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Info for Professionals

Nocturnal Enuresis

Definition and prevalence

Nocturnal enuresis is defined as ‘the symptom of involuntary wetting during sleep without any inherent suggestion of frequency or pathophysiology’. (NICE 2010).
(nocturnal enuresis) that occurs less than twice a week is a common condition and 21% of children aged four and a half years and 8% of nine and a half year olds wet the bed occasionally.

More frequent bedwetting is known to affect 8% at four and a half and only 1.5% will still have the problem at nine and a half. (Butler and Heron 2008). There is a heredity link and boys are affected more than girls.

Treating the condition

Although the causes of bedwetting are not fully understood, it is thought to be a symptom arising from a combination of predisposing factors. These are categorised as sleep arousal difficulties, production of large volumes of urine and bladder dysfunction.

The natural reduction in prevalence with age has previously led to the conclusion that children will ‘grow out of it’ and the condition has often been trivialised. However research shows that this distressing condition can have far reaching effects on emotional well being and social development. Children and young people often miss out on opportunities such as sleepovers and school trips and start to feel ‘different’ when they are not dry by the age of 5.

There is evidence that children with bedwetting are more likely to have behaviour problems (Joinson 2007) and stress within families can be considerable with an increased risk of child punishment including child abuse. (Sapi 2009).

Key priorities for health professionals dealing with childhood bedwetting:

Inform the child and families that bedwetting is not the child’s fault and punitive measures should not be used

Tailor intervention to the needs and circumstances of the child and family

Do not exclude younger children Discuss what support is needed especially if anger or negativity is expressed by parents or carers.

Consider what is the most appropriate treatment fro the child and family

Ensure that the child is drinking sufficient fluids and has a toileting routine in place

Suggest reward systems are for agreed actions such as engaging in management rather than for dry nights

Offer an alarm as first-line treatment unless unacceptable to the child and family or bedwetting is infrequent

Offer desmopressin to children over 7 years if short term improvement is a priority or the alarm is inappropriate

Refer children who have not responded to treatment with an alarm and/or desmopressin for further review and assessment

Assessment and investigation

History taking should include asking about and keeping a record of:

Pattern of wetting
Daytime symptoms
Toileting patterns
Fluid intake

Routine urine testing is not necessary unless the wetting has started recently; occurs in the daytime; the child is unwell or there are signs or symptoms of urinary tract infection or diabetes mellitus.

Investigate possible triggers if the bedwetting has started again after being dry for six months or more (secondary enuresis).

Assess for other co morbidities such as constipation and assess, investigate and/or refer to specialist.

Identify the priorities and views of the child and other factors affecting treatment such as sleeping arrangements at home and level of commitment and time available to engage in treatment.

Information and advice

Information suitable to the needs of the child and family should be provided including:

Ways to reduce the effects of bedwetting such as using bedding protection
Where to find support
Fluid intake, diet and toileting patterns
How to use reward systems
Advice on lifting and waking
Discouraging the use of training programmes

Initial treatments include

Advice and reward system alone
Alarm
Desmopressin
Alarm and desmopressin

Further treatments include

Desmopressin combined with an anticholinergic
Imipramine

It is vital that health professionals have a broad knowledge of bedwetting and are familiar with the treatments and how they work. Their support and expertise will be paramount in achieving a positive outcome with children and their families. Professionals who are new to this area of work should request training to prepare them for the challenge.

ERIC provides a range of childhood continence training suitable for all health and social care professionals.

Enuresis alarms

There are two types of bedwetting alarms, the bed alarm (mat) and the body-worn alarm. Both have a moisture sensor, connected to sound unit. Urine triggers the alarm to sound. There are different models to choose from. Some are available with a vibrator unit in the alarm box, ideal for children with hearing difficulties or in shared sleeping situations.

When the sleeping child passes urine onto the sensor it activates an audible sound and/ or vibration. At this point the child reacts by contracting the muscles of the pelvic floor in response to the noise, interrupting the flow and waking up.

In time the child should either start to wake up to the sensation of a full bladder, or sleep through the night, without wetting. The alarm appears to enhance the process of communication and control between the brain and bladder, although the mode of action is not fully understood.

