Enuresis - Bed wetting and Monosymptomatic Enuresis

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  • See also

    Constipation

    Key Points

    1. Attaining night time continence is a normal developmental process, with significant age variation. There is a strong genetic tendency to bedwetting.
    2. Enuresis is common and generally causes no lasting problems. Typically treatment is not started before age 6 years, as there is a high rate of spontaneous resolution.
    3. The presence of daytime, lower urinary tract symptoms requires a different approach.
    4. Alarm therapy is the most effective treatment modality available in children older than 6 years of age, but requires motivation of both child and parent.

    Background

    • Monosymptomatic enuresis (MSE) is defined as enuresis without any other lower urinary tract symptoms or history of bladder dysfunction. MSE is usually divided into primary and secondary enuresis.
    • Most children who wet the bed have no significant underlying physical or emotional problems.  However, many will feel embarrassed or ashamed and suffer from decreased self-esteem, particularly as the child gets older.
    • For most children, enuresis is only seen as a problem when it interferes with their ability to socialise with friends (for example overnight stays or school camps). If the enuresis is infrequent and/or not distressing to the child or parents, treatment is not indicated.
    • Daytime bladder control and coordination usually occurs by 4 years of age, however night-time bladder control typically takes longer and is not expected until a child is 5–7 years old.  At 4 years of age, nearly 1 in 3 children wets the bed, but this falls to about 1 in 10 by age 6.
    • The pathogenesis involves several possible mechanisms including nocturnal polyuria, detrusor overactivity and an increased arousal threshold. 

    Assessment

    Red flag features in Red

    History

    Much of the history should focus on voiding habits.

    • Onset of bedwetting (if acute- last few days to weeks- consider whether this is a presentation of systemic illness)
    • Has the child previously been dry at night without assistance for 6 months? (If so, consider possible medical, emotional, or physical triggers). The presence of unexplained persistent secondary enuresis despite adequate management should prompt specialist referral.
    • Presence of day-time symptoms (frequency, urgency, polyuria, dysuria/recurrent UTI, poor urinary stream/straining, leakage). If daytime symptoms predominate, consider treating before bedwetting.
    • Bedwetting pattern and trend (nights per week/month, amount, time of night, arousal from sleep)
    • Fluid intake (restrictions in fluid intake, caffeine containing drinks, polydipsia)
    • Bowel habit (constipation / soiling).
    • Sleeping arrangements and routine (including own bed/bedroom, snoring and disturbed sleep).
    • Medical History: consider other co-morbid factors which may exacerbate or prolong nocturnal enuresis; developmental or behavioural problems, diabetes mellitus or sleep apnoea.
    • Family history of bedwetting or renal problems.
    • Social history; family capacity and motivation to engage in treatment, social difficulties (vulnerable child/family). 

    Examination

    • Height, weight, BP – poor growth / loss of weight / hypertension
    • Abdomen – distended bladder, faecal mass.
    • Inspection of external genitalia (and perianal area if constipation also present).
    • Lower Back/Spine – exclude occult spinal dysraphism or tethered cord (asymmetric/deviation of gluteal cleft).
    • Assessment of lower limb neurology.

    Management

    Investigations

    Dipstick urinalysis is not required in primary enuresis. Consider if red flags apparent. Further imaging or blood tests are not routinely recommended in enuresis.

    Treatment

    General Advice:

    • Constipation, if present, should be adequately managed before addressing enuresis. 
    • Advise on normal bladder function and the pathogenesis of enuresis, including the genetic tendency.  Also, that this is a common problem effecting their peer group and they should not be embarrassed.
    • Encourage regular fluids and toileting throughout the day (e.g. during school break times) and just before bedtime.
    • Advise against fluid restriction, but eliminate caffeinated beverages in the evening.
    • Both parent and child must be motivated before starting behavioural interventions.

    Bedwetting (Pad and Bell) Alarms:

    • Considered the most useful and successful initial way to treat bedwetting - good long-term success and fewer relapses than medication.
    • Require a supportive and helpful family and it is important to communicate to families that it may take 6 to 8 weeks to work.
    • Generally recommended in children from 6-7 years of age, depending on their physical ability, maturity and motivation.
    • Mild to moderate intellectual impairment does not preclude treatment and in hearing impaired children consider using a vibrating alarm.
    • Not suitable if the carer is experiencing emotional difficulty, expressing anger or blame toward the child, or is unlikely to cope with the additional burden of a bedwetting alarm and sleep disruption in the household. 

    Practical considerations and duration of therapy:

    • Bedwetting alarms are available for hire from selected pharmacies, community continence services, tertiary centres, and private practitioners. The Continence Foundation of Australia has a list of service providers.
    • Children should be ‘in charge’ of their alarm and may need to be woken initially to turn the alarm off themselves. It is critical for success of alarm therapy that 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 or going to the toilet when the alarm goes off (Not for dry nights per se).
    • If a child is showing early signs of response after 4 weeks, continue treatment until 2 weeks of uninterrupted dry nights are achieved.
    • Discontinue treatment if no early signs of response within 4 weeks.
    • If there is incomplete dryness after 3 months, reconsider if ongoing treatment is appropriate or a further trial of the alarm in 3-6 months. 

    Overlearning

    • Once dryness is achieved for 2 weeks or more, consider introducing “overlearning” - to over condition the bladder. Encourage the child to drink extra fluids in the hour before bedtime, providing a greater challenge to remaining dry, which may reduce the rate of relapse.

    Pharmacological Therapy 

    NB: Tricyclic medications are no longer recommended.  They are less effective than other therapies and have a higher risk of adverse events.

    Desmopressin: MinirinTM melt/tablet

    • Indicated when:
      • alarm therapy has failed or is not suitable
      • if rapid onset/short-term improvement is a priority of treatment.
    • Relapse rates are high when withdrawn, (60 to 70 percent).
    • Evaluate maturational appropriateness of use for children <7 years of age. 

    Sublingual

    >6 years, sublingual, initially 120 micrograms at bedtime; if needed, after 1-2 weeks increase to a maximum of 240 micrograms at bedtime.

    Oral

    >6 years, oral, initially 200 micrograms at bedtime; if needed, increase to 400 micrograms at bedtime.

    Intranasal route is not recommended due to higher risk of hyponatraemia.

    Practice Points

    • Restrict fluid from 1 hour before the dose until at least 8 hours after the dose. Desmopressin is contraindicated for children who can’t control fluid restriction.
    • Assess response after 4 weeks to determine continuation of treatment (if no response consider cessation).
    • Withdraw for at least 1 week every 3 months to assess for relapse and ongoing need for medication. 

    Behavioural Therapy: Lifting, Walking & Waking

    • Neither lifting (carrying a child to the toilet with an effort not to wake them) nor waking and walking the child to the toilet will promote long-term dryness.
    • Waking a child by parents or carers, either regularly or randomly, is only a short-term method of managing bedwetting.  A young person who self-instigates waking (using a mobile phone alarm or an alarm clock) may be a useful strategy.

    Consider referral to a general paediatrician or continence service when:

    • Red flags are present.
    • 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 urinary tract infections.
    • Comorbidities such as type 1 diabetes, physical or neurological problems.
    • Substantial psychological or behavioural problems (consider mental health referral, paediatrician and/or child protection services if significant concern exists).

    Parent information 

    Kids health info: Bedwetting 
    Raising Children Network: Bedwetting

    Last updated July 2019

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