Bedwetting is incredibly common—but it’s also often misunderstood, leaving families feeling frustrated, confused, or even ashamed. In this episode, pediatric urologist Dr. Andrew Kirsch joins Dr. Jessica Hochman to demystify nighttime wetting and offer real, evidence-based guidance for parents.
They explore:
- Why bedwetting happens (hint: it’s not your child’s fault)
- When to worry and when to wait
- The truth about bedwetting alarms and medications
- A promising new non-drug device called Soluu that could reshape how we treat bedwetting
Whether you're in the thick of it with your child or just want to be prepared, this episode offers clarity, compassion, and plenty of practical tips.
Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.
For more content from Dr Jessica Hochman:
Instagram: @AskDrJessica
YouTube channel: Ask Dr Jessica
Website: www.askdrjessicamd.com
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Tiny Health using code: DRJESSICA
Do you have a future topic you'd like Dr Jessica Hochman to discuss? Email Dr Jessica Hochman askdrjessicamd@gmail.com.
The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.
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Transcript
Episode Transcript
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Unknown (00:00):
Hi everyone, and welcome back to your child is
(00:02):
normal. I'm Dr Jessica Hochman,and today we're talking about
one of the most common and oftenconfusing pediatric concerns,
and that is bedwetting. My guestis Dr Andrew Kirsch. He's a
pediatric urologist. He's aresearcher and the co author of
the new book, The Ultimatebedwetting Survival Guide. With
over two decades of experience,Dr Kirsch brings both clinical
expertise and practical adviceto families that are navigating
(00:24):
nighttime wetting. We talk aboutthe real causes of bed wetting,
how to avoid blame andfrustration and what treatments
actually help. Dr Kirsch alsotalks about an exciting new
device and development thatoffers a fresh and hopeful
approach to families that arelooking for alternatives to
medication and traditionalbedwetting alarms. If you've
ever wondered when to worry orhow to help your child stay dry,
this conversation is for you,and also as a reminder. If
(00:46):
you're enjoying this podcast, Iwould be so grateful if you
could take a moment and leave afive star review wherever it is
you listen to podcasts, greatreviews help other people find
this podcast, which really makesa difference in helping this
podcast grow. Now on to my talkabout nighttime bedwetting with
Dr Andrew Kirsch. DrKirsch, thanks so much for being
here. I'm looking forward tohaving this conversation with
you. Thank you. It's great to behere. So tell everybody a bit
(01:07):
about yourself. What do you dofor work, and
tell us then about the book thatyou wrote. I'm a pediatric
urologist, so we're a smallgroup. There's only about 400 of
us in the country, and I've beena full time urologist at George
urology, which is the nation'slargest private practice. And I
wear several hats, so I atEmory, that's my academic track,
(01:29):
where I am professor and chiefof Urology. I'm also chief
Urology at children's healthcare of Atlanta, which is the
largest children's healthcaresystem right now in the country,
and I am, as I said, also atGeorge urology, where I am the
medical director. So those arethe hats I wear, but I'm also an
(01:49):
entrepreneur, a writer, a parentof three kids and a grandchild,
a father of one granddaughter.
So clearly, you're a busy man,and there's a lot of things that
you could spend your time doingso I'm so curious what inspired
you to write a book aboutbedwetting. It's
been something where afterpracticing for 25 years and
(02:09):
seeing literally 1000s ofpatients, you get to hear all
their stories, and a lot of thestories have to do with sleep
deprivation or not being able togo to summer camp, anxiety, the
feeling that there's got to be abetter way of treating these
kids. So one of the things I dida couple of years ago was to
(02:31):
survey pediatricians how theymanaged bedwetting. And what we
learned in our survey is thatabout 50% of these families were
unaware of the multitude oftreatment options that are out
there. Not that they're great,but they're also unaware of
these options. And sopediatricians were surveyed with
(02:53):
a 24 Question voluntary survey,just asking them, is that
wedding important? How manypatients do you treat how
experienced you are? And welearned a lot, and hopefully
we'll get to some of thoseanswers as well.
It's true that bed wetting is socommon, and I think, for myself,
as a pediatrician, you're right.
It comes up a lot in practice,and I know that most kids grow
(03:15):
out of it, so you want to makesure that parents are given the
best direction? Yes, it's truethat there's biology involved,
but also there are options thatI think we could make better for
families. Yeah, absolutely.
And the impetus for writing thisbook, and my co author, by the
way, is ubira jaraborosso, andhe's an international leader in
(03:36):
treating all kinds ofincontinence issues. He's the
secretary of the InternationalChildren's cotton society, and
he's co author of the book, aswell as one of my business
partners in a company that wedeveloped that I'll talk to you
about as well.
That's great. I think withBedwetting, it's an embarrassing
topic to discuss freely, and soI hear it in my office. I know
(03:57):
how common it is, but I thinkfor parents listening, they may
not recognize how prevalent itis and how normal it is. So
thanks for having thisconversation. I am sure that's
gonna help many families. Thankyou.
So first, what I would like totalk about, and you
talk about this in your book, iswhat we call primary nocturnal
enuresis. Can you describe whatthat term means? Exactly sure.
(04:19):
Sowhat primary nocturnal enuresis
refers to are kids that havereally never been dry at night.
So they've never had a six monthperiod, for example, where
they've been dry. Because ifthere was a six month period,
that's when we call it secondaryenuresis. Okay, so enuresis can
be secondary to other problems,whether it's going to be
(04:41):
diabetes or it's going to bebowel and bladder dysfunction or
a neurologic problem, those arethe ones we get a little bit
more concerned about, and wehave to work up a little bit
more thoroughly, but primarynoctulinary system makes up the
vast majority of the patientsthat we see. You.
And just to shine some light onthis, how common is it? Exactly.
(05:04):
Sobed wetting is extremely common.
So if you just look at the worlddata, 200 million children
suffer from bed wetting. If youlook at kids that are around age
five, where we start to make thediagnosis, that's probably about
15% a higher incidence in boysthan girls, because there is
delayed maturity in boys. Askids get older, by the age of
(05:26):
seven or eight, that numberdrops to about five to 10% so
the average age of our referralsfrom people like you, the
pediatrician, is probably nine,and there's as they get older,
about 3% of 11 or 12 year olds,and then it drops to about 1%
and even in adulthood, 1% ofadults have bed wedding,
(05:49):
something they don't think abouta lot, but
that's a lot of people, and thisis a neurologically normal
people. Theseare primary nocturnal enuresis.
They're still waiting for it togo away. And you know when you
first saw them, when they werefive or six, and you said, Don't
worry, it's not much of aproblem. It all goes away when
it doesn't in the smallpercentage, you have to start
thinking about some othertreatments. We'll get to
(06:12):
treatments. A lot of them aren'tas effective as you may think.
And can you comment on familyhistory as well. Sure
there is a genetic component tonocturnal neurosis. So if one
parent has bed wetting, there'sabout a 40% chance that their
child will have bed wetting, andif both parents have it, it goes
(06:33):
up to about 75 or 80% and whatis interesting is that you
should always ask the parent,how old were you when you
stopped wetting your bed,because that correlates with the
child's bed wetting cessation aswell.
So in this situation, the Applereally doesn't fall far from the
tree.
That's correct. It doesn't. Butit could be very helpful,
(06:54):
because they bring thatexperience to their child and
they normalize it, and that'svery important.
I do find it comforts the childwhen I can talk about it with
families in the office, and amother or father will relate to
the child and say, for me, itlasted till 910, years old. And
I do think that does provide alot of comfort for kids. Yeah,
everybody'sindividual, right? So you don't
know what they're experiencing.
(07:17):
I could tell you that I saw oneof my anesthesiologists kids a
couple weeks ago, and I saw herin the operating room, and I
said, How'd the appointment gofor your child? And she said she
was kind of covering her face upwhen she was leaving the office
because she was so embarrassedthat people would see her
because of this problem, notrealizing that we see a
(07:39):
multitude of other problems, butthey don't really know what's in
the head of a child, and theirexperiences, their relationships
with their siblings, theirparents, their friends, they're
all so different, so everybodyhas to be treated as an
individual.
Absolutely, Ido think, though, it's
reassuring to hear that there'sa genetic component, because I'm
interested in the child beingreassured that it's not their
(07:59):
fault.
Absolutely, that's probably theone kind of myth that will lead
to the most damage, if you will.
We see a lot of kids that alsohave psychological issues. They
deal with anxiety, depression orthey have that problem. In
addition to this, what camefirst certainly doesn't make it
better if they started off withanxiety, and it's so important
(08:21):
to address that as well.
And it's interesting that youpoint out that you don't
typically define primarynocturnal enuresis until five
years old. So if I'munderstanding correctly, if a
kid is four years old andthey're wetting their bed at
night, parents really shouldn'tbe alarmed or concerned.
You know, as well as I do,you're going to see a four year
(08:41):
old whose parents are veryconcerned because they've had
other kids, maybe a daughterthat was toilet trained and
perfect at age two, and they'vedealt with three more years of
diapers, and it's not normal forthem. So you do have to
normalize it, and sometimes youeven have to offer treatments to
these families, just to givethem something to work towards,
(09:05):
working towards hope is areasonable goal when dealing
with this problem, absolutelyand I completely agree. I do
find that comparison in thissituation is very prevalent,
very often. I hear a family talkabout one child, one child was
trained at two, two and a half,and why is it taking so long for
the other child? And I do thinkit can be frustrating for
family. So this is a goodreminder Absolutely. Now, the
(09:26):
big question I have is, ofcourse, there are different
scenarios for different kids,but do we know the main
physiologic reason why bedwetting occurs? Is it because
they're deep sleepers? Do theyhave a small bladder? Do we know
in most situations? Why does itactually happen?
