HNY Policy and Pathway Repository - York

Nocturnal enuresis (bedwetting) is involuntary wetting during sleep. It is considered normal up to 5 years and uncommon up to 10 years.

Primary nocturnal enuresis: recurrent involuntary passage of urine during sleep in children aged 5 or over, who has never achieved consistent night-time dryness. Often represents developmental delay which resolves over time.

This is divided into those with or without daytime symptoms such as urgency, frequency or daytime wetting.

Secondary nocturnal enuresis: involuntary passage of urine during sleep by a child who has previously been dry for at least 6 months. Requires the exclusion of underlying pathology.

Response to intervention: 14 consecutive dry nights or a 90% improvement in number of wet nights per week

Partial response: improved but 14 consecutive dry nights or 90% improvement in number of wet nights per week has not been achieved

Paediatric Normal Values (adapted from APLS)
Age	Resp Rate	Heart Rate	Systolic BP
Neonate <4w	40-6	120-160	>60
Infant <1 y	30-40	110-160	70-90
Toddler 1-2 yrs	25-35	100-150	75-95
2-5 yrs	25-30	95-140	85-100

• Day and night symptoms: frequency, urgency, wetting 
• Poor stream
• Dysuria
• Recurrent UTIs
• Safeguarding concerns 
• Polydipsia, polyuria – consider diabetes 
• Abdominal mass 
• Abnormal spine/neurology – exclude occult spinal dysraphism or tethered cord (asymmetric/deviation of gluteal cleft)

General Points 

• Widespread and distressing condition that can have deep impact on the emotional, behavioural and social wellbeing of children
• Can be stressful for parents and carers
• Can limit the child’s social life and experiences, e.g. sleepovers, school trips
• May generate negative emotions and behaviours for the child, this may include helplessness, a lack of hope, an awareness of being different from peers, guilt and shame, humiliation, victimisation, and loss of self esteem
• Parents may feel frustrated and helpless
• More common in cases of neglect or abuse
• More common in boys (2:1)
• At age 5y, about 15% of children experience nocturnal enuresis
• There is a strong family predisposition (both parents = 77%, single parent = 43%)
• Only 1/3 affected will seek medical support 
• It is very common, the prevalence decreases with age

Age (y)	5	6	7	8	10	12-14	>15
Prevalence (%)	16	13	10	7	5	2-3	1-2

 

History

• Onset of nocturnal enuresis – if very recent consider whether this is a part of a systemic illness
• Previously dry at night without assistance for 6 months
• Presence of day time symptoms such as frequency, urgency, polyuria, dysuria, poor urinary stream or straining – suggests overactive bladder or rarely an underlying urological disease
• Bedwetting pattern; nights per week, amount, time of night, arousal from sleep
• Large volume in first few hours of night is typical
• Variable volume of urine, often more than once per night, may also have daytime symptoms – consider overactive bladder
• Every night – severe, less likely to resolve than infrequent bedwetting
• Fluid intake; how much do they drink, are they drinking less because if bed wetting, caffeine containing drinks, polydipsia
• Bowel habit; constipation, soiling
• Sleeping arrangements; own room, snoring, disturbed sleep
• Do they have easy access to a toilet at night
• Consider proximity to parents for support
• Consider developmental or behavioural problems, diabetes mellitus or sleep apnoea
• Family history of renal problems or bed wetting
   

Examination

• Check growth
• Abdominal examination – distended bladder, faecal mass
• Check lumbosacral spine for swelling, tuft of hair suggesting spinal dysraphism
• Lower limb neurological examination including tone, power and reflexes
• Visual inspection of perineum
• DO NOT perform a digital rectal examination
   

Differential Diagnoses

• Urinary tract infection – daytime wetting with frequency and urgency
• Constipation and/or soiling
• Diabetes mellitus – polydipsia, weight loss, polyuria
• Developmental delay, attention or learning difficulties
   

Investigations

Usually investigations aren’t indicated for primary nocturnal enuresis, therefore most children will not require any investigations.

