Dr Mark Mackenzie explains how the NICE guideline on nocturnal enuresis in children will help GPs to assess and manage this often distressing condition

Bedwetting or nocturnal enuresis is a widespread and distressing condition that can have a deep impact on a child or young person’s behaviour, emotional wellbeing, and social life. A recent study by Butler and Heron (2007) showed that over one-fifth (21%) of children aged between 4 and 5 years wet the bed at least once a week.1 Although the prevalence of bedwetting decreases with age, this is a condition that also affects many teenagers: approximately 61,000 11–14 year olds.2 It can affect normal daily routines and social activities, such as sleepovers and school trips, and can also generate serious feelings of alienation, guilt, shame, humiliation, and victimisation, and a loss of self-esteem. Bedwetting can also be stressful for the parents or carers and lead them to experience negative or blameful feelings towards their child.

Need for the guideline

The treatment and management of bedwetting in general practice varies greatly across the NHS and could be improved. The reasons for this are likely to be multi-factorial:

  • Bedwetting is underreported to GPs and when it does present, it is normally in children aged <7 years
  • There is a lack of good evidence for treatments and their efficacy, and medications are somewhat limited by potential side-effects and recommendations on duration of use
  • Many GPs have received little, if any, training in continence care and few of them know much about treatments and services available other than medications. Accessing appropriate paediatric clinics is difficult due to a lack of paediatric renal physicians.

This means that patients tend to be diagnosed at tertiary care level. Furthermore, proper assessment and management with follow up for patients with bedwetting can be quite time-consuming.

Remit of the guideline

The NICE guideline on nocturnal enuresis is the first time that national guidance has been published for the NHS on how to assess and treat children and young people who wet the bed.3 The guideline is based on the best available evidence and expert clinical opinion and so the recommendations represent best current practice. In most cases, the treatment of nocturnal enuresis can take place in primary care—either through a GP or an adequately trained nurse.

Treatments within primary care can range from simple bladder or lifestyle advice to the use of alarms and medication, such as desmopressin. The importance of a proper history and voiding chart cannot be overstated. While bedwetting is a common condition, children are generally expected to no longer wet the bed (to be ‘dry’) by a developmental age of 5 years. Historically it has been common practice to only consider treating children for their bedwetting when they reach the age of 5 years. However, the NICE guideline does not specify a minimum age limit for treatment, thus representing a significant change in practice.3 This is because there are existing treatments on the NHS currently given to children aged 7 years and above, which could benefit those below this age. NICE advises the GP or other healthcare professionals not to exclude children under 7 years of age from treatment on the basis of age alone.3 Instead they should take into account other criteria such as the frequency of bedwetting and the needs, motivation, and circumstances of the child/young person and family. The guideline details advice on how to support children under the age of 5 years, as well as children aged between 5 and 7 years, and patients aged up to 19 years who experience bedwetting.3

As the guideline covers the full spectrum of age groups for children and adolescents, it can be used as a comprehensive guide for assessment and treatment within primary care.

Assessment and investigation

When the GP or other appropriately trained healthcare professional is first presented with a child or adolescent who has experienced bedwetting, he or she should undertake a thorough clinical history. They should ask whether the bedwetting started in the last few days or weeks, as well as how many times a night/week it occurs (i.e. its duration and frequency). A child or young person who has been dry at night without assistance for 6 months may have medical, emotional, or physical triggers for bedwetting.

Healthcare professionals should also ask about the presence of daytime symptoms, toileting patterns, and the child’s/young person’s fluid intake throughout the day (in particular, whether the child/young person or the parents/carers are restricting fluids).3

The healthcare professional should be prepared to give advice about toileting patterns, diet, and fluid intake (e.g. regarding caffeine-based drinks). The recommended fluid-intake levels for different age groups are shown in Table 1. Dietary restriction should never be used as a form of treatment. Children and young people should be advised of the importance of using the toilet at regular intervals during the day and before sleep—this should be continued alongside the chosen treatment. A trial without nappies or pull-ups for a child with bedwetting who is toilet trained by day, may be useful. The NICE guideline advises healthcare professionals to address excessive or insufficient fluid intake or abnormal toileting patterns before considering the treatments options for bedwetting.3

The healthcare professional should consider asking the parent/carer to record information on the child’s or young person’s fluid intake, daytime symptoms, bedwetting, and toileting patterns if this would be useful in the assessment and management of bedwetting.