Yeah, and we talked a little bitabout the genetics, but the
(09:49):
physiology is multi factorial,for sure. In the most basic
sense, there is a disconnectbetween the brain and the
bladder, so you should be. Ableto sense when your bladder is
full, get that message to yourbrain, get up and go to the
bathroom. So kids that have bedwetting are very deep sleepers.
(10:10):
Amen, all of them are and soit's a sleep disturbance. Their
arousal threshold is elevatedcompared to otherwise normal
children. So that has a lot todo with it. It could also just
be that they make more urine atnight, so nocturnal polyurea,
they may not have enough hormonethat's responsible for holding
(10:31):
on to urine, anti diuretichormone, but that doesn't
explain all of them. That's whysome of the treatments, like
medications, are not 100%effective, the way less than
that. And so it ismultifactorial. It could be
related to other stressors intheir lives. And we talked a
little bit about anxiety,depression, and what these kids
(10:52):
are feeling. If those thingsaffect their sleep, the
medications they take affecttheir sleep, well, that's also
going to make their bed wettingworse, and that's why a lot of
the drugs are ineffective,especially in kids with ADHD,
and you have to start looking atother ways of treating it. That
was something that I reallyenjoyed learning in your book,
because of my experience whenI've given the medication. For
(11:13):
some kids, it is very effective,it's very helpful, but for other
kids, it's not helpful. So thatwas an interesting point that
you brought up in the book thatI appreciated learning about,
yeah,one of the examples we give in
the book, you might notice thatsomebody has hyperactivity, or
somebody's in a divorced family,and they with the mother, and
they're with the Father, andthey do different things when
they're at different houses. Andif you look at that, and you
(11:34):
look at what the differenttreatment options are, it's no
wonder that some of thesetreatment options are
ineffective because thescenarios change so often. In
your opinion, I know there's avariety of reasons about why
bedwetting happens, but wouldyou say that in most situations,
it's probably because of adevelopmental lag that where the
brain and the bladder aren'tquite synced up yet.
(11:57):
I think that makes the mostsense. But as I said, if you
have treatments and one of themhas the highest success, you
would think that addresses themain physiology, but the gold
standard is a bed wetting alarm,and the bed wetting alarm is
about 50 to 70% successful. Andsome of the success may be on
the timing of the kid aging. Soit's not always clear what it
(12:21):
is. Not everybody understandsthat you cannot make your
bladder contract. So we talkabout parents getting frustrated
with their child and maybe evenblaming their child for being
lazy, or you're doing this onpurpose, and that,
unfortunately, I try to tellpeople that you could only make
(12:43):
your bladder empty by relaxingyour sphincter and bedwetting
actually has no effectwhatsoever on your ability to
hold your urine with your pelvicmuscle which makes up your
sphincter and you can't makeyour bladder contract, right? So
at night when your bladdercontracts, your sphincter is
relaxing in response to thatmechanism. Okay, it's not
(13:05):
because you relaxed it. You haveno control of it whatsoever. I
think that's it helps themunderstand a little bit about
why it's not their child'sfault.
I like this point because Ithink it's so important for
parents to trust that the kidisn't doing it on purpose in
most scenarios, yeah, they'resleeping. So it's kind of hard
to blame a child who's sleepingfor doing something voluntarily.
(13:28):
But this problem also happens inkids that nap during the day, so
it is a sleep issue for sure.
Now while we're on the subjectof myths and bed wetting. Can I
also ask you, because this issomething that my mom and I talk
about. My mom really believes inwaking a kid up, having them go
pee after they've gone to sleep,to help them get over being a
(13:50):
bed wetter. Do you find there'sany validity to having a child
sleep, waking them up to go tothe bathroom and then putting
them back to sleep? Does thatmake them overcome bed wetting
any faster.
So there's no evidence tosupport that. And some of these
kids wet multiple times a night.
So we talked earlier about thebrain and bladder connection and
sleep deprivation. So you add tothis whole process, sleep
(14:15):
deprivation, because now theparent and the child are both
getting up, it's going to affecttheir day the next day. So timed
awakenings are not really partof the behavioral therapy that
we talk about in treating bedwetting. So behavioral therapy
would be limit your fluidsbefore you go to sleep and make
sure you empty your bladder.
(14:38):
That's all you could really do.
We do those things. And if youlook at the largest study that's
ever been published, 6000patients, a Cochrane Review, it
looked at all the differenttreatments. And if you look at
behavioral therapy, it had an18% success rate. And as a
pediatrician that you're tellingevery single one of your
families to do that. We all doit because maybe it'll make the
(15:00):
amount of bed wetting a littlebit better. But there's really
not a lot of strong evidencethat actually works. There is
evidence from Sweden that ifkids have timed voiding during
the daytime that they're reallyconscientious about emptying
their bladders, it has no effectwhatsoever on bed weight. That's
(15:24):
really interesting, becauseyou're right. I've always been
taught about the importance oftimed voiding, so that means
going every two to three hoursduring the day. And you're
telling me that the time voidingactually doesn't make a
difference.
I mean, if you look at thenumbers, it's a placebo effect.
18. Interesting, yeah. But wedefinitely all do it. And I
think avoiding habits is goodfor other reasons. I may not
stop bedwetting. It might makeit a little bit less in terms of
(15:46):
quantity, but it's not really avery effective treatment.
Just explain to me that you wantto think about the bladder as a
rubber band, and if it'sstretched too much during the
day, then it might not work aswell at night. So just like a
rubber band, if it's continuallystretched, it loses its
elasticity, and it might notrespond as well to the stretch,
but if there's not the evidenceto back it, I can see that
that's interesting. Ithink what you're saying is true
(16:08):
for daytime problems orsecondary enuresis. So we see a
lot of kids with bowel andbladder dysfunction. Remember,
the pelvic floor in the frontmakes up your sphincter, which
you can't control in your sleep,and it also makes up your your
rectal sphincter as well. Sokids that have pelvic floor
problems tend to hold theirurine and hold their stool, and
(16:31):
the treatment of that is fullon, bowel clean out timed, time
voiding, like you described. Andif you don't do that, then you
get bladder instability. Sobladder instability will cause
some of the secondary enuresis,or what we call polysyptomatic
poly means they have daytimeproblems, urgency, frequency,
(16:51):
constipation, sometimes fecalincontinence, if they have other
issues. And those all could bemanaged pretty well during the
daytime. And so what you talkabout is overdistent of the
bladder, you know, that couldcertainly cause problems. And we
do see some kids where they havesuch bad, overactive bladder
(17:12):
that might actually make theirnighttime worse if they're
having bladder contraction. Soyou talk about using first line
therapy, which would includesomething like DDAVP or
vasopressin. If that's notworking, or maybe it works a
little bit, you could alwaysthrow on a medication like an
anticholinergic, like oxybutynor ditropan, which will then
(17:36):
relax the bladder, and that hasbeen shown to improve the
results with kind ofpolytherapy, and those two
together, DDAVP and oxybutyn orditropan, are the ones that we
may use in combination in caseswhere one is not effective. The
problem with ditropan, ofcourse, is side effects, and
(17:57):
that includes constipation. Sonow you're in this vicious cycle
of having bowel and bladderdysfunction during the day that
you treat with something thatmakes it worse, making the
constipation harder to treat.
And that's why I mentioned thatwe very aggressively treat
constipation these children,because our therapy sometimes
(18:18):
leads to it.
I really appreciate thatdistinction. That makes sense,
that the timed voiding thebladder exercises helps with the
daytime urination when yourbrain is working and alert and
you can tell when you have to gothe bathroom, as opposed to
being in a deep sleep whenyou're not aware. That makes
total sense.
And we also did a survey ofparents asking them about their
(18:39):
school bathroom policies,because one of my colleagues,
years ago wrote an article inthe Journal of Urology that was
picked up by the New York Timesthat basically says schools are
creating bowel and bladderdysfunction, and if you think
about it, they're lining up allthese kids when they're little.
The kids may or may not need togo to the bathroom. That's your
(18:59):
time to go, and then they havecertain times where you can use
the restroom. So what we'velearned is that in doing a
survey of the parents, and we'vesurveyed probably three or 400
of them now, and we found outthat you have a certain number
of times where you could use thebathroom, if you overuse that,
(19:20):
then that could be used againstyou. And what is really
shocking, and this happenedprobably less than 5% of the
time, but they were actuallyrewarding kids for not using the
restroom. And so think aboutwhat we tell them to do, like
you mentioned earlier, the time,voiding and making sure they
drink and do everything else totreat their daytime issues. The
(19:41):
schools are reversing thatcircumstances. You
can understand why, because Ithink it's hard for teachers,
right? If they're managing aclassroom of 30 kids, and if
they're all going to thebathroom at different times,
it's just not practical. So butI can also understand that if a
kid doesn't have to go andthey're being told to go, that
can be confusing to the body.
Yeah, yep. Absolutely. The otherthing that I hear a lot from
(20:01):
kids is that they don't likegoing to the school restrooms
because of the way it smells, orjust because of the general
atmosphere. They don't want togo while they're at school. And
I think that's another issue aswell for little kids. Yeah,
the other thing is, a lot ofbathrooms are dirty. They don't
want to use them, and they willjust hold the entire day. A lot
of these kids are running back,either from the bus stop or out
(20:23):
of their parents car, at pickup,running back to their house,
holding themselves, trying notto urinate, because they just
held all day.
It's true. There are so manykids they do not go all day at
school. When I ask them aboutit, they don't like anything
about their school bathroom theway it smells. They don't want
to go number two in public, ormaybe their friend might find
out they don't want anything todo with their school bathroom.
