June Rogers shows how NICE Quality Standard 70 could help to improve outcomes for children and young people with nocturnal enuresis and their families

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Read this article to learn more about:

  • why bedwetting should be addressed at an early stage
  • the importance of a comprehensive assessment and timely review
  • how access to treatments improves outcomes for children and families.

Key points

Audit points

GP commissioning messages

 

Nocturnal enuresis (bedwetting) affects approximately 20% of 5-year-olds, with the incidence decreasing by about 15% each year to around 6% by age 11 years.1 This common condition can have a deep impact on a child's behaviour, emotional wellbeing, and social life.2 Bedwetting has been associated with parental intolerance and in some cases punishment.3,4 Authors of a large British cohort study5 identified that children who are considered to have either severe bedwetting (i.e. wet every night at age 4.5–5 years) or the non-monosymptomatic form (i.e. with signs of bladder dysfunction) and whose condition is left untreated are likely to persist with bedwetting throughout childhood and into adolescence.5 Untreated bedwetting has also been linked to persistence of the condition into adulthood, with a prevalence rate of 2–3%.6 Early intervention and active management is therefore recommended.5,6

This article focuses on NICE Quality Standard (QS) 70 for Nocturnal enuresis: the management of bedwetting in children and young people (2014) (see also Table 1, below). This quality standard covers the assessment and treatment of all children and young people aged from 5 to 18 years with bedwetting.7

The five quality statements are based on key recommendations in NICE CG111 and describe those high-priority areas requiring quality improvement including assessment and treatment, with equality and diversity considerations threaded through each statement.

Table 1: NICE quality standard for nocturnal enuresis (bedwetting) in children and young people—list of quality statements7
No.Quality statement
1 Children and young people who are bedwetting have a comprehensive initial assessment.
2 Children and young people have an agreed review date if they, or their parents or carers, are given advice about changing their daily routine to help with bedwetting.
3 Children and young people, and their parents or carers if appropriate, have a discussion about initial treatment if bedwetting has not improved after changing their daily routine.
4 Children and young people who are bedwetting receive the treatment agreed in their initial treatment plan.
5 Children and young people whose bedwetting has not responded to courses of initial treatments are referred for a specialist review.

NICE (2014) QS70. Quality standard for nocturnal enuresis: the management of bedwetting in children and young people. Available at: www.nice.org.uk/guidance/qs70

Reproduced with permission.

NICE Quality Standard 70 for nocturnal enuresis in children and young people

Comprehensive initial assessment—statement 1

A number of factors can cause bedwetting in children and young people, including the volume of night-time urine produced, the ability of the bladder to store urine, and the child's level of arousal to bladder signals.8 Other contributing factors can include social and emotional issues, constipation, fluid intake, toileting, and family history. A comprehensive history will enable all factors to be identified and help determine the most appropriate treatment (see Table 2, below).2

A thorough history should be taken to include the pattern, frequency, and volume of the bedwetting and related factors such as fluid intake, day-time symptoms, toileting patterns, and bowel history (including both frequency and consistency of stools, using the Bristol stool form scale2,9).

Studies have identified the role that constipation can play in contributing towards bedwetting, and because constipation is often asymptomatic in its early stages, it may be only when a parent presents with a bedwetting problem in their child that the constipation is found.10,11 Untreated constipation can lead to impaction and soiling. For further advice on the management of constipation, see NICE CG99 on Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care.12

Similarly, we know that a number of children with bedwetting have daytime bladder problems.5 Many parents, however, dismiss urgency, frequency, and the odd pair of wet pants as part of the natural maturation process and so do not seek help; again, it is only when they come forward with the bedwetting problem that these potentially serious underlying bladder problems are identified.13 Other co-morbidities, such as diabetes and the presence of urinary tract infections, will also need to be excluded.2

It may be appropriate to suggest that the child/young person, and/or their parent or carer, complete a record of fluid intake and toileting, as well as maximum voided volumes on at least three occasions, to help determine any contributory factors.8

