Exclusion of organic pathology, for example, urinary tract infection, diabetes mellitus, neurogenic bladder should be carried out first.
- referral to specialists is only required if there is an underlying physical abnormality, if there are associated complex psychological difficulties, or if the child does not respond to initial management (1)
- NICE state that the clinician should (2):
- consider assessment, investigation and/or referral when nocturnal enuresis is associated with:
- severe daytime symptoms
- a history of recurrent urinary infections
- known or suspected physical or neurological problems
- comorbidities or other factors
- constipation and/or soiling
- developmental, attention or learning difficulties
- diabetes mellitus
- behavioural or emotional problems
- family problems or a vulnerable child or young person or family
- investigate and treat children and young people with suspected urinary tract infection
- investigate and treat children and young people with soiling or constipation
- children and young people with suspected type 1 diabetes should be offered immediate (same day) referral to a multidisciplinary paediatric diabetes care team that has the competencies needed to confirm diagnosis and to provide immediate care
Once the contributory factors (e.g. constipation, urinary tract infection) have been ruled out or addressed, the following treatment approach can be commenced in physically and psychologically normal children (3):
- note that it is important to assess the parental expectations
- if the child (under 7 years of age) and the parents do not find the symptoms troublesome, active interventions might not be necessary
- generally it is considered inappropriate to treat nocturnal enuresis in children under 5 years of age
- the first step in management is to reassure both the child and the parent that the condition is common and beyond conscious control (3)
- explain the effects, aims, advantages and disadvantages of possible treatment
- inquire whether short term dryness is important for family or recreational reasons (e.g. – sleep over)
- ask about the personal views of the patients on bedwetting e.g. - what the main problem is and whether it requires treatment (2)
- address excessive or insufficient fluid intake and abnormal toileting patterns before starting other treatments - advise children and young people and their parents or carers:
- that adequate daily fluid intake is important (see linked item)
- that the amount of fluid needed varies according to the ambient temperature, dietary intake and physical activity
- that caffeine-based drinks should be avoided
- to eat a healthy diet and not to restrict diet to treat bedwetting ?
- about the importance of using the toilet to pass urine regularly during the day and before sleep (between four and seven times a day). Parents or carers should continue to encourage regular toilet use alongside treatment
- advise on using a reward system - explain that reward systems with positive rewards for agreed behaviour rather than dry nights should be used either alone or in conjunction with other treatments for bedwetting. For example, rewards may be given for:
- drinking recommended levels of fluid during the day
- using the toilet to pass urine before sleep
- engaging in management (for example, taking medication or helping to change sheets)
- suggest a trial without nappies or pull-ups for children and young people wearing them at night
- consider whether or not it is appropriate to offer alarm or drug treatment, depending on the age of the child or young person, the frequency of bedwetting and the motivation and needs of the child or young person and their family (2)
NICE suggested algorithm for treatment of nocturnal enuresis (2)
- a rewards system is appropriate for a young child who has some dry nights
- alarm treatment is appropriate if :
- bedwetting has not responded to advice on fluids, toileting and appropropriate reward system and
- alarm treatment is desirable and appropriate
- then
- offer an alarm as first-line treatment
- consider an alarm for children under 7 years
- pharmacological treatment is appropriate if:
- rapid-onset and/or short-term dryness is a priority or
- alarm treatment is undesirable or
- alarm treatment is inappropriate (particularly if parents or carers are having emotional difficulty coping or are expressing anger, negativity or blame)
- then
- offer desmopressin for children and young people over 7 years
- consider desmopressin for children aged 5-7 years if treatment is required
- other pharmacological treatment options include anticholinergics and imipramine
There are a variety of non-pharmacologic measures which can be employed, including:
- conditioning alarm - for example, bell and pad technique
- bladder training - consciously prolong intervals between voidings
- reward systems - for example, gold star on a chart
Pharmacologic measures, which are usually reserved for the older child, include:
- desmopressin - 12-40% cure rate; of benefit in up to 80%
- may be used short-term or as a one-off measure, for example, an overnight stay at a friend's house. This drug must be used with caution because of the risk of hyponatraemic convulsions (4)
- desmopressin should not be used for longer than 3 months without a review (1)
- because of the serious adverse effects associated with the nasal spray formations, oral formations of desmopressin are recommended (5)
- tricyclic antidepressants - for example, imipramine
- these have an antimuscarinic effect, but the effect is temporary in the majority of cases, with a high relapse rate, and long term cure in 25%. Generally not used as a first-line treatment
- in consideration of imipramine and the potential for fatal accidental ingestion or overdose a review (1) stated that "the risks of using imipramine generally outweigh any potential benefit in tackling bedwetting"
- some experts suggest screening for long QT syndrome with an electrocardiogram before initiation of therapy (6)
- oxybutynin - sometimes used if there are features of bladder instability or refractory enuresis (7)
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