(20:44):
So I don't know how to fix thisproblem, but I do agree it's a
problem. Yeah,it's a big problem. I'm on the
board of the American Academy ofPediatrics in Georgia, and one
of my projects has been schoolpolicy. So it's up to interest,
and hopefully we'll get sometraction on it. That's
great. That's great. Okay, sofor parents that are listening,
and maybe they have a childthemselves who is wedding at
(21:07):
night, I want to go through thelist of practical advice to give
them and practical things tothink about. So we talked about
limiting fluids beforebed. What does that look like?
Yeah, limiting fluids isprobably something you do like
right after dinner. It reallydepends on bedtime. And you
could talk about limitingfluids, but you also have to
(21:29):
talk about sleep hygiene and howyou wind down before you go to
bed. If these kids are drinkingand they're playing video games
right up to the time they go tosleep, they're getting over
stimulated, that's also not goodfor them, so that will affect
their sleep cycle. You shouldlimit fluids, but there are
other things that you need to doin conjunction with that all
surrounded around that conceptof sleep hygiene.
(21:52):
Okay, I completely agree. So, agood bedtime routine, offering
sips of fluids before bed ifthey request it, but trying to
limit guzzling large quantitiesof fluid, I think that would be
helpful.
There are situations where youreally shouldn't limit fluids,
and it may be that you're doingsports that end at seven to
eight o'clock at night, andthere's no way you're going to
(22:14):
be able to limit fluids afteryou just drank a gallon of water
during practice. We'll get tothat in a little more detail. We
talked about the medicaltherapies that kind of is the
category of fluid limitation.
Yes,it's true. If a child is telling
you they're thirsty, it'd beoppressed as a parent not to let
them drink fluids. Okay. Now,bed wetting alarms are a big
topic of conversation. A lot ofparents are interested in using
(22:35):
a bed wetting alarm because it'snot a medication. It feels more
natural, but there's a lot ofquestions that come up. So I
guess my first question to youis, do you have a favorite type
of bed wetting alarm? And whatwould using a bed wetting alarm
look like for a family?
Part of the frustration as aspecialist is that I do see a
(22:56):
lot of kids that have alreadyfailed bedwetting alarms. If you
ask me, Is there a favorite?
There's really isn't, becausethey all kind of work with the
same concept. It's going to be aloud noise, it might be
vibration, it might be flashinglights, it may be all of those.
And the success is not thatdifferent between them. And so
think about what happens nowthat we talked about the
(23:21):
physiology and sleep, and howthis is a sleep disturbance. The
child wets completely. An alarmgoes off. There's nothing
stopping that child fromfinishing so if the alarm goes
off most of the time, they'regoing to sleep through it. And
in the ones that don't, they areawakened to a wet bed. So what
(23:43):
do they learn? They learn thatthe bed is a cold place to be,
and now they have to go to thebathroom to finish urinating,
which they most of the time,have already finished. They're
taught, and this is how I wastrained. This is the opportunity
for them to clean their sheets,and that's supposed to change
the brain bladder connection. Itdoes not do that. It does
(24:04):
nothing to neuro modulate. Soneuromodulation is when the
brain can sense a full bladder,and then that sense of a full
bladder awakens you to use therestroom. It's true,
that's what I've been taught, isthat you're supposed to involve
the child in the cleanupprocess. But you're right. That
doesn't make any sense, thatit's how would this speed up
(24:25):
their learning process, to notwet their beds?
It's just more frustration.
They're extremely frustratedalready. There is one alarm that
is not available in the UnitedStates that involves a vibrating
orb. It goes under your pillow,and it also has an industrial
speaker next to your bed, and itshakes your head, and it is very
(24:46):
loud. And they claim to have a90% success, but I don't know it
still. There's really no reasonwhy it would work based on the
whole process ofneuromodulation.
So is there a time when youwould most likely recommend it?
So for example, I find that kidsthat have never been dry, it's
not worth recommending a bedwetting alarm, but for the kids
(25:08):
that are dry a couple days aweek, I find that there's a
higher success rate. Would youagree with that?
It's probably worth trying outeverybody, because what's your
alternative? The alternative isto limit fluids, which we talked
about. And then there'sbedwetting alarms, which is the
gold standard. And the goldstandard is pretty tarnished,
because the success is 30 to 60%you have to use bed wetting
(25:32):
alarms for four to six months.
So the child is alarmed by thealarm. The siblings wake up, the
parents get frustrated becausethe child is pretty much already
wet. They're basically taking akid that is spending very little
time with good quality sleep.
They're zombies. They're takingthese kids to the bathroom,
(25:55):
pretty much dragging them therewith them to sleep, and then
that process is supposed to goon for four to six months, no
wonder that the dropout ratewith bed wetting alarms is up to
80% okay, so what I'd like totalk about is a new device that
my partner, Dr Barroso and Ihave been developing for the
last five years, and it'scurrently under FDA review and
(26:18):
hopefully will be available Withthe next year or so, and it's a
product called Solu s, o, l, u,u. Our company is called Global
continence, and we developedthis device because of
everything we just talked about.
And so how does it work? So it'sa wearable, which means that you
have electrodes or stickers thatgo on the bottom. It has a
(26:39):
little moisture sensing area anda neuromodulation device or a
nerve stimulator attached to it,so as soon as one drop of urine
hits this, the nerve stimulatorwill make the sphincter close.
And we talked before about howyou can't make your sphincter
close. You can only relax it inresponse to the bladder
emptying. What this device doesis it makes the sphincter close
(27:01):
for five seconds, and it'spainless, and the guarding
reflex that allows your bladderto relax as your sphincter
closes happens at the same time.
So you get closure of thesphincter, relaxation of the
bladder, and then we have abuilt in app that will send a
message to the parents that itwent off, so now they could go
(27:23):
in the kid is dry, and then theywill bring that child to the
bathroom, where they actuallywill complete voiding. And after
using this device for twomonths, in our first study in
Brazil, we found that 83% of ourchildren were cured within two
months, and at one year,everybody that was cured was
still cured. So we're about tostart a multi institutional,
(27:47):
multinational study looking atVanderbilt Children's Hospital
of Philadelphia, where Itrained, as well as two sites in
Brazil, and we're going tocompare our device to a placebo
device that will alarm but itwon't have the 10s unit
stimulation or the app. So we'rereally excited about this
product, and if your listenerswant to hear more about it, they
(28:08):
could go to ourwebsite@globalcontinence.com or
look up Salou and get moreinformation on it. So this is
something that I think will be agame changer in the treatment of
bed wetting. If you askpediatricians, we'll get back to
the survey, is it important totreat bed wetting? 70% says
Absolutely. But if you ask them,when do you use bed wetting
(28:30):
alarms and medications in oursurvey, 2% less than age eight,
were offered any medications orbed wetting alarms. And what it
tells you is that even thougheverybody thinks it's important
to treat, the reason they don'ttreat, when we ask this direct
question, 70% of pediatricianssay finding effective treatments
(28:51):
is the biggest problem. And so Idon't blame pediatricians for
not using these things. I thinkthere are certainly frustration
involved with better waitingalarms and there are side
effects. That's probably thenumber one reason why
pediatricians don't like toprescribe medications and
parents don't like to give theirkids medications. Having this
device salute will hopefullychange the whole paradigm in
treating bedwetting.
(29:12):
I'm so excited to see what therest of your research shows,
because this could be a gamechanger for a lot of families.
I could tell you, devicedevelopment takes years, and so
I told you, I've been doing thisfor five years. I have families
that I told it's coming threeyears ago, they're all on
waiting lists. So if they go tothe
website@globalcontinence.com, wehave a way of getting on on the
(29:32):
list as well. Can youexplain to me a little more
about the nerve modulation? Whatdoes it feel like to kids? Is it
painful? What will theyexperience? So
right now, neuromodulationdevices are over the counter,
and so you use them mostly forpain, and you use them for
muscle conditioning, and thosepeople put on their bodies for
(29:53):
multiple minutes. Our devicedelivers five seconds of
stimulation. So. Sure that kidsdon't really sense it that much.
It does wake some of them up,though, and it's not because
they had pain. They just feltmaybe a little bit jolted by it.
And the reason why it's onlyfive seconds is the you can't
contract your sphincter musclefor more than about five to 10
(30:16):
seconds. So the device makes thesphincter contract. The bladder
relaxation comes free, becausethat's a reflex, and so we don't
have to really do anything tothe bladder with this therapy.
How many participants were inthe study in Brazil? That
was about 30 patients in Brazil,and our study will be 70
(30:36):
patients that will berandomized, controlled, double
blinded, multi institutional,and so it's going to be a good
study. We're really lookingforward to those results. But
the one thing that the Saloudevice offers is that you may
not even need an alarm, okay,you just need the stimulation.
The parents may not need to getup, because if those wake the
(30:58):
child up, they could go and soit gives you all the benefits of
not waking up the entirehousehold, one of the reasons
why people drop out. Sois it the idea that it re
establishes that brain bladderconnection? Exactly
your neuromodulation is reestablishing the connection
between the brain and thebladder.
I wish you all the best, becausethis is such an issue for so
(31:19):
many families, and if there wasa way that was successful, I do
agree that a lot ofpediatricians would be behind
recommending it. Yeah.
