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Flowchart – Night Time Wetting (Nocturnal Enuresis / Bedwetting)
Every child must be fully assessed using the appropriate Continence Assessment Form. If constipation is identified, follow the flowchart below to ensure the child receives the correct assessment, treatment and management.
The ‘pop-up’ information boxes suggest who might deliver each intervention. In England the local CCG (Clinical Commissioning Group) can clarify who is commissioned to do so. Information to support the commissioning of children’s continence services can be found in the PCF’s Paediatric Continence Commissioning Guide. In Scotland and Wales, ask your GP, Health Visitor or School Health Nurse for advice on who provides local continence care.
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Night time wetting identified by GP
Night time wetting identified by School Health Nursing / Health Visiting / Children's Community Nursing / Learning Disability Team
GP to inform/refer to School Health Nursing / Health Visiting / Children’s Community Nursing / Learning Disability Team
Only night time wetting / monosymptomatic nocturnal enuresis OR constipation and/or daytime bladder symptoms treated and night time wetting persists
Primary – never been dry for a 6 month period
Secondary – dry for at least 6 months prior to this episode
Assess for a systemic cause or trigger or comorbidities e.g. UTI, constipation, Diabetes mellitus, psychosocial situation, neurological cause. If present refer or treat as appropriate
No concerns
Initial advice
• Demystify, reassure, educate
• Provide Advice for Children with Night Time Wetting
• Fluid optimisation – 6-8 drinks/day – offer Drinking Reward Chart
• Toileting advice – 4-7 voids/day - offer Toileting Reward Chart
• Advise on rewards for compliance
• Suggest trial without nappies or pull-ups
• Signpost to ERIC for further information/reassurance and advice on bedding protection etc
Pre school age
School age
Reassure that 1 in 5 children age 4½ wet the bed at least once a week and many achieve dryness spontaneously. Advise to continue to follow above advice and to seek help from School Health Nurse if wetting persists beyond 5 years of age and intervention is desired.
No progress after implementation of initial advice
• Refer to School Health Nurse if not yet seen
• Reassess number of wet nights/week, size of wet patches, number of times/night, time of occurrence using Night Time Diary
• Discuss, explain, and offer treatment options
Child seems suitable for an alarm as first line treatment
Child seems suitable for Desmopressin as first line treatment. Start on e.g. 120mcg DesmoMelt
• Refer to Advice for Children with Night time Wetting
for information about using alarms
• Provide Bedwetting Alarms – Your Questions Answered
• Monitor progress using Bedwetting Alarm Diary
• Refer to Advice for Children with Night time Wetting for information about taking Desmopressin
• Provide Using Desmopressin as a treatment for bedwetting
• Monitor progress using Night Time Diary