There is no need to perform a urinalysis routinely at the initial assessment of a child or adolescent who wets the bed because there are other ways that the examining doctor or nurse can establish its underlying cause or offer appropriate treatments.3 Further investigation and/or referral should be considered in patients where bedwetting is associated with:3

  • severe daytime symptoms
  • a history of recurrent urinary infections
  • known or suspected physical or neurological problems
  • co-morbidities or other factors such as constipation/soiling; developmental, attention, or learning difficulties; diabetes mellitus; behavioural or emotional problems; or family problems.

Healthcare professionals will be able to treat children or young people with suspected urinary tract infection or with soiling and/or constipation, as per previously published clinical guidelines from NICE.4,5 They should consider involving a professional with psychological expertise if the patient’s bedwetting is linked to emotional or behavioural problems.

Before deciding on the appropriate course of intervention, the healthcare professional should:3

  • ascertain whether there are any factors that might have an impact on treatment effectiveness (e.g. the child’s/young person’s sleeping arrangements)
  • determine the impact of bedwetting on the child/young person and family and their support needs (e.g. does the child/young person and parents/carers have the necessary level of commitment, including available time to engage in a treatment programme?)
  • assess whether the child’s/young person’s parents or carers need support, particularly if they are having difficulty coping with the burden of bedwetting or if they are expressing anger, negativity, or blame towards the child or young person.

Maltreatment
Maltreatment should be considered if:3

  • a child or young person is reported to be deliberately bedwetting
  • parents or carers are seen or reported to have punished a child or young person for bedwetting despite professional advice that the symptom is involuntary
  • a child or young person has secondary daytime wetting or secondary bedwetting that persists despite adequate assessment and management unless there is a medical explanation (e.g. urinary tract infection) or a clearly identified stressful situation that is not part of maltreatment (e.g. bereavement and parental separation).
Table 1: Suggested daily intake of drinks for children and young people3
Age (years) Sex Total drinks per day (ml)
4-8 Female
Male
1000–1400
1000–1400
9-13 Female
Male
1200–2100
1400–2300
14-18 Female
Male
1400–2500
2100–3200
National Institute for Health and Care Excellence (NICE) (2010) CG111. Nocturnal enuresis: the management of bedwetting in children and young people. London: NICE. Available from www.nice.org.uk/guidance/CG111 Reproduced with permission.

Initial treatment

Prior to deciding on a treatment plan, it is important to find out what the child or young person feels about his or her bedwetting: whether they see it as a problem; and what they hope to achieve from treatment (for example, if short-term dryness is a priority due to a sleepover or holidays). The examining doctor or nurse should ensure that they explain the condition, the effect, aims of the chosen treatment, and its pros and cons. Lifting and waking should not be used other than as a short-term practical measure as there is no evidence that this helps promote long-term dryness.3

Reward systems
Reward systems may be used for the initial treatment of bedwetting in young children who have some dry nights. However, rewards should be given for agreed behaviour (e.g. drinking recommended levels of fluid during the day or using the toilet before bedtime) rather than for dry nights as this will further instil the idea that the bedwetting is not patient’s fault. Reward systems can be used either alone or in conjunction with other treatments. Systems that penalise or remove previously gained rewards should not be used.3

Alarms
An enuresis alarm is an electronic device that activates when it detects that the wearer has urinated. Although there are various types of alarms, they all function in a similar way. There is a moisture sensor component that triggers the alarm component when the child begins to urinate. The alarm then wakes the child. These devices are an effective treatment for bedwetting as they teach the child or teenager to recognise when their bladder needs emptying while asleep. They can be offered as a first-line treatment unless:3

  • it is considered undesirable to the child/young person or parents/carers
  • it is considered inappropriate, particularly if:
    • the child/young person only wets the bed once or twice a week
    • the parents/carers are finding it difficult to cope with the burden of bedwetting
    • the parents/carers are expressing anger, negativity, or blame towards the child/young person.

The type of alarm should be tailored to the child’s or young person’s needs and abilities. Factors that should be considered are: maturity, understanding of the alarm, hearing impairments, and learning difficulties.3

The NICE guideline advises that the child’s progress with the use of alarms should be reviewed after 4 weeks. If bedwetting has shown early signs of improvement (e.g. fewer wetting episodes per night or week), treatment should be continued until a minimum of 2 weeks’ uninterrupted dry nights has been achieved. However, if after 3 months, the child or young person is still wetting the bed then other treatments/treatment combinations should be considered.3

Desmopressin

Desmopressin can be offered to children or young people with bedwetting if rapid-onset and/or short-term improvement in bedwetting is the priority of treatment or an alarm is inappropriate or undesirable. Weight, serum electrolytes, blood pressure, and urine osmolality should not be routinely measured in children or young people being treated with desmopressin for bedwetting.3

If the child or young person has not achieved complete dryness after 1–2 weeks on desmopressin, then the healthcare professional should consider increasing the dose (e.g. from 200 mg to 400 mg for Desmotabs or from 120 mg to 240 mg for DesmoMelts). Response should be assessed after 4 weeks and treatment should be continued for 3 months if there are signs of improvement (e.g. smaller wet patches, an increase in dry nights).3

The doctor or nurse should also explain to the child or young person and parents/carers that desmopressin must be taken at bedtime. Fluid should be restricted 1 hour before and 8 hours post-administration and that wetting is only prevented the night desmopressin is taken and is therefore not a cure.3 Parents should therefore be made aware that medication may be required in the short or longer term to reduce or prevent bedwetting.