So we're gonna be doing a lot ofeducation, obviously, you know,
our bed wedding, and participatein a lot of meetings at the
American Academy of Pediatrics,and a lot of meetings around the
country, and truly trying to getin front of as many
(31:40):
pediatricians as we canI'd also love to just talk with
you about the pros and cons ofthe medication that we prescribe
for bed wetting, because Ipractice pediatrics with my dad,
so he's been in practice for 45years as a pediatrician, and he
tells me that many years ago, weused to get a lot of
pharmaceutical Sales Reps comingaround, and there was a lot more
(32:01):
emphasis about using themedication, the DDAVP for
Bedwetting, and we don't reallyhear about it as much anymore,
which I find interesting. It'sfallen out of popularity. Yeah,
and I talk a lot with one of oursenior nephrologists, and he
said that pediatricians gave alot of talks for the companies
(32:21):
that basically sold DDAVP, so itwas used a lot, but you talk
about kind of side effects ofthat medication. Fortunately,
rare. If you take DDAVP and youdrink, okay, so you're taking a
medication that makes you holdwater, and now you're drinking
water that could lead to lowsodium levels, and that could
lead to seizures, lethargy andother issues. So a lot of the
(32:45):
folks, like the nephrologistthat we work with, they're not
very into DDAVP at all for thatreason. And
I find that it's a band aid. Ithink it's fine in the short
term. So for kids that are goingon a sleepover or to sleep away
camp, I think people likeknowing that there's something
that they can use. But I willalso tell you there's a number
of kids, whereas medication isnot effective,
yeah, and that's exactly correctagain, 30 to 50% and it loses
(33:10):
its effect over time, and it'sexpensive in some countries that
have where people have to payfor it on their own. When they
get referred to me, I'm alwaysgiving DDAVP because they've
already failed so many otherthings, and I just want to see
if it's effective. And so Iusually tell people, you know
what, let's try this stop fluidsan hour before you go to sleep.
(33:31):
And I say after three months, ifit's working, stop it. Let's see
if you still need it. And we gothrough that because nobody
likes to put their kids onmedications long term, at least
that gives them a little bit ofhope. But you mentioned camps,
and I used to think exactly likeyou. Let's give DDAVP for
situational things likesleepovers, which is fine,
(33:52):
you'll get to speak to a parentand you'll say, maybe you'll
tell them that they're takingthe medication if they're old
enough, they probably don't needto. It's a
small pill. And then why shouldthe child miss out on some fun
for something that isn't theirfault Exactly? Some people say
we don't have to treat bedwetting. It's not a medical
problem. It's a social problem,but it's associated with anxiety
and mental health issues, andwhy wouldn't we treat it? When
(34:13):
we ask the question topediatricians, if you knew of a
device that was non medical andit gave you a cure within two
months? What age would youtreat? And that went from less
than 2% to almost everybodybefore age six, of course.
Because why wouldn't you, ofcourse, an opportunity to change
a kid's life? Yeah, not amedical problem. I don't think
(34:33):
so. I think it is a potentialmedical issue. If it's
psychological anxiety provoking,those are reasons to do
something that's minimallyinvasive.
Of course, no. Parents can'twait to get their kids out of
diapers, that's for sure. Yeah.
So not tomention the cost. It costs up to
$1,200 a year to deal with bedwetting, so it's a very
expensive problemto me, when you're describing
(34:55):
waking up with your child withbed wetting alarms, that sounds.
Exhausting, and my kids areolder now, but thinking about
getting up in the middle of thenight with them every once in a
while, okay, but to get up withthem every night for months on
end, that just doesn't soundsustainable, and that sounds
very stressful on families.
Yeah, agree 100% a couple morequestions about salute, because
(35:17):
I find this really interesting.
When do you envision it beingavailable to families.
So we have to complete a trial.
The good thing about our trialis it's two month trial, because
we think we're going to get alot of people care within that
time period, compared to analarm only, and we already know
the alarm is 30 to 50% so that'swhat our control group is. So
after that it gets done, weexpect it'll take several months
(35:39):
to go through the FDA process,and then we hope to launch
probably in early 2026 hopefullyI'll come back on your podcast
and we could talk more about it.
Absolutely. Just appreciate thismessage of hope, because the
saying is, when parents ask,Will this ever go away? And our
answer is yes, it will go awayby the time they walked on the
(36:00):
aisle. Don't worry they won't bein diapers, or by the time
they're at graduation from highschool, don't worry they'll be
out of diapers. But, boy, it'dbe a lot nicer to reassure them
that it'd be solved a lot soonerthan that. Yeah,
absolutely. And the reassuranceis important. I think it's
important also when you tellthem they're gonna outgrow it,
that it's about 15% each year,with the greatest chance,
(36:21):
probably in your first couple ofyears. So when you get to be
seven or eight and you stillhave the problem, you should be
a little more aggressive at thattime about treatment options.
Yes,and just to bring it back to the
DDAVP, I'm just curious. Haveyou ever seen a kid have
seizures from hyponatremia, fromhaving too low sodium? I
haven't. Yeah, I've only heardabout it. I personally, I told
(36:41):
you I put, like everybody, onDDAVP, and I have not seen it,
but I also read them the riotact about how to manage fluids
during it same so it's importantto understand, yes, the side
effect is significant, but it'srare. But I think another point
to get through that we didn'ttalk about. We talked about
sleep deprivation when we talkedabout sleep hygiene. But deep
(37:04):
sleep does not always equate togood sleep, and kids that sleep
deeply are not always in REMsleep, and it's the amount of
time in REM sleep where they'redreaming, where they're having
that deficiency, and that waswhat leads to the bed wetting
and another problem that theyget an offshoot, which I have
seen are parasomnias, and youmay have seen these as well.
(37:26):
These are kids that are havingnight terrors and sleep walking.
These are really bizarre thingsthat happen, so anything you
could do to improve their sleepis potentially helpful.
Interesting. Yeah, thatwas something brand new to me
that I learned from reading yourbook, even though we label these
kids, these kids as deepsleepers and we think of them as
deep sleepers, they're notactually getting as quality
sleep as they could be getting.
(37:49):
Yeah, absolutely Okay, so beforewe wrap up, is there any advice
that you'd like parents to learnfrom you, especially if their
kids feeling embarrassed orshamed because they're bed
wetting? Yeah, Ithink the most important thing
is to normalize it as much asyou can. And as we discussed at
the beginning, that's sometimeseasier said than done. Avoid
blame. The book describes a lotof misconceptions and myths
(38:11):
around bed wetting, and I thinkit's important that people
understand that it's really notthe child's fault. It's
important to be supportive. It'simportant to praise them for the
dry nights, but not to usebribes. And I say, if you're dry
tonight, I will get you whateveryou want. That doesn't work, but
giving them praise and rewardsdoes potentially work. So I
(38:34):
would stress that. And I thinkafter doing this for a long
time, and this applies to otherdiseases that I see. Sometimes
it's better to have an acuteproblem than to have a chronic
problem. And this book, which isabout 130 pages, and you got
your copy there, we wrote thiswith parents in mind, and I
tried to get as much informationto the parents as I can about
(38:58):
what's in this book. And I thinkthe other thing say at this
point is that there arepublished guidelines to treat
bedwetting. There's the AmericanAcademy of Pediatrics, there's
the International Children'scontinent society, there's one
from the United Kingdom, fromCanada, and they all say that
it's important to treatBedwetting, and that if you have
(39:18):
four months of failure, startingat age five or six, you should
step it up to either medicationsor alarms. And we talked about
my survey that I don't thinkthat's happening, and I think
the reason it's not happening isbecause people know that these
treatment options always are notalways effective, but it doesn't
mean we shouldn't try them, andI think it's important to try
(39:38):
some of these things for all thebenefits that we had discussed
earlier.
Are there any times when parentsshould think to take their kids
to the doctor about nighttimebedwetting? Yeah.
So yeah. Very important questionis about, when should you be
concerned about bed wetting? SoI would say if it's if it's
sudden, like my kid was fine forthree years. And then they're
(40:00):
wet in the bed. The things thatare really the most concern, it
could be child abuse. Could besexual abuse. It could be your
child has type one diabetes. Weask these questions, and we do a
urinalysis, which is quick andeasy, just to check their
glucose. We ask questions aboutthe social support, what's going
(40:21):
on in the family. And then youmay also want to understand that
there could be neurologicproblems, which sometimes are
more obvious, but sometimesthey're not. So when you're
running out of reasons why thischild is having day and
nighttime wedding physical exam,sometimes you'll see a hair tuft
on their back. That's somethingthat indicates that there's a
(40:41):
nerve problem, potentially. Soit's important to do a physical
exam, get a urinalysisscreening, address social
issues, abuse, very important.
And then some of these medicalissues that you know that you
absolutely need to make everyeffort to diagnose.
Yeah. So just to conclude, ifyou're a parent out there whose
child doesn't have a familyhistory of bed wetting. It's a
(41:03):
sudden onset. Something justdoesn't feel right to you.
Definitely talk to your doctorabout it.
Yeah, absolutely. So starts offwith the pediatrician, the
primary care doctor, and thenfrom there, if there's
difficulty managing it, use yourlocal pediatric urologist.
There's only 400 of us, butwe're in most places. The other
thing that we do a lot sinceCOVID is telehealth. So at
(41:25):
George urology, I see a lot ofpatients through telehealth from
all over the country. Otherproblems that I treat, such as
urinary reflux, I see from allover the world. I'm in
California. Can people make atelehealth visit with you? I
see a lot of people fromCalifornia and from a lot of
different states. So yeah, soI'm available to talk about
really any problem in pediatricurology and telehealth has
(41:48):
really changed things, and itjust makes it so much easier.
I think it's in a lot ofsituations. It's very practical
and very helpful for families. Ialso want to tell everybody, in
your book, there's a lot ofhelpful resources for families.
So thanks for writing this book.
I think a lot of families willget a lot out of it. Thank
you. I appreciate that, andspread the word. The book is
available on every major placeto buy books, including Amazon
(42:13):
and Barnes and Noble and I thinkit'll be helpful, not only for
parents, but for primary careproviders, and I hope it's going
to be useful to all the familiesthat you see.