Table 2: Findings from the history taking and their possible interpretation2
Findings from historyPossible interpretation
Large wet patches within a few hours of sleep Typical pattern of bedwetting as a result of nocturnal polyuria (lack of vasopressin)
Wetting more than once with variable wet patches Typical pattern of bedwetting as a result of possible underlying bladder problem such as overactive bladder
Bedwetting every night Classed as severe bedwetting which is less likely to resolve spontaneously than infrequent bedwetting
Bedwetting after a period of dryness of more than 6 months Bedwetting is defined as secondary
Day-time symptoms including:
  • frequency
  • urgency
  • abdominal straining
  • poor stream
  • wetting accidents
  • history of UTI
Any of these may indicate an underlying bladder disorder, such as OAB or dysfunctional voiding, which would warrant further assessment
Constipation A common comorbidity that can cause bedwetting and which requires treatment (see Constipation in children and young people [NICE CG99])12
Soiling Frequent soiling is usually an indication of underlying constipation with faecal impaction
Inappropriate fluid intake, including:
  • inadequate fluid intake
  • high consumption of fizzy/caffeine drinks
  • maximum fluid intake late in the day
  • Inadequate fluid intake may mask an underlying bladder problem (e.g OAB) and also may affect the development of an adequate bladder capacity
  • Fizzy and caffeine-containing drinks have been shown to irritate the bladder in some cases
  • Having majority of fluid intake later in the day can contribute towards the bedwetting
Behavioural and emotional problems These may be a cause or a consequence of bedwetting. Treatment may need to be tailored to the specific requirements of each child or young person and family
Practical issues Easy access to a toilet at night, sharing a bedroom or bed, and proximity of parents to provide support are important issues to take into account and address when considering treatment, especially that with an alarm
Family issues including parental intolerance A difficult or 'stressful' environment may be a trigger for bedwetting. These factors should be addressed alongside the management of bedwetting

UTI=urinary tract infection; OAB=overactive bladder

Adapted from: NICE (2010) CG111. Nocturnal enuresis: the management of bedwetting in children and young people. Clinical Guideline 111. NICE, 2010.
Available at: www.nice.org.uk/guidance/cg111 Reproduced with permission.

An example chart for recording fluid intake and voided volumes.

Agreed review date—statement 2

Initial advice may be given to children and young people and their parents or carers about making changes to the child's daily routine based on the initial assessment. This advice could include adjustment of fluid intake and changes to toileting, as well as discussions around lifting and waking, and reward systems.7

It is important that after this initial advice has been given, a date is set to review progress and to assess whether initial treatment is required.7 Toileting adjustment in the form of bladder training has long been the mainstay of initial therapy for all children with bedwetting; a recent study of children aged 6 years and over with enuresis, however, has suggested that this recommendation can no longer be supported. Instead, the authors recommend that treatment of children with bedwetting should start with an enuresis alarm or desmopressin without delay.14

Discussion about initial treatment if bedwetting has not improved—statement 3

If bedwetting has not improved following changes to the child's daily routine, then initial treatment with either an alarm or desmopressin should be discussed.2,7

Consideration of which treatment is most appropriate should take into account both the outcome of the assessment and the family's preferences. Factors such as the child's age, motivation, any associated functional difficulties, and the impact of the bedwetting should also be taken into account (see Table 3, below).2,7

Alarms

An alarm is recommended for children who wet more than once or twice a week, are considered motivated, and have the maturity and understanding to cope with the treatment. The alarm consists of a moisture sensor and sound box and works by waking the child as they wet the bed. It can take a number of weeks before any progress is shown and as a result the family must also be tolerant and supportive, otherwise poor compliance and early withdrawal from treatment is common.15