It is important for children to choose the type of alarm they feel most comfortable with. There seems to be no difference between the body-worn alarm and the bedside alarm in overall effectiveness (Butler et al 1990). It is important to let the child and family gain familiarity with both types before choosing. (Salt water will activate the bedside alarm and water will activate the body-worn alarm in a demonstration).

Download ERIC's Dry Night Chart for use with an alarm.

Tips for using the alarm

Bedside alarm

Discourage the use of pyjamas because urine needs to go straight onto the detector mat. A long T shirt is a good idea.
The alarm mat should be covered with a cotton sheet or placed in a pillow case.
Wet sheets should always be washed, even if the wet patch is small, because stale urine and sweat can trigger false alarms.

Body worn alarm

Place the sensor between two pairs of snug fitting pants under pyjamas (girls can insert it into a suitable panty liner inside a pair of pants).
Choose the preferred setting or sound according to the model available.
Make sure the lead is attached.
Clip or attach the sound unit to the pyjama top near shoulder.

What to do when the alarm goes off

Wake up and switch the alarm off (with both types of alarm the switch is on the sound unit). With the body-worn alarm the sensor must also be dried or unplugged to completely de-activate the alarm.
Get up and go to the toilet and finish emptying the bladder.
Help remake the bed and change out of wet clothing.
Record time of wetting on a personal chart.
Reset alarm if there is a history of multiple wettings (if child usually wets only once in the night it can be left off for the rest of the night).

Desmopressin

Desmopressin (paediatric) is a synthetic form of a naturally occurring anti-diuretic hormone called arginine vasopressin (AVP). Its mode of action is to decrease urine production and increase urine concentration and possibly increase arousability. It is available as a tablet, or as a Melt that dissolves under the tongue. It is only available on prescription and recommended for children over seven. It is important that the child does not drink more than sips for 1 hour before taking the medication until 8 hours after. The dose can be increased if necessary. It should be taken for three months at a time. Details about contraindications and side effects are available in the product literature.

Anticholinergics (sometimes called Antimuscarinic medication)

Anticholinergics are thought to act by blocking the muscarinic receptors in the detrusor muscle, therefore reducing bladder contractions. Some also have local anaesthetic properties.

The most commonly used anticholinergic medication is oxybutynin. This is licensed for children with neurogenic bladders and bladder over-activity (day and night) from the age of five years.

Full details concerning contraindications and dosage can be found in the product literature.

Imipramine

This is a tricyclic antidepressant and is not recommended as first-line treatment. It has the effect of improving the bladder capacity. Medical review is recommended every 3 months and gradual withdrawal is required. The risks associated with overdose necessitate safe storage.

Practical ways to help manage the problem

Use waterproof bedding protection
Put dry sheets and nightwear ready for use
Leave a light on the landing to guide to bathroom.
Ensure child is not too warm or too cold in bed

NICE clinical guideline 111 Nocturnal enuresis: The management of bedwetting in children and young people

In November 2010 a new guideline was been published by The National Institute for Health and Clinical Excellence (NICE) for diagnosing and managing bedwetting, a common but often distressing childhood condition.

The guideline is aimed at health professionals involved in the health and well being of children and young people, so that they can offer best practice advice and treatment options based on individual needs and preferences.

The accompanying ‘Understanding NICE guidance’ (NICE 2010) for service users gives an outline of what can be expected from health professionals and should encourage more families to seek treatment at an earlier stage.

Health professionals are ideally placed to provide accessible contact for these families and will be relied upon to deliver good quality information and appropriate intervention.

Download NICE guidelines.

References

Butler RJ, Heron J (2008) The prevalence of infrequent bedwetting and nocturnal enuresis in childhood: A large British cohort. Scandinavian Journal of Urology and Nephrology 42: 257-64

Joinson C, Heron J, Edmond A, Butler R (2007) Psychological problems in children with bedwetting and combined (day and night) wetting: A UK population based study. J Paediatr Psychol; 32(5): 605-616

Sapi MC, Vasconcelos JS, Silva FG, Damiao R, da Silva EA. Assessment of domestic violence against children and adolescents with enuresis. J Pediatr ( Rio J) 2009; 85(5):433-437