Thank you so much. I wish you somuch luck with your book sales,
with your device. I think you'regoing to help a lot of families,
and I really applaud you forwhat you're doing.
Thank you very much. Iappreciate you. It was great
(42:35):
talking to you. Good talking toyou. Take care. Thank you
for listening, and I hope youenjoyed this week's episode of
your child is normal. Also, ifyou could take a moment and
leave a five star review,wherever it is you listen to
podcasts, I would greatlyappreciate it. It really makes a
difference to help this podcastgrow. You can also follow me on
Instagram at ask Dr Jessica, seeyou next Monday. You.
Hi everyone, and welcome back to your child is
(00:02):
normal. I'm Dr Jessica Hochman,and today we're talking about
one of the most common and oftenconfusing pediatric concerns,
and that is bedwetting. My guestis Dr Andrew Kirsch. He's a
pediatric urologist. He's aresearcher and the co author of
the new book, The Ultimatebedwetting Survival Guide. With
over two decades of experience,Dr Kirsch brings both clinical
expertise and practical adviceto families that are navigating
(00:24):
nighttime wetting. We talk aboutthe real causes of bed wetting,
how to avoid blame andfrustration and what treatments
actually help. Dr Kirsch alsotalks about an exciting new
device and development thatoffers a fresh and hopeful
approach to families that arelooking for alternatives to
medication and traditionalbedwetting alarms. If you've
ever wondered when to worry orhow to help your child stay dry,
this conversation is for you,and also as a reminder. If
(00:46):
you're enjoying this podcast, Iwould be so grateful if you
could take a moment and leave afive star review wherever it is
you listen to podcasts, greatreviews help other people find
this podcast, which really makesa difference in helping this
podcast grow. Now on to my talkabout nighttime bedwetting with
Dr Andrew Kirsch. DrKirsch, thanks so much for being
here. I'm looking forward tohaving this conversation with
you. Thank you. It's great to behere. So tell everybody a bit
(01:07):
about yourself. What do you dofor work, and
tell us then about the book thatyou wrote. I'm a pediatric
urologist, so we're a smallgroup. There's only about 400 of
us in the country, and I've beena full time urologist at George
urology, which is the nation'slargest private practice. And I
wear several hats, so I atEmory, that's my academic track,
(01:29):
where I am professor and chiefof Urology. I'm also chief
Urology at children's healthcare of Atlanta, which is the
largest children's healthcaresystem right now in the country,
and I am, as I said, also atGeorge urology, where I am the
medical director. So those arethe hats I wear, but I'm also an
(01:49):
entrepreneur, a writer, a parentof three kids and a grandchild,
a father of one granddaughter.
So clearly, you're a busy man,and there's a lot of things that
you could spend your time doingso I'm so curious what inspired
you to write a book aboutbedwetting. It's
been something where afterpracticing for 25 years and
(02:09):
seeing literally 1000s ofpatients, you get to hear all
their stories, and a lot of thestories have to do with sleep
deprivation or not being able togo to summer camp, anxiety, the
feeling that there's got to be abetter way of treating these
kids. So one of the things I dida couple of years ago was to
(02:31):
survey pediatricians how theymanaged bedwetting. And what we
learned in our survey is thatabout 50% of these families were
unaware of the multitude oftreatment options that are out
there. Not that they're great,but they're also unaware of
these options. And sopediatricians were surveyed with
(02:53):
a 24 Question voluntary survey,just asking them, is that
wedding important? How manypatients do you treat how
experienced you are? And welearned a lot, and hopefully
we'll get to some of thoseanswers as well.
It's true that bed wetting is socommon, and I think, for myself,
as a pediatrician, you're right.
It comes up a lot in practice,and I know that most kids grow
(03:15):
out of it, so you want to makesure that parents are given the
best direction? Yes, it's truethat there's biology involved,
but also there are options thatI think we could make better for
families. Yeah, absolutely.
And the impetus for writing thisbook, and my co author, by the
way, is ubira jaraborosso, andhe's an international leader in
(03:36):
treating all kinds ofincontinence issues. He's the
secretary of the InternationalChildren's cotton society, and
he's co author of the book, aswell as one of my business
partners in a company that wedeveloped that I'll talk to you
about as well.
That's great. I think withBedwetting, it's an embarrassing
topic to discuss freely, and soI hear it in my office. I know
(03:57):
how common it is, but I thinkfor parents listening, they may
not recognize how prevalent itis and how normal it is. So
thanks for having thisconversation. I am sure that's
gonna help many families. Thankyou.
So first, what I would like totalk about, and you
talk about this in your book, iswhat we call primary nocturnal
enuresis. Can you describe whatthat term means? Exactly sure.
(04:19):
Sowhat primary nocturnal enuresis
refers to are kids that havereally never been dry at night.
So they've never had a six monthperiod, for example, where
they've been dry. Because ifthere was a six month period,
that's when we call it secondaryenuresis. Okay, so enuresis can
be secondary to other problems,whether it's going to be
(04:41):
diabetes or it's going to bebowel and bladder dysfunction or
a neurologic problem, those arethe ones we get a little bit
more concerned about, and wehave to work up a little bit
more thoroughly, but primarynoctulinary system makes up the
vast majority of the patientsthat we see. You.
And just to shine some light onthis, how common is it? Exactly.
(05:04):
Sobed wetting is extremely common.
So if you just look at the worlddata, 200 million children
suffer from bed wetting. If youlook at kids that are around age
five, where we start to make thediagnosis, that's probably about
15% a higher incidence in boysthan girls, because there is
delayed maturity in boys. Askids get older, by the age of
(05:26):
seven or eight, that numberdrops to about five to 10% so
the average age of our referralsfrom people like you, the
pediatrician, is probably nine,and there's as they get older,
about 3% of 11 or 12 year olds,and then it drops to about 1%
and even in adulthood, 1% ofadults have bed wedding,
(05:49):
something they don't think abouta lot, but
that's a lot of people, and thisis a neurologically normal
people. Theseare primary nocturnal enuresis.
They're still waiting for it togo away. And you know when you
first saw them, when they werefive or six, and you said, Don't
worry, it's not much of aproblem. It all goes away when
it doesn't in the smallpercentage, you have to start
thinking about some othertreatments. We'll get to
(06:12):
treatments. A lot of them aren'tas effective as you may think.
And can you comment on familyhistory as well. Sure
there is a genetic component tonocturnal neurosis. So if one
parent has bed wetting, there'sabout a 40% chance that their
child will have bed wetting, andif both parents have it, it goes
(06:33):
up to about 75 or 80% and whatis interesting is that you
should always ask the parent,how old were you when you
stopped wetting your bed,because that correlates with the
child's bed wetting cessation aswell.
So in this situation, the Applereally doesn't fall far from the
tree.
That's correct. It doesn't. Butit could be very helpful,
(06:54):
because they bring thatexperience to their child and
they normalize it, and that'svery important.
I do find it comforts the childwhen I can talk about it with
families in the office, and amother or father will relate to
the child and say, for me, itlasted till 910, years old. And
I do think that does provide alot of comfort for kids. Yeah,
everybody'sindividual, right? So you don't
know what they're experiencing.
(07:17):
I could tell you that I saw oneof my anesthesiologists kids a
couple weeks ago, and I saw herin the operating room, and I
said, How'd the appointment gofor your child? And she said she
was kind of covering her face upwhen she was leaving the office
because she was so embarrassedthat people would see her
because of this problem, notrealizing that we see a
(07:39):
multitude of other problems, butthey don't really know what's in
the head of a child, and theirexperiences, their relationships
with their siblings, theirparents, their friends, they're
all so different, so everybodyhas to be treated as an
individual.
Absolutely, Ido think, though, it's
reassuring to hear that there'sa genetic component, because I'm
interested in the child beingreassured that it's not their
(07:59):
fault.
Absolutely, that's probably theone kind of myth that will lead
to the most damage, if you will.
We see a lot of kids that alsohave psychological issues. They
deal with anxiety, depression orthey have that problem. In
addition to this, what camefirst certainly doesn't make it
better if they started off withanxiety, and it's so important
(08:21):
to address that as well.
And it's interesting that youpoint out that you don't
typically define primarynocturnal enuresis until five
years old. So if I'munderstanding correctly, if a
kid is four years old andthey're wetting their bed at
night, parents really shouldn'tbe alarmed or concerned.
You know, as well as I do,you're going to see a four year
(08:41):
old whose parents are veryconcerned because they've had
other kids, maybe a daughterthat was toilet trained and
perfect at age two, and they'vedealt with three more years of
diapers, and it's not normal forthem. So you do have to
normalize it, and sometimes youeven have to offer treatments to
these families, just to givethem something to work towards,
(09:05):
working towards hope is areasonable goal when dealing
with this problem, absolutelyand I completely agree. I do
find that comparison in thissituation is very prevalent,
very often. I hear a family talkabout one child, one child was
trained at two, two and a half,and why is it taking so long for
the other child? And I do thinkit can be frustrating for
family. So this is a goodreminder Absolutely. Now, the
(09:26):
big question I have is, ofcourse, there are different
scenarios for different kids,but do we know the main
physiologic reason why bedwetting occurs? Is it because
they're deep sleepers? Do theyhave a small bladder? Do we know
in most situations? Why does itactually happen?
Yeah, and we talked a little bitabout the genetics, but the
(09:49):
physiology is multi factorial,for sure. In the most basic
sense, there is a disconnectbetween the brain and the
bladder, so you should be. Ableto sense when your bladder is
full, get that message to yourbrain, get up and go to the
bathroom. So kids that have bedwetting are very deep sleepers.
