Hot Topic
Enuresis
Definition
•
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Uncontrolled/Involuntary passage of urine by
day/night/both
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Children aged 5 or over
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In absence of physical disease
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DSMM defines nocturnal enuresis as wetting
at least x2/wk in the above group
Day or night?
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85% nocturnal enuresis
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Daytime enuresis more likely associated with
pathology
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Potentially large effect on family
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Bullying, problems with schoolwork, social life
Nocturnal enuresis
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Common - approx 15% of children experience
it, rising to 75% if both parents had it.
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Disorder of sleep arousal, a low nocturnal
bladder capacity and nocturnal polyuria
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History needs to distinguish b/w primary and
secondary nocturnal enuresis.
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Primary - bladder control has never been
achieved
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Secondary - lost after having had bladder
control for at least 6 months
Nocturnal enuresis
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15% of 5 year olds
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5% of 10 year olds
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Teenagers 1-2% occasionally wet the bed
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Yearly spontaneous remission rate is 15%
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Usually can be considered a variation of the
normal rate of maturation
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Girls usually ahead of boys
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23% of nocturnal enuresis is associated with
encopresis and daytime incontinence
Contributing factors
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Genetics - 70% have +ve family history
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Caffeine
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Emotional stress
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ADHD, premature delivery
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Organic pathology
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Disturbed sleep, mother young or smoker
Organic causes
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1-2% have underlying physical cause
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UTI
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Chronic constipation
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Bladder overactivity
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Diabetes
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Renal failure
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Congenital anomalies eg ectopic ureter
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Neurological disorders eg neural tube defect
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Sleep apnoea
Assessment - History
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Age of child
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Nocturnal or daytime or both?
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Primary or secondary?
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Other urinary symptoms? (UTI, bladder
overactivity)
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Hx of constipation/soiling?
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Sx of diabetes or of sleep apnoea?
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Family history?
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Girls: early morning wetting? (ectopic ureter)
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PMHx
Assessment - history
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How many dry nights past wk/month?
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Any potential causes of emotional distress
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Fluid intake at bedtime
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Diet - caffeine containing foods eg chocolate
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Impact on family
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Any strategies tried so far, ways parents
respond to the wetting
Examination
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Abdo exam - distended
bladder/mass/constipation
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Inspect perineum/genitals
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Spine
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Check lower limb neurology
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Growth chart
Investigations
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Urine for glucose, protein, C&S in more or less
all.
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If daytime enuresis - consider USS abdo to
exclude anatomical abnormalities/residual
volume
Management
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If indication of underlying cause manage/refer
as appropriate Eg deal with constipation/UTI
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Most children with enuresis are normal
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<5 yrs no need to treat
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<7 yrs and parents/child coping ok often no
need to treat
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>10 treat promptly
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Advice
Management - advice
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Primary enuresis - occurs because the volume
of urine produced at night exceeds the bladder
capacity and the sensation of a full bladder
doesn’t wake the child
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Not done out of defiance/contrariness
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Try not to be angry with the child, stress
aggravates the situation
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Try to reinforce success
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Give it time if child is young
Simple advice for all
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Empty bladder before bed
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Avoid drinking after 1hr before bed
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Otherwise don’t restrict fluids - encourage
regular intake throughout the day but avoid
any containing methylxanthines
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Check access to bathroom at night
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Waterproof covers for bed
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Involve child in cleaning up mess but not as
punishment
Enuresis alarms
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Tx of choice for long-term Mx.
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Children >7yrs. Needs to be a well-motivated
child and family; Usually needed for 3-5
months. 30-50% of children relapse
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Sensor in pad under child or attached to
underwear
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Alarms if gets wet - child has to get up to stop
it. Parents must hear it too (eg baby monitor).
Child to help with cleaning up.
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Child learns to waken before alarm sounds or
to sleep through night without passing urine
Enuresis alarms
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If dry for 14 nights in a row can stop alarm
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Can be used together with drug treatment of
needed
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Treat relapses promptly
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“Overlearning” - once dryness achieved
encourage drinking at bedtime to “overcondition” bladder, stop once 14 dry nights.
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Avoid if child shares a room, more than one
child has enuresis at once, unmotivated
parents.
Star charts
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Alternative to enuresis alarm
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Involves a wall calendar and star stickers
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If dry in the morning child gets a sticker on the
chart and praise as a reward
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Child responds to rewards - reinforce success
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As wetting less frequent can increase rewards
value
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If bed is wet - no punishment but stay calm
and practical
Desmopressin
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2nd line treatment
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In general practice use as short-term measure
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School trips, sleepovers, holidays
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Effective in 70% but high relapse rate once
stop use
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Can be used longer term but not initiated in
primary care
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May be useful adjunct to alarm treatment
Desmopressin
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Synthetic version of antidiuretic hormone
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Reduces amount of urine produced increased water resorption from distal tubules
and collecting ducts
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Taken at night as tablet or a melt
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SEs - headache, nausea, congestion,
nosebleeds, sore throat, cough, mild abdo
cramps
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Risk of water overload - need to counsel
parents and child - limit fluid intake to 1 cup
from 1hr before to 8hrs after taking tab
Desmopressin
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Preferably use in >7yr olds
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Never use for daytime enuresis due to risk of
fluid overload
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Usual dose 200mcg tab/120mcg sublingual tab
at bedtime
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To determine dose and effectiveness trial of
2wks desmopressin. If not enough can try
2wks at double dose
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Once effective dose established can prescribe
it for intermittent use when needed eg school
trip
Secondary enuresis
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If wets after being dry for min 6 months
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Look for underlying cause physical/emotional
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Treat when able but consider referral for some
causes or if can’t identify cause - enuresis
clinic/paediatrics/child psychologist
Daytime enuresis
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Rule out organic causes
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Refer on to secondary care
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MSU + dipstix
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Usually USS
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Star charts/bladder training/pelvic floor
exercises
When to refer
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Most cases can be managed in primary care
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Failed trials of alarm/star chart/desmopressin
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If parents not coping
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If suspicion of underlying cause
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Older children
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Daytime enuresis
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Severe psychological distress
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Secondary nocturnal enuresis if caused by
emotional distress, cause not clearly identified
or enduring/big impact
Who can you involve?
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Health visitor if child is pre-school
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School nurse
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Local enuresis clinic
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Voluntary groups eg ERIC for support and
advice for parents
Resources
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ERIC - Education and Resources for
Improving Childhood Continence
www.eric.org.uk
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Clinical Knowledge Summaries
www.cks.nhs.uk
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Tayside intranet - Bedwetting leaflet in
Children’s hospital section wih local clinic
details
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Oxford Handbook of General Practice
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DXS has selection of leaflets/evidence