Recurrent bedwetting

If a child or young person who was previously dry with an alarm has started regularly bedwetting again, the healthcare professional should suggest either starting alarm treatment again or offering it in combination with desmopressin.3

Similarly, if a child or young person relapses after their desmopressin treatment has been withdrawn, the healthcare professional should consider prescribing repeated courses of the medication. They should also withdraw desmopressin treatment at regular intervals (for 1 week, every 3 months) to check if dryness has been achieved when using it for the long-term treatment of bedwetting.3

Gradually withdrawing desmopressin treatment is more effective than suddenly stopping it if a child or young person has had a recurrence of bedwetting following response to previous treatment courses. In children who have repeated recurrences of bedwetting after successful treatment with desmopressin, healthcare professionals should also consider alarm treatment (if now considered appropriate and desirable) as an alternative to restarting desmopressin.3

Referral

Children and young people whose bedwetting has not responded to courses of treatment with an alarm and/or desmopressin should be referred for further review and assessment of factors that may be associated with a poor response (e.g. an overactive bladder, an underlying disease, or social and emotional factors).3

Implications for primary care

There may be a possible increase in service users, in use of alarms and desmopressin, and repeated use of desmopressin. This may require the provision of more trained nurses in some areas and their associated costs. There is also a cost issue with the provision of alarms and desmopressin at a younger age, and repeated courses of desmopressin.

The NICE guideline recommends (if appropriate) the combined use of alarms and desmopressin treatment where these treatments have failed individually.3 This may have cost implications but the impact of this is likely to be low.

The inclusion of all age groups up to 19 years should ensure that treatment is afforded to all children and young people. There are benefits to the NHS as a result of treating children at a young age. Problems may be resolved earlier rather than later and this will ensure that children gain self-esteem, as they grow older.

Conclusion

The NICE guideline provides a comprehensive overview of how to assess and manage nocturnal enuresis in children and young people based on expert opinions and best available evidence. As this is the first time that national guidance has been published for the NHS on this topic, it will improve the way that primary care healthcare professionals treat individuals that have this common condition.

Further information

For further information and to download copies of the clinical guideline, visit: www.nice.org.uk/CG111. This link also includes practical tools to help healthcare professionals implement the guideline, as well as information that they can give to parents/carers detailing the treatment options that they can expect their child to receive.

Implementation tools

NICE has developed the following tools to support implementation of Clinical Guideline 111 on Nocturnal enuresis: The management of bedwetting in children and young people. The tools are now available to download from the NICE website: www.nice.org.uk/CG111

Audit support

Audit support has been developed to support the implementation of this guideline. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. The audit support is based on the key recommendations of the guidance and includes criteria and data collection tools.

Baseline assessment tool

The baseline assessment tool is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.

Costing tools

A costing statement and local cost templates for the guideline have been produced:

  • The costing statement estimates the financial impact to the NHS of implementing this clinical guideline. This statement focuses on the financial impact of the recommendations that require most change in resources to implement in England
  • Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.

Slide set

The slides provide a framework for discussing the NICE guideline with a variety of audiences and can assist in local dissemination. This information does not supersede or replace the guidance itself.

Guide to resources

NICE has developed a joint guide for those individuals who have a role in putting guidance into practice. This guide provides a overview of information related to the guidance on nocturnal enuresis (Clinical Guideline 111) and also constipation in children and young people (Clinical Guideline 99).

  1. 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.
  2. National Institute for Health and Care Excellence. Costing statement. Nocturnal enuresis: the management of bedwetting in children and young people. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG111/CostingStatement/pdf/English
  3. National Institute for Health and Care Excellence. Nocturnal enuresis: The management of bedwetting in children and young people. Clinical Guideline 111. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG111
  4. National Institute for Health and Care Excellence. Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. Clinical Guideline 99. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG99
  5. National Institute for Health and Care Excellence. Urinary tract infection in children: diagnosis, treatment and long-term management. Clinical Guideline 54. London: NICE, 2007. Available at: www.nice.org.uk/CG54 G