(10:10):
Amen, all of them are and soit's a sleep disturbance. Their
arousal threshold is elevatedcompared to otherwise normal
children. So that has a lot todo with it. It could also just
be that they make more urine atnight, so nocturnal polyurea,
they may not have enough hormonethat's responsible for holding
(10:31):
on to urine, anti diuretichormone, but that doesn't
explain all of them. That's whysome of the treatments, like
medications, are not 100%effective, the way less than
that. And so it ismultifactorial. It could be
related to other stressors intheir lives. And we talked a
little bit about anxiety,depression, and what these kids
(10:52):
are feeling. If those thingsaffect their sleep, the
medications they take affecttheir sleep, well, that's also
going to make their bed wettingworse, and that's why a lot of
the drugs are ineffective,especially in kids with ADHD,
and you have to start looking atother ways of treating it. That
was something that I reallyenjoyed learning in your book,
because of my experience whenI've given the medication. For
(11:13):
some kids, it is very effective,it's very helpful, but for other
kids, it's not helpful. So thatwas an interesting point that
you brought up in the book thatI appreciated learning about,
yeah,one of the examples we give in
the book, you might notice thatsomebody has hyperactivity, or
somebody's in a divorced family,and they with the mother, and
they're with the Father, andthey do different things when
they're at different houses. Andif you look at that, and you
(11:34):
look at what the differenttreatment options are, it's no
wonder that some of thesetreatment options are
ineffective because thescenarios change so often. In
your opinion, I know there's avariety of reasons about why
bedwetting happens, but wouldyou say that in most situations,
it's probably because of adevelopmental lag that where the
brain and the bladder aren'tquite synced up yet.
(11:57):
I think that makes the mostsense. But as I said, if you
have treatments and one of themhas the highest success, you
would think that addresses themain physiology, but the gold
standard is a bed wetting alarm,and the bed wetting alarm is
about 50 to 70% successful. Andsome of the success may be on
the timing of the kid aging. Soit's not always clear what it
(12:21):
is. Not everybody understandsthat you cannot make your
bladder contract. So we talkabout parents getting frustrated
with their child and maybe evenblaming their child for being
lazy, or you're doing this onpurpose, and that,
unfortunately, I try to tellpeople that you could only make
(12:43):
your bladder empty by relaxingyour sphincter and bedwetting
actually has no effectwhatsoever on your ability to
hold your urine with your pelvicmuscle which makes up your
sphincter and you can't makeyour bladder contract, right? So
at night when your bladdercontracts, your sphincter is
relaxing in response to thatmechanism. Okay, it's not
(13:05):
because you relaxed it. You haveno control of it whatsoever. I
think that's it helps themunderstand a little bit about
why it's not their child'sfault.
I like this point because Ithink it's so important for
parents to trust that the kidisn't doing it on purpose in
most scenarios, yeah, they'resleeping. So it's kind of hard
to blame a child who's sleepingfor doing something voluntarily.
(13:28):
But this problem also happens inkids that nap during the day, so
it is a sleep issue for sure.
Now while we're on the subjectof myths and bed wetting. Can I
also ask you, because this issomething that my mom and I talk
about. My mom really believes inwaking a kid up, having them go
pee after they've gone to sleep,to help them get over being a
(13:50):
bed wetter. Do you find there'sany validity to having a child
sleep, waking them up to go tothe bathroom and then putting
them back to sleep? Does thatmake them overcome bed wetting
any faster.
So there's no evidence tosupport that. And some of these
kids wet multiple times a night.
So we talked earlier about thebrain and bladder connection and
sleep deprivation. So you add tothis whole process, sleep
(14:15):
deprivation, because now theparent and the child are both
getting up, it's going to affecttheir day the next day. So timed
awakenings are not really partof the behavioral therapy that
we talk about in treating bedwetting. So behavioral therapy
would be limit your fluidsbefore you go to sleep and make
sure you empty your bladder.
(14:38):
That's all you could really do.
We do those things. And if youlook at the largest study that's
ever been published, 6000patients, a Cochrane Review, it
looked at all the differenttreatments. And if you look at
behavioral therapy, it had an18% success rate. And as a
pediatrician that you're tellingevery single one of your
families to do that. We all doit because maybe it'll make the
(15:00):
amount of bed wetting a littlebit better. But there's really
not a lot of strong evidencethat actually works. There is
evidence from Sweden that ifkids have timed voiding during
the daytime that they're reallyconscientious about emptying
their bladders, it has no effectwhatsoever on bed weight. That's
(15:24):
really interesting, becauseyou're right. I've always been
taught about the importance oftimed voiding, so that means
going every two to three hoursduring the day. And you're
telling me that the time voidingactually doesn't make a
difference.
I mean, if you look at thenumbers, it's a placebo effect.
18. Interesting, yeah. But wedefinitely all do it. And I
think avoiding habits is goodfor other reasons. I may not
stop bedwetting. It might makeit a little bit less in terms of
(15:46):
quantity, but it's not really avery effective treatment.
Just explain to me that you wantto think about the bladder as a
rubber band, and if it'sstretched too much during the
day, then it might not work aswell at night. So just like a
rubber band, if it's continuallystretched, it loses its
elasticity, and it might notrespond as well to the stretch,
but if there's not the evidenceto back it, I can see that
that's interesting. Ithink what you're saying is true
(16:08):
for daytime problems orsecondary enuresis. So we see a
lot of kids with bowel andbladder dysfunction. Remember,
the pelvic floor in the frontmakes up your sphincter, which
you can't control in your sleep,and it also makes up your your
rectal sphincter as well. Sokids that have pelvic floor
problems tend to hold theirurine and hold their stool, and
(16:31):
the treatment of that is fullon, bowel clean out timed, time
voiding, like you described. Andif you don't do that, then you
get bladder instability. Sobladder instability will cause
some of the secondary enuresis,or what we call polysyptomatic
poly means they have daytimeproblems, urgency, frequency,
(16:51):
constipation, sometimes fecalincontinence, if they have other
issues. And those all could bemanaged pretty well during the
daytime. And so what you talkabout is overdistent of the
bladder, you know, that couldcertainly cause problems. And we
do see some kids where they havesuch bad, overactive bladder
(17:12):
that might actually make theirnighttime worse if they're
having bladder contraction. Soyou talk about using first line
therapy, which would includesomething like DDAVP or
vasopressin. If that's notworking, or maybe it works a
little bit, you could alwaysthrow on a medication like an
anticholinergic, like oxybutynor ditropan, which will then
(17:36):
relax the bladder, and that hasbeen shown to improve the
results with kind ofpolytherapy, and those two
together, DDAVP and oxybutyn orditropan, are the ones that we
may use in combination in caseswhere one is not effective. The
problem with ditropan, ofcourse, is side effects, and
(17:57):
that includes constipation. Sonow you're in this vicious cycle
of having bowel and bladderdysfunction during the day that
you treat with something thatmakes it worse, making the
constipation harder to treat.
And that's why I mentioned thatwe very aggressively treat
constipation these children,because our therapy sometimes
(18:18):
leads to it.
I really appreciate thatdistinction. That makes sense,
that the timed voiding thebladder exercises helps with the
daytime urination when yourbrain is working and alert and
you can tell when you have to gothe bathroom, as opposed to
being in a deep sleep whenyou're not aware. That makes
total sense.
And we also did a survey ofparents asking them about their
(18:39):
school bathroom policies,because one of my colleagues,
years ago wrote an article inthe Journal of Urology that was
picked up by the New York Timesthat basically says schools are
creating bowel and bladderdysfunction, and if you think
about it, they're lining up allthese kids when they're little.
The kids may or may not need togo to the bathroom. That's your
(18:59):
time to go, and then they havecertain times where you can use
the restroom. So what we'velearned is that in doing a
survey of the parents, and we'vesurveyed probably three or 400
of them now, and we found outthat you have a certain number
of times where you could use thebathroom, if you overuse that,
(19:20):
then that could be used againstyou. And what is really
shocking, and this happenedprobably less than 5% of the
time, but they were actuallyrewarding kids for not using the
restroom. And so think aboutwhat we tell them to do, like
you mentioned earlier, the time,voiding and making sure they
drink and do everything else totreat their daytime issues. The
(19:41):
schools are reversing thatcircumstances. You
can understand why, because Ithink it's hard for teachers,
right? If they're managing aclassroom of 30 kids, and if
they're all going to thebathroom at different times,
it's just not practical. So butI can also understand that if a
kid doesn't have to go andthey're being told to go, that
can be confusing to the body.
Yeah, yep. Absolutely. The otherthing that I hear a lot from
(20:01):
kids is that they don't likegoing to the school restrooms
because of the way it smells, orjust because of the general
atmosphere. They don't want togo while they're at school. And
I think that's another issue aswell for little kids. Yeah,
the other thing is, a lot ofbathrooms are dirty. They don't
want to use them, and they willjust hold the entire day. A lot
of these kids are running back,either from the bus stop or out
(20:23):
of their parents car, at pickup,running back to their house,
holding themselves, trying notto urinate, because they just
held all day.
It's true. There are so manykids they do not go all day at
school. When I ask them aboutit, they don't like anything
about their school bathroom theway it smells. They don't want
to go number two in public, ormaybe their friend might find
out they don't want anything todo with their school bathroom.
(20:44):
So I don't know how to fix thisproblem, but I do agree it's a
problem. Yeah,it's a big problem. I'm on the
board of the American Academy ofPediatrics in Georgia, and one
of my projects has been schoolpolicy. So it's up to interest,
and hopefully we'll get sometraction on it. That's
great. That's great. Okay, sofor parents that are listening,
and maybe they have a childthemselves who is wedding at
(21:07):
night, I want to go through thelist of practical advice to give
them and practical things tothink about. So we talked about
limiting fluids beforebed. What does that look like?
