When to refer

• Night wetting persistent or failed treatment.
• Day wetting persistent after constipation / UTI treated.
• Night and day wetting.
• Complex presentation (Neurodevelopmental)
• Family distress (punishment, conflict)

Referral Information needed

Please collect and include in your referral as much detail as possible. This will assist triage.

• Previous management and outcome
• Associated symptoms of constipation or soiling
• Co-morbidities
• Social vulnerability
  

Initial Work-up

Night wetting

• Offer treatment  7 years or older.
• Use diary to measure and monitor.
• Explore parenting practices e.g. night fluid restricting, overnight toileting, punitive practices.
• Urine microscopy not required unless separate symptoms indicative of urinary tract infection.
• Assess whether constipation is a problem.

Day wetting

• Consider overactive bladder, low awareness bladder sensation, poor attention / concentration.
• Exclude urinary tract infection with urine microscopy.
• Consider constipation.

Recommended pre-referral treatment

Night wetting

• Explain causes including genetics.
• Cease night fluid restriction.
• Ensure parents understand that overnight toileting is not curative.
• Treat constipation. (see Clinical Practice Guideline Constipation)
• Enuresis alarm 6-12 weeks.
• Oral Desmopressin
  • Authority for failed alarm treatment and when alarm not suitable (eg school camp)
  • Also useful for symptom relief and for short periods (school camp).
  • 'Melts' have better bioavailability than tablets.
  • Desmopressin nasal spray not recommended (higher risk of hyponatremia). 
• NB: Imipramine not recommended (high risk and desmopressin safer alternative).
• Alarm should be re-tried each year.

Day wetting

• Treat constipation (see Clinical Practice Guideline Constipation )
• Treat rinary ract nfection (UTI) 
• Institute regular toileting program

Resources and links

• RCH Clinical Practice Guideline- Enuresis
• Make a referral to RCH Specialist Clinics
• Melbourne Health Pathways (GP Password required )
  
  Parent Information about bedwetting:

•  Kids Health Info
• Videos - Using a Bell and Pad alarm - Using a personal alarm 
•  Raising Children Network 
  
  

Guideline first published Jan 2008. Reviewed August 2018. Please read  Copyright and Disclaimer