than they are to the actual bed-wetting.
"That's why before starting something, you want to have a good chance of success. You want to go to an M.D., who tells you why it's happening. If you can rule out things like too much urine production, or a bladder abnormality, you know you are in a good place to begin.
"You don't want to just go to the Internet and see if something there works. For the child, the risk of repeated failure just gets higher and higher."
For those with physical or emotional complications, treatments may involve pediatric urologists (about half their cases are incontinent children), nephrologists, rehabilitational therapists, psychologists or psychiatrists. Sometimes drugs are prescribed, sometimes not. Surgery is a rare option. There is a lot of new technology.
"It is new, but is it necessary?" asked Jens Christian Djurhuus, chairman of the Institute of Clinical Medicine at Aarhus University Hospital in Denmark.
"Technological developments provide an increasing amount of options," he said. "The investigational setup on one hand should be more comprehensive . . . (but) conducted with minimal invasiveness.
"Cooperation of the child is of paramount importance."
At the end of an eight-hour run of exhibits and discussion (with three bathroom breaks), a speaker on alternative medical therapies asked the doctors: Who wants to be hypnotized?
About 100 hands went up.
So they turned down the lights. The big PowerPoint projection screen showed wiggly blobs. Soft music played.
"Count one to 10 and take a deep breath after each number," said Dennis Hoover, senior partner in the Children's Urology Group.
"Deep breath.
"Relax.
"Deep breath.
"Relax."
It got very quiet.
"Focus on your feet, focus on the muscles of your toes."
Urologists, pediatricians, psychiatrists, psychologists, all focused on their toes.
"Excellent," Hoover said softly.
"Now imagine a flight of stairs. There are 10 steps. They lead to two large golden doors that open into the most beautiful place in the universe.
"Count the steps. The first step. The second . . ."
Eyes closed, doctors climbed all 10 steps.
"The doors open."
These international experts looked happy, blissful. You knew what they must be picturing:
Gold faucets. Gleaming porcelain. A soothingly powerful "whoosh."
Child back in bed. Dry.
John Barry can be reached at (727) 892-2258 or jbarry@sptimes.com.