Yeah, limiting fluids isprobably something you do like
right after dinner. It reallydepends on bedtime. And you
could talk about limitingfluids, but you also have to
(21:29):
talk about sleep hygiene and howyou wind down before you go to
bed. If these kids are drinkingand they're playing video games
right up to the time they go tosleep, they're getting over
stimulated, that's also not goodfor them, so that will affect
their sleep cycle. You shouldlimit fluids, but there are
other things that you need to doin conjunction with that all
surrounded around that conceptof sleep hygiene.
(21:52):
Okay, I completely agree. So, agood bedtime routine, offering
sips of fluids before bed ifthey request it, but trying to
limit guzzling large quantitiesof fluid, I think that would be
helpful.
There are situations where youreally shouldn't limit fluids,
and it may be that you're doingsports that end at seven to
eight o'clock at night, andthere's no way you're going to
(22:14):
be able to limit fluids afteryou just drank a gallon of water
during practice. We'll get tothat in a little more detail. We
talked about the medicaltherapies that kind of is the
category of fluid limitation.
Yes,it's true. If a child is telling
you they're thirsty, it'd beoppressed as a parent not to let
them drink fluids. Okay. Now,bed wetting alarms are a big
topic of conversation. A lot ofparents are interested in using
(22:35):
a bed wetting alarm because it'snot a medication. It feels more
natural, but there's a lot ofquestions that come up. So I
guess my first question to youis, do you have a favorite type
of bed wetting alarm? And whatwould using a bed wetting alarm
look like for a family?
Part of the frustration as aspecialist is that I do see a
(22:56):
lot of kids that have alreadyfailed bedwetting alarms. If you
ask me, Is there a favorite?
There's really isn't, becausethey all kind of work with the
same concept. It's going to be aloud noise, it might be
vibration, it might be flashinglights, it may be all of those.
And the success is not thatdifferent between them. And so
think about what happens nowthat we talked about the
(23:21):
physiology and sleep, and howthis is a sleep disturbance. The
child wets completely. An alarmgoes off. There's nothing
stopping that child fromfinishing so if the alarm goes
off most of the time, they'regoing to sleep through it. And
in the ones that don't, they areawakened to a wet bed. So what
(23:43):
do they learn? They learn thatthe bed is a cold place to be,
and now they have to go to thebathroom to finish urinating,
which they most of the time,have already finished. They're
taught, and this is how I wastrained. This is the opportunity
for them to clean their sheets,and that's supposed to change
the brain bladder connection. Itdoes not do that. It does
(24:04):
nothing to neuro modulate. Soneuromodulation is when the
brain can sense a full bladder,and then that sense of a full
bladder awakens you to use therestroom. It's true,
that's what I've been taught, isthat you're supposed to involve
the child in the cleanupprocess. But you're right. That
doesn't make any sense, thatit's how would this speed up
(24:25):
their learning process, to notwet their beds?
It's just more frustration.
They're extremely frustratedalready. There is one alarm that
is not available in the UnitedStates that involves a vibrating
orb. It goes under your pillow,and it also has an industrial
speaker next to your bed, and itshakes your head, and it is very
(24:46):
loud. And they claim to have a90% success, but I don't know it
still. There's really no reasonwhy it would work based on the
whole process ofneuromodulation.
So is there a time when youwould most likely recommend it?
So for example, I find that kidsthat have never been dry, it's
not worth recommending a bedwetting alarm, but for the kids
(25:08):
that are dry a couple days aweek, I find that there's a
higher success rate. Would youagree with that?
It's probably worth trying outeverybody, because what's your
alternative? The alternative isto limit fluids, which we talked
about. And then there'sbedwetting alarms, which is the
gold standard. And the goldstandard is pretty tarnished,
because the success is 30 to 60%you have to use bed wetting
(25:32):
alarms for four to six months.
So the child is alarmed by thealarm. The siblings wake up, the
parents get frustrated becausethe child is pretty much already
wet. They're basically taking akid that is spending very little
time with good quality sleep.
They're zombies. They're takingthese kids to the bathroom,
(25:55):
pretty much dragging them therewith them to sleep, and then
that process is supposed to goon for four to six months, no
wonder that the dropout ratewith bed wetting alarms is up to
80% okay, so what I'd like totalk about is a new device that
my partner, Dr Barroso and Ihave been developing for the
last five years, and it'scurrently under FDA review and
(26:18):
hopefully will be available Withthe next year or so, and it's a
product called Solu s, o, l, u,u. Our company is called Global
continence, and we developedthis device because of
everything we just talked about.
And so how does it work? So it'sa wearable, which means that you
have electrodes or stickers thatgo on the bottom. It has a
(26:39):
little moisture sensing area anda neuromodulation device or a
nerve stimulator attached to it,so as soon as one drop of urine
hits this, the nerve stimulatorwill make the sphincter close.
And we talked before about howyou can't make your sphincter
close. You can only relax it inresponse to the bladder
emptying. What this device doesis it makes the sphincter close
(27:01):
for five seconds, and it'spainless, and the guarding
reflex that allows your bladderto relax as your sphincter
closes happens at the same time.
So you get closure of thesphincter, relaxation of the
bladder, and then we have abuilt in app that will send a
message to the parents that itwent off, so now they could go
(27:23):
in the kid is dry, and then theywill bring that child to the
bathroom, where they actuallywill complete voiding. And after
using this device for twomonths, in our first study in
Brazil, we found that 83% of ourchildren were cured within two
months, and at one year,everybody that was cured was
still cured. So we're about tostart a multi institutional,
(27:47):
multinational study looking atVanderbilt Children's Hospital
of Philadelphia, where Itrained, as well as two sites in
Brazil, and we're going tocompare our device to a placebo
device that will alarm but itwon't have the 10s unit
stimulation or the app. So we'rereally excited about this
product, and if your listenerswant to hear more about it, they
(28:08):
could go to ourwebsite@globalcontinence.com or
look up Salou and get moreinformation on it. So this is
something that I think will be agame changer in the treatment of
bed wetting. If you askpediatricians, we'll get back to
the survey, is it important totreat bed wetting? 70% says
Absolutely. But if you ask them,when do you use bed wetting
(28:30):
alarms and medications in oursurvey, 2% less than age eight,
were offered any medications orbed wetting alarms. And what it
tells you is that even thougheverybody thinks it's important
to treat, the reason they don'ttreat, when we ask this direct
question, 70% of pediatricianssay finding effective treatments
(28:51):
is the biggest problem. And so Idon't blame pediatricians for
not using these things. I thinkthere are certainly frustration
involved with better waitingalarms and there are side
effects. That's probably thenumber one reason why
pediatricians don't like toprescribe medications and
parents don't like to give theirkids medications. Having this
device salute will hopefullychange the whole paradigm in
treating bedwetting.
(29:12):
I'm so excited to see what therest of your research shows,
because this could be a gamechanger for a lot of families.
I could tell you, devicedevelopment takes years, and so
I told you, I've been doing thisfor five years. I have families
that I told it's coming threeyears ago, they're all on
waiting lists. So if they go tothe
website@globalcontinence.com, wehave a way of getting on on the
(29:32):
list as well. Can youexplain to me a little more
about the nerve modulation? Whatdoes it feel like to kids? Is it
painful? What will theyexperience? So
right now, neuromodulationdevices are over the counter,
and so you use them mostly forpain, and you use them for
muscle conditioning, and thosepeople put on their bodies for
(29:53):
multiple minutes. Our devicedelivers five seconds of
stimulation. So. Sure that kidsdon't really sense it that much.
It does wake some of them up,though, and it's not because
they had pain. They just feltmaybe a little bit jolted by it.
And the reason why it's onlyfive seconds is the you can't
contract your sphincter musclefor more than about five to 10
(30:16):
seconds. So the device makes thesphincter contract. The bladder
relaxation comes free, becausethat's a reflex, and so we don't
have to really do anything tothe bladder with this therapy.
How many participants were inthe study in Brazil? That
was about 30 patients in Brazil,and our study will be 70
(30:36):
patients that will berandomized, controlled, double
blinded, multi institutional,and so it's going to be a good
study. We're really lookingforward to those results. But
the one thing that the Saloudevice offers is that you may
not even need an alarm, okay,you just need the stimulation.
The parents may not need to getup, because if those wake the
(30:58):
child up, they could go and soit gives you all the benefits of
not waking up the entirehousehold, one of the reasons
why people drop out. Sois it the idea that it re
establishes that brain bladderconnection? Exactly
your neuromodulation is reestablishing the connection
between the brain and thebladder.
I wish you all the best, becausethis is such an issue for so
(31:19):
many families, and if there wasa way that was successful, I do
agree that a lot ofpediatricians would be behind
recommending it. Yeah.
So we're gonna be doing a lot ofeducation, obviously, you know,
our bed wedding, and participatein a lot of meetings at the
American Academy of Pediatrics,and a lot of meetings around the
country, and truly trying to getin front of as many
(31:40):
pediatricians as we canI'd also love to just talk with
you about the pros and cons ofthe medication that we prescribe
for bed wetting, because Ipractice pediatrics with my dad,
so he's been in practice for 45years as a pediatrician, and he
tells me that many years ago, weused to get a lot of
pharmaceutical Sales Reps comingaround, and there was a lot more
(32:01):
emphasis about using themedication, the DDAVP for
Bedwetting, and we don't reallyhear about it as much anymore,
which I find interesting. It'sfallen out of popularity. Yeah,
and I talk a lot with one of oursenior nephrologists, and he
said that pediatricians gave alot of talks for the companies
(32:21):
that basically sold DDAVP, so itwas used a lot, but you talk
about kind of side effects ofthat medication. Fortunately,
rare. If you take DDAVP and youdrink, okay, so you're taking a
medication that makes you holdwater, and now you're drinking
water that could lead to lowsodium levels, and that could
lead to seizures, lethargy andother issues. So a lot of the
(32:45):
folks, like the nephrologistthat we work with, they're not
very into DDAVP at all for thatreason. And
I find that it's a band aid. Ithink it's fine in the short
term. So for kids that are goingon a sleepover or to sleep away
camp, I think people likeknowing that there's something
that they can use. But I willalso tell you there's a number
of kids, whereas medication isnot effective,
yeah, and that's exactly correctagain, 30 to 50% and it loses
(33:10):
its effect over time, and it'sexpensive in some countries that
have where people have to payfor it on their own. When they
get referred to me, I'm alwaysgiving DDAVP because they've
already failed so many otherthings, and I just want to see
if it's effective. And so Iusually tell people, you know
what, let's try this stop fluidsan hour before you go to sleep.