The following can be considered 

• Urinalysis: new onset bedwetting, daytime symptoms, signs of illness, unresponsive to treatment
• Ultrasound with post-void volumes: daytime symptoms, unresponsive to treatment, poor stream, palpable bladder

Management

Refer to health child team for first line assessment and advice

Key principles

• Discuss with parents/carer whether they need support
• The management plan should be tailored to the individual child
• Reassure many children under 5 years wet the bed
• Advise parents/carers to take their child to the toilet if they wake during the night
• Suggest a trial of 2 nights in a row without nappies for a child who has been toilet trained during the day for 6 months
• Explain the important of appropriate fluid intake and using the toilet to pass urine regularly during the day and before sleep (4-7x/d); this helps to train the bladder to hold larger volumes
• Consider whether emotional or behavioural problems need the involvement of a professional with psychological expertise
• Treat constipation if present
• Both parent and child must be motivated before starting behavioural interventions

Fluid intake 

• Amount of fluid needed varies according to the ambient temperature, dietary intake and physical activity
• Advise against fluid restriction
• Avoid caffeine-based drinks

Age (y)	Gender	Water from drinks (ml)*
4-8	All	1200
9-13	Girls	1600
	Boys	1800
14-18	Girls	1800
	Boys	2600

*Adequate intakes and not specific requirements

Behavioural

• Adapted to stage of development
• Include encouragement and reward systems
• Rewards should be given for agreed behaviour rather than dry nights,
• Drinking recommended fluid levels during the day
• Using the toilet to pass urine before sleep
• Engaging in management, such as taking medication or changing bedding
• Previously gained rewards should not be removed

Alarm Treatment

• The most useful and successful way to treat bedwetting
• It may take 6-8 weeks to work
• Recommended from 6y onwards, depending on physical ability, maturity and motivation
• Children should be ‘in charge’ of their alarm and may need to be woken initially to turn the alarm off
• It is critical the child is fully awake during the process of going to the bathroom
• Reward systems can be useful during alarm therapy to reward behaviours such as
  • Waking up when the alarm goes off
  • Going to the toilet
  • Returning to bed
  • Resetting the alarm
• If the child is showing signs of response after 4 weeks, continue treatment until 2 weeks of uninterrupted dry nights are achieved
• Discontinue if not improvement within 4 weeks
• Alarm use can be restarted immediately without consulting a healthcare professional, if bedwetting starts again after stopping treatment

Desmopressin Treatment

Desmopressin is a synthetic analogue of vasopressin with an anti-diuretic action, which results in decreased urine production and increased urine concentration.

• It can be used in children >5y
• Relapse rates are high; 60-70%

Indications

• Alarm therapy has failed or is not suitable
• If rapid onset/short-term improvement is a priority of treatment

Sublingual desmopressin oral lyophilisates
>5y, initially 120 micrograms at bedtime; if needed, after 1-2 weeks increase to a maximum of 240 micrograms at bedtime

Or

Oral desmopressin tablets
>5y, initially 200 micrograms at bedtime, if needed, after 1-2 weeks increase to a maximum of 400 micrograms at bedtime

Indications for referral to bladder and bowel specialist nurses

• Primary nocturnal enuresis where red flags have been excluded
• AND little progress despite intervention and advice from the Healthy Child team
• Only available to Vale of York CCG patients

Indications for referral to paediatrics

• Unexplained persistent secondary enuresis
• Persistent enuresis with failure of an enuresis alarm
• Day-time enuresis or combined day/night enuresis after exclusion or treatment of a UTI and constipation
• History of recurrent UTIs
• Co-morbidity such as type 1 diabetes, physical or neurological problems
• Substantial psychological or behavioural problems

Information to include

• How long has problem been present?
• What treatment has been offered
• Any investigations and results
• Current medication
• Any developmental, attention or learning difficulties
• Any family problems

Patient information leaflets/ PDAs

Patient info -childrens-health/bedwetting-nocturnal-enuresis

Eric.org.uk - bedwetting

Nocturnal enuresis parent leaflet

 

References

• National Institute for Clinical Excellent [NICE] (2010) Bedwetting in under 19s: Clinical guidelines CG111 [Viewed 23 Aug 2021]
• National Institute for Clinical Excellent [NICE] (2020) Bedwetting (enuresis) [Viewed 23 Aug 2021]
• BNFc Nocturnal enuresis in children: Treatment summary [Viewed 23 Aug 2021]
• Kiddoo D; Nocturnal enureisis: non-pharmacological treatments. BMJ Clin Evid. 2015 Jan