Table 3: Tailoring treatment to underlying pathophysiology
Presenting symptom(s)Suggested treatment
  • Normal night-time urine output
  • No daytime bladder symptoms
  • Average bladder capacity for age using the following formula:
    • age × 30 + 30 = maximum voided volume in mls
Consider either alarm or desmopressin as first-line treatment taking into account child's:
  • age
  • motivation
  • previous experiences
  • parental expectations and preferences
Nocturnal polyuria (indicated by wetting large patches within a few hours of going to sleep) Consider desmopressin as first-line treatment taking into account child's age and motivation
Small bladder capacity/apparent high arousability/good motivation and family support Consider alarm as first-line treatment taking into account child's age and motivation
Day-time bladder symptoms, including frequency (> × 7 voids per day) or urgency suggestive of an OAB Initiate bladder retraining programme and introduce anticholinergics (e.g. oxybutinin) if necessary
If single first-line treatment fails, consider for those with:
  • nocturnal polyuria with voided volumes
  • nocturnal polyuria with suspected OAB
  • OAB/small voided volumes/high arousal threshold

  • desmopressin plus alarm
  • desmopressin plus anticholinergic
  • anticholinergic plus alarm

OAB=overactive bladder

Desmopressin

Desmopressin is a synthetic analogue of vasopressin and can be prescribed from age 5 years. It works by reducing the volume of urine produced at night.

Desmopressin also has a level 1 grade A recommendation from the International Consultation on Incontinence.16,17 It is available in tablet or melt formulation (see Box 1, below); the latter is recommended in a number of studies for children because of its increased bioavailability and ease of administration.17,18 It is more effective for children with suspected nocturnal polyuria.

Children receive the treatment agreed in their initial treatment plan—statement 4

Once the child and family have made an informed choice to use either an alarm or desmopressin as initial treatment, they should be able to receive that treatment. Any delay in the agreed treatment could put further pressure on families already struggling to cope with a very stressful problem and may also have a negative impact on outcomes for the child.7

It is important, therefore, that policies and resources are in place to support healthcare professionals to deliver agreed treatments and that there are no barriers to treatment, such as lack of suitable alarms, long waiting lists, or treatment policies that, for example, exclude children with additional needs or those aged under 7 years.

Box 1: Desmopressin formulations

  • By mouth (as desmopressin acetate)
    • Child 5–18 years: 200 micrograms at bedtime, only increased to 400 micrograms at bedtime if lower dose not effective (important: see also Cautions); withdraw for at least 1 week for reassessment after 3 months
  • Sublingually (as desmopressin base)
    • Child 5–18 years: 120 micrograms at bedtime, only increased to 240 micrograms at bedtime if lower dose not effective (important: see also Cautions); withdraw for at least 1 week for reassessment after 3 months.

NB Follow BNF/BNFC cautions on prescribing desmopressin. Advice on desmopressin can be found in the current online version of BNF/BNFC. The endocrine system chapter and other relevant sections should be consulted. Available at www.bnf.org/bnf/index.htm

Access to specialist review for children whose bedwetting has not responded to initial treatment—statement 5

Children whose bedwetting has not responded to initial treatments should be referred for specialist review so that any underlying factors, such as overactive bladder, can be assessed. Specialist services could include communitybased paediatric continence services or dedicated enuresis clinics, which besides benefiting the child might ultimately reduce the number of inappropriate hospital referrals and therefore overall costs.7

Non-response to treatment is defined as when the child has not had 14 consecutive dry nights or a 90% improvement in the number of wet nights per week. Response to either the alarm or desmopressin should be assessed at 4 weeks and the treatment reviewed if signs such as reduction in wet nights or smaller wet patches are not present.2,7

If a response is present, treatment should be continued for a further 3 months by which time complete dryness would be expected. If this has not been achieved, then treatment should again be reviewed. If the child is using an alarm, treatment should only continue if there are clear signs of continuing improvement and the family remains motivated.2,7

Desmopressin can continue to result in improvement for up to 6 months after starting treatment and can be continued for as long as necessary. It is important, however, that treatment is withdrawn for 1 week after every 3 months to check response and evaluate the need for ongoing treatment.2,7

For those children who fail to show a response with single treatments, combined treatments could be tried. This could be any combination of treatments, for example, desmopressin and an alarm, or desmopressin and an anticholinergic.2 NB Not all anticholinergics have a UK marketing authorisation for treating bedwetting in children and young people. If a drug without a marketing authorisation for this indication is prescribed, informed consent should be obtained and documented.

