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Nocturnal enuresis: assessing and treating children and young people.


Bedwetting, sometimes referred to as nocturnal enuresis, is a common and distressing condition. There are many different definitions, but for the purpose of the new National Institute for Health and Clinical Excellence (NICE) clinical guideline (2010a) it is described as involuntary wetting during sleep. It not only has an impact on the child but on the whole family. The emotional wellbeing of the child is affected with possible loss of self-esteem. Children feel different from their peers and live in fear of these peers knowing about their condition. They may decline social activities, such as 'sleepovers' and school residential trips, in case they wet the bed. Bedwetting can be stressful for families to deal with. They may struggle to find support for their child but also face ongoing financial implications.

Prevalence decreases with age--bedwetting less than two nights a week has a prevalence of 21% at about 4.5 years of age and 8% at 9.5 years. More frequent bedwetting is less common and has a prevalence of 8% at 4.5 years and 1.5% at 9.5 years (Butler and Heron, 2008). If children have severe wetting --defined as bedwetting every night--it is less likely to resolve spontaneously.

Children with bedwetting are often seen by a variety of practitioners, such as school health nurses, specialist enuresis nurses, continence advisors, health visitors and GPs. The first ever NICE clinical guideline on this condition (2010a) aims to help practitioners in assessments and management plans, and applies to children and young people up to the age of 19 years of age. Importantly, it does not specify a minimum age limit, thus allowing practitioners to use their professional judgement when considering treatments for children under the age of seven years where deemed appropriate (NICE, 2010a).


Although the causes of bedwetting are not fully understood, identified predisposing factors are sleep arousal difficulties, polyuria and bladder dysfunction. Accurate assessment is key to identifying whether the bedwetting is a presentation of a systemic illness, such as:

* Urinary tract infection (UTI) (NICE, 2007)

* Constipation and/or soiling (NICE, 2010b)

* Diabetes mellitus (NICE, 2004)

* Medical, emotional or physical triggers

* History of recurrent urinary infections

* Known or suspected physical or neurological problems

* Developmental, attention or learning difficulties

* Family problems or vulnerable child, young person or family

* Behavioural or emotional problems

* Maltreatment (NICE, 2009).

All children with bedwetting should be offered an assessment that is suitable to their circumstance and needs.

It is important to asses the family's needs and ability to cope with treatment options. Support should be offered if the family is finding it difficult to cope with the burden of bedwetting.

Consider assessment, investigations and/or referral for children with severe daytime symptoms, a history of UTIs or previous comorbidities (see Table 1 and Figure 1).

Do not perform urinalysis routinely in bedwetting unless any of the following apply:

* Recent onset

* Daytime symptoms

* Signs of ill health

* History or symptoms of UTI

* History suggestive of diabetes mellitus.

Management: general principles

There are some general principles that the healthcare professional can go through with the parent or carer to help their child achieve dryness at night. For younger children (aged under seven years) these can be suggested independently, but they can also run alongside any other treatment options.

An adequate daily fluid intake is important. Parents and carers should be advised that this can vary according to ambient temperature, dietary intake and physical activity (see Table 2). Caffeine-based drinks should be avoided.

A healthy balanced diet is also advisable, and there is no need to restrict diet as a form of treatment.

Advise on the importance of using the toilet to pass urine at regular intervals throughout the day. This is typically four to seven times a day, including before sleep.

It may be necessary