Chiropractic Management of Nocturnal Enuresis (Bedwetting)
You probably know of a child who deals with the stigma of being a bed-wetter. It’s trying not only for the parents, interrupted sleep and washing sheets every day, but also on the child. They are afraid to spend the night away from home at a friend’s, at camp or with grand-parents. The constant threat of soiling the sheets and waking up wet can be very troublesome. In this article I intend to lift the covers on this subject and discuss how chiropractic care may be able to end the nightly stress for the patient and the parents alike.
I recently worked with a sweet 11 year old girl who had been wetting the bed 3 to 5 nights a week since diapers. After 4 visits in my office over 1 month, she was dry and has been for the last 2 months! Another little boy, 7 years old, is brought in by his mother when she knows his back is “out”. He wets the bed. I’ve adjusted him after slips on the wet tile and falls from his bike. One adjustment is all it takes to get him dry again!
I know I’ve had great results treating the issue in my office, but I wanted to check the literature to see what’s been done. I discovered a study published in the Journal of Manipulative and Physiologic Therapeutics in October of 2009. It followed 33 children ages 3 to 18 through chiropractic care for nocturnal enuresis and for a year afterwards. 66% of participants were still dry 1 year after beginning care!
The first thing parents need to understand is that it’s not their children’s fault. In the past, psychologists tried to pin the condition to some type of mental health problem in which the child is acting out against the parents. This is simply very rarely ever the case. The most common culprit is structural and resulting neurological distress from what chiropractors call subluxation complex. If you are a regular reader of my column then you already know what a subluxation is. But for my new readers; a subluxation is the loss of proper position or motion of a spinal joint. These misalignments can have a far-reaching effect by irritating the nervous system – the brain, spinal cord and spinal nerves. The nervous system controls and coordinates all the other systems of the body; therefore, if a subluxation is present, the affected individual will not be able to function at their full potential.
Just how does the subluxation complex cause nocturnal enuresis? There are several regions within the spinal column that provide nerve supply to the bladder and sphincter muscle which opens and closes it. First we’ll discuss the phrenic nerve and its role in the condition.
The phrenic nerve is the nerve that supplies the diaphragm, our breathing muscle. It arises from three different levels of the spine, in the neck at cervical vertebrae 3, 4 and 5 (C3-C5). The phrenic reflex is a reflexive action that takes place when carbon dioxide levels in the blood get too high. Children tend to have a decreased, or under-developed, phrenic reflex, which means that their brain is slow on picking up the fact that they have a higher than optimal concentration of carbon dioxide in their bloodstream, especially in a deep sleep. A high concentration of CO2 causes smooth muscle tissue to relax. The sphincter muscle that controls the opening and voiding of the bladder is composed of smooth muscle fibers. So…as your child sleeps like a zombie, their CO2 concentration raises and the smooth muscle fibers are more apt to relax and…they waken in a wet bed!
Now 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 frequently bed-wetters. In some children the phrenic reflex is simply slow to develop. In fact this slow development does at times run in families (hereditary factors), but in other children this reflex is disturbed by a vertebral misalignment or a subluxation.
There are other regions of the spine that play a role as well. Three nerves in the pelvic region are responsible for carrying signals from the bladder to the brain to let it know the bladder is full. These nerves also carry signals from the brain to the sphincter muscle at the base of the bladder to let it know when to open and drain the bladder. These nerves include the Hypogastric nerve, which originates in the middle back from the tenth thoracic through to the second lumbar levels, (T10-L2). The Pudendal nerve which originates in the lower back from the fourth lumbar level of the spine through the fourth sacral level, (L4-S4) and the Pelvic nerve from the tailbone region, the second, third and fourth sacral nerve roots, (S2-S4).
It’s important to understand that while the sacral segments are fused together in adults into what we know as the sacrum, in children, the sacral segments of the tailbone are still freely moveable. They don’t finish fusing together until the age of 25. This makes those important sacral nerve roots vulnerable to roughhousing or to slip and falls in children. Subluxations in this area will play a role in the condition.
Unfortunately, there is really no way to tell if a child is simply slow in the development of the phrenic reflex, or if a subluxation is the direct cause of the problem. Chiropractic examination can help pinpoint spinal problems, but the only real way to see if chiropractic care will help Nocturnal Enuresis is to actually try it. A series of chiropractic adjustments will generally determine whether or not chiropractic care will be of help. Some cases respond spontaneously with instant cessation of the bed wetting problem. In difficult cases it is sometimes wise to bring the child in for a series of spinal adjustments.
Additional strategies to employ when working with bed-wetters include:
1. During the day – have your child note when they need to void, then, try to hold it. Have them wait until the 2nd strong urge to go, then…
2. While voiding, have them start and stop the flow by contracting the muscle that opens the bladder. Have them perform this exercise 2 or 3 times during each bathroom break.
These two exercises help train the nerve pathways of both sensation that the bladder is full and the muscular control of the opening/closing of the bladder.
3. Limit the amount of water intake after dinner and before bedtime to no more than 8 ounces.
4. ½ hour before the time they are to be asleep, have them go to the bathroom and void the bladder. Then keep them occupied with a quiet activity such as reading, a board game or watching TV. After ½ hour, head to the bathroom to void again. (The bladder tends to fill the fastest when it’s empty.) Then it’s off to bed.
If all this fails to get us the desired result, the last resort is to take your child off milk. Research shows that milk is one of the most common allergens. Eosinophils, (the type of white blood cells associated with allergies), have shown up in the lining of the bladder in children who are bed-wetters.
Hopefully, understanding the condition and recognizing that your child is not aware that they are wetting will lead to less stress and anxiety in the house. Chiropractic care should be evaluated as an option in the treatment of Nocturnal Enuresis. Have your child properly evaluated by a chiropractor like myself who specializes in the unique needs of children.
Dr. Donohoe is a family practice chiropractor who specializes in the unique needs of pregnant women and children. His office is located at 41880 Kalmia St., Suite 135 in Murrieta. He can be reached at 951-677-6500 or through his website at www.DonohoeChiropractic.com.