Traditionally the majority of children with bedwetting are seen by school nurses or dedicated paediatric continence services and this should continue, however, those working in primary care are in an ideal position to manage the problem of bedwetting. The majority of affected children do not require extensive investigations or treatments and the NICE quality standard gives clear recommendations regarding the assessment and treatment process.

A range of resources for children, young people, parents, carers, and healthcare professionals are available, see Box 2, below for more information.

Box 2: Sources of further information

PromoCon: promoting continence and product awareness

Education and Resources for Improving Childhood Continence (ERIC)

Stop Bedwetting

Conclusion

NICE QS70 on nocturnal enuresis (bedwetting) in children and young people highlights the importance of a comprehensive assessment for children with bedwetting, not only to identify causative factors but also to help direct treatment.7

The statements in NICE QS70 around access to treatment were chosen because of the misinterpretation of the recommendations in the original guideline. In NICE CG111 the alarm was recommended as first-line treatment depending on the outcome of the assessment and patient preference deeming it suitable. However, this recommendation was taken out of context with the belief that the alarm should be tried first for every child with bedwetting without considering the assessment outcomes or preferences of the child and family. This resulted in long waiting lists for the alarm and its inappropriate use in many cases with many children being denied access to appropriate treatment.

Practitioners should remember that bedwetting is potentially also a symptom of an underlying problem (e.g. with the bladder or with constipation) and the assessment will be an opportunity to identify these problems at an early stage. We know that nocturnal enuresis can improve with treatment and, importantly, that successful treatment can improve self-esteem and quality of life.7 It is important, therefore, to offer timely treatment and to have pathways in place for referring children on to more specialist services when first-line treatments have proved ineffective.

Assessment

  • The proportion of children and young people who are bedwetting and who receive:
    • a comprehensive initial assessment (to include both bladder and bowel)
    • that assessment to include a completed fluid intake and output diary

Treatment

  • The number of decisions regarding treatment that have taken into account:
    • the outcome of initial comprehensive assessment
    • factors such as age, any associated difficulties, motivation
    • preferences of the child and family.

Key points

  • Bedwetting is a common and often distressing childhood problem that, if left untreated, can continue through adolescence into adulthood
  • Initial assessment could include a fluid intake, bladder, and bowel diary completed by the child and family
  • Day-time bladder symptoms and any underlying constipation should be identified and addressed if present
  • If initial advice regarding lifestyle changes do not result in improvement, then first-line treatments need to be discussed
  • The choice of first-line treatment (either desmopressin or alarm) should be informed by the initial assessment and take into account personal preferences and individual needs
  • Treatment should be considered for all children with bedwetting from age 5 years, including those with additional needs
  • GPs will be able to carry out initial assessment and offer advice as necessary, including prescribing medication as appropriate
  • Further detailed assessment and advice, particularly around the alarm, should be available via local services such as school nurse clinics or community-based paediatric continence services
  • Guidelines and pathways need to be in place to ensure children with bedwetting receive timely assessment and treatment, and are referred for specialist care if necessary.