(33:31):
And I say after three months, ifit's working, stop it. Let's see
if you still need it. And we gothrough that because nobody
likes to put their kids onmedications long term, at least
that gives them a little bit ofhope. But you mentioned camps,
and I used to think exactly likeyou. Let's give DDAVP for
situational things likesleepovers, which is fine,
(33:52):
you'll get to speak to a parentand you'll say, maybe you'll
tell them that they're takingthe medication if they're old
enough, they probably don't needto. It's a
small pill. And then why shouldthe child miss out on some fun
for something that isn't theirfault Exactly? Some people say
we don't have to treat bedwetting. It's not a medical
problem. It's a social problem,but it's associated with anxiety
and mental health issues, andwhy wouldn't we treat it? When
(34:13):
we ask the question topediatricians, if you knew of a
device that was non medical andit gave you a cure within two
months? What age would youtreat? And that went from less
than 2% to almost everybodybefore age six, of course.
Because why wouldn't you, ofcourse, an opportunity to change
a kid's life? Yeah, not amedical problem. I don't think
(34:33):
so. I think it is a potentialmedical issue. If it's
psychological anxiety provoking,those are reasons to do
something that's minimallyinvasive.
Of course, no. Parents can'twait to get their kids out of
diapers, that's for sure. Yeah.
So not tomention the cost. It costs up to
$1,200 a year to deal with bedwetting, so it's a very
expensive problemto me, when you're describing
(34:55):
waking up with your child withbed wetting alarms, that sounds.
Exhausting, and my kids areolder now, but thinking about
getting up in the middle of thenight with them every once in a
while, okay, but to get up withthem every night for months on
end, that just doesn't soundsustainable, and that sounds
very stressful on families.
Yeah, agree 100% a couple morequestions about salute, because
(35:17):
I find this really interesting.
When do you envision it beingavailable to families.
So we have to complete a trial.
The good thing about our trialis it's two month trial, because
we think we're going to get alot of people care within that
time period, compared to analarm only, and we already know
the alarm is 30 to 50% so that'swhat our control group is. So
after that it gets done, weexpect it'll take several months
(35:39):
to go through the FDA process,and then we hope to launch
probably in early 2026 hopefullyI'll come back on your podcast
and we could talk more about it.
Absolutely. Just appreciate thismessage of hope, because the
saying is, when parents ask,Will this ever go away? And our
answer is yes, it will go awayby the time they walked on the
(36:00):
aisle. Don't worry they won't bein diapers, or by the time
they're at graduation from highschool, don't worry they'll be
out of diapers. But, boy, it'dbe a lot nicer to reassure them
that it'd be solved a lot soonerthan that. Yeah,
absolutely. And the reassuranceis important. I think it's
important also when you tellthem they're gonna outgrow it,
that it's about 15% each year,with the greatest chance,
(36:21):
probably in your first couple ofyears. So when you get to be
seven or eight and you stillhave the problem, you should be
a little more aggressive at thattime about treatment options.
Yes,and just to bring it back to the
DDAVP, I'm just curious. Haveyou ever seen a kid have
seizures from hyponatremia, fromhaving too low sodium? I
haven't. Yeah, I've only heardabout it. I personally, I told
(36:41):
you I put, like everybody, onDDAVP, and I have not seen it,
but I also read them the riotact about how to manage fluids
during it same so it's importantto understand, yes, the side
effect is significant, but it'srare. But I think another point
to get through that we didn'ttalk about. We talked about
sleep deprivation when we talkedabout sleep hygiene. But deep
(37:04):
sleep does not always equate togood sleep, and kids that sleep
deeply are not always in REMsleep, and it's the amount of
time in REM sleep where they'redreaming, where they're having
that deficiency, and that waswhat leads to the bed wetting
and another problem that theyget an offshoot, which I have
seen are parasomnias, and youmay have seen these as well.
(37:26):
These are kids that are havingnight terrors and sleep walking.
These are really bizarre thingsthat happen, so anything you
could do to improve their sleepis potentially helpful.
Interesting. Yeah, thatwas something brand new to me
that I learned from reading yourbook, even though we label these
kids, these kids as deepsleepers and we think of them as
deep sleepers, they're notactually getting as quality
sleep as they could be getting.
(37:49):
Yeah, absolutely Okay, so beforewe wrap up, is there any advice
that you'd like parents to learnfrom you, especially if their
kids feeling embarrassed orshamed because they're bed
wetting? Yeah, Ithink the most important thing
is to normalize it as much asyou can. And as we discussed at
the beginning, that's sometimeseasier said than done. Avoid
blame. The book describes a lotof misconceptions and myths
(38:11):
around bed wetting, and I thinkit's important that people
understand that it's really notthe child's fault. It's
important to be supportive. It'simportant to praise them for the
dry nights, but not to usebribes. And I say, if you're dry
tonight, I will get you whateveryou want. That doesn't work, but
giving them praise and rewardsdoes potentially work. So I
(38:34):
would stress that. And I thinkafter doing this for a long
time, and this applies to otherdiseases that I see. Sometimes
it's better to have an acuteproblem than to have a chronic
problem. And this book, which isabout 130 pages, and you got
your copy there, we wrote thiswith parents in mind, and I
tried to get as much informationto the parents as I can about
(38:58):
what's in this book. And I thinkthe other thing say at this
point is that there arepublished guidelines to treat
bedwetting. There's the AmericanAcademy of Pediatrics, there's
the International Children'scontinent society, there's one
from the United Kingdom, fromCanada, and they all say that
it's important to treatBedwetting, and that if you have
(39:18):
four months of failure, startingat age five or six, you should
step it up to either medicationsor alarms. And we talked about
my survey that I don't thinkthat's happening, and I think
the reason it's not happening isbecause people know that these
treatment options always are notalways effective, but it doesn't
mean we shouldn't try them, andI think it's important to try
(39:38):
some of these things for all thebenefits that we had discussed
earlier.
Are there any times when parentsshould think to take their kids
to the doctor about nighttimebedwetting? Yeah.
So yeah. Very important questionis about, when should you be
concerned about bed wetting? SoI would say if it's if it's
sudden, like my kid was fine forthree years. And then they're
(40:00):
wet in the bed. The things thatare really the most concern, it
could be child abuse. Could besexual abuse. It could be your
child has type one diabetes. Weask these questions, and we do a
urinalysis, which is quick andeasy, just to check their
glucose. We ask questions aboutthe social support, what's going
(40:21):
on in the family. And then youmay also want to understand that
there could be neurologicproblems, which sometimes are
more obvious, but sometimesthey're not. So when you're
running out of reasons why thischild is having day and
nighttime wedding physical exam,sometimes you'll see a hair tuft
on their back. That's somethingthat indicates that there's a
(40:41):
nerve problem, potentially. Soit's important to do a physical
exam, get a urinalysisscreening, address social
issues, abuse, very important.
And then some of these medicalissues that you know that you
absolutely need to make everyeffort to diagnose.
Yeah. So just to conclude, ifyou're a parent out there whose
child doesn't have a familyhistory of bed wetting. It's a
(41:03):
sudden onset. Something justdoesn't feel right to you.
Definitely talk to your doctorabout it.
Yeah, absolutely. So starts offwith the pediatrician, the
primary care doctor, and thenfrom there, if there's
difficulty managing it, use yourlocal pediatric urologist.
There's only 400 of us, butwe're in most places. The other
thing that we do a lot sinceCOVID is telehealth. So at
(41:25):
George urology, I see a lot ofpatients through telehealth from
all over the country. Otherproblems that I treat, such as
urinary reflux, I see from allover the world. I'm in
California. Can people make atelehealth visit with you? I
see a lot of people fromCalifornia and from a lot of
different states. So yeah, soI'm available to talk about
really any problem in pediatricurology and telehealth has
(41:48):
really changed things, and itjust makes it so much easier.
I think it's in a lot ofsituations. It's very practical
and very helpful for families. Ialso want to tell everybody, in
your book, there's a lot ofhelpful resources for families.
So thanks for writing this book.
I think a lot of families willget a lot out of it. Thank
you. I appreciate that, andspread the word. The book is
available on every major placeto buy books, including Amazon
(42:13):
and Barnes and Noble and I thinkit'll be helpful, not only for
parents, but for primary careproviders, and I hope it's going
to be useful to all the familiesthat you see.
Thank you so much. I wish you somuch luck with your book sales,
with your device. I think you'regoing to help a lot of families,
and I really applaud you forwhat you're doing.
Thank you very much. Iappreciate you. It was great
(42:35):
talking to you. Good talking toyou. Take care. Thank you
for listening, and I hope youenjoyed this week's episode of
your child is normal. Also, ifyou could take a moment and
leave a five star review,wherever it is you listen to
podcasts, I would greatlyappreciate it. It really makes a
difference to help this podcastgrow. You can also follow me on
Instagram at ask Dr Jessica, seeyou next Monday. You.
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