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Audit points

Assessment

  • The proportion of children and young people who are bedwetting and who receive:
  • a comprehensive initial assessment (to include both bladder and bowel)
  • that assessment to include a completed fluid intake and output diary

 

Treatment

The number of decisions regarding treatment that have taken into account:

  • the outcome of initial comprehensive assessment
  • factors such as age, any associated difficulties, motivation
  • preferences of the child and family

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GP commissioning messages

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • CCGs should map the commissioning and provision of services for this condition and identify any gaps and improvements that need to be made to meet the standards set in NICE QS70
  • The majority of cases can be dealt with in primary care but responsibility for providing this care can fall with GPs, school nurses, and health visitors so responsibility needs to be clearly defined as to 'who does what'
  • An initial comprehensive assessment is a vital part of the process and should be commissioned against the quality requirements identified in this standard
  • Care pathways should also identify a step-wise treatment plan and ensure prompt access to any specific aids e.g nocturnal alarms
  • Responsibility for the initiation and prescribing of any pharmacotherapy for enuresis should be clearly defined along with licensed indications for any drugs used
  • Access to specialist children's services should be ensured for those with atypical symptoms or who are resistant to first-line community management.

CCG=clinical commissioning group; QS=quality standard

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References 

  1. Kilicoglu A, Mutlu C, Bahali M et al. Impact of enuresis nocturna on health-related quality of life in children and their mothers. Journal of Pediatric Urology 2014; 10: 1261–1266.
  2. NICE. Nocturnal enuresis: the management of bedwetting in children and young people. Clinical Guideline 111. NICE, 2010. Available at: www.nice.org.uk/guidance/cg111
  3. Butler R, McKenna S. Overcoming parental intolerance in childhood nocturnal enuresis: a survey of professional opinion. BJU Int 2002; 89 (3): 295–297.
  4. Can G, Topbas M, Okten A, Kizil M. Child abuse as a result of enuresis. Pediatr Int 2004; 46: 64–66.
  5. Butler R, Heron J. The prevalence of infrequent bedwetting and nocturnal enuresis in childhood. A large British cohort. Scand J Urol Nephrol 2008; 42 (3): 257–264.
  6. Yeung C, Streedhar B, Sihoe J et al. Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int 2006; 97 (5): 1069–1073.
  7. NICE. Nocturnal enuresis (bedwetting) in children and young people. Quality Standard 70. NICE, 2014. Available at: www.nice.org.uk/guidance/qs70
  8. Harari M. Nocturnal enuresis. Journal of Paediatrics and Child Health 2013; 49: 264–271.
  9. Lewis S, Heaton K. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997; 32 (9): 920–924.
  10. Akyol I, Adayener C, Senkul T et al. An important issue in the management of elimination dysfunction in children: parental awareness of constipation. Clin Paediatr 2007; 46 (7): 601–603.
  11. McGrath K, Caldwell P, Jones M. The frequency of constipation in children with nocturnal enuresis: a comparison with parental reporting. J Paediatr Child Health 2008; 44 (1–2): 19–27.
  12. NICE. Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. Clinical Guideline 99. NICE, 2010. Available at: www.nice.org.uk/guidance/cg99
  13. Naseri M, Hiradfar M. Abnormal urodynamic findings in children with nocturnal enuresis.Indian Pediatr. 2012 May; 49 (5): 401–3.
  14. Cederblad M, Sarkadi A, Engvall G, Nevéus T. No effect of basic bladder advice in enuresis: a randomized controlled trial. J Pediatr Urol 2015, doi: 10.1016/j.jpurol.2015.03.004 [article in press].
  15. Evans J, Malmsten B, Maddocks A et al. Randomized comparison of long-term desmopressin and alarm treatment for bedwetting. J Pediatr Urol 2011; 7 (1): 21–29.
  16. Marschall-Kehrel D, Harms T, Enuresis Algorithm of Marschall Survey Group. Structured desmopressin withdrawal improves response and treatment outcome for monosymptomatic enuretic children. J Urol 2009; 182: 2022–2026.
  17. Vande Walle J, Rittig S, Bauer S et al. Practical consensus guidelines for the management of enuresis. Eur J Pediatr 2012; 171: 971–983.
  18. Vande Walle J, Bogaert G, Mattsson S. A new fast-melting oral formulation of desmopressin: a pharmacodynamic study in children with primary nocturnal enuresis. BJU Int 2006; 97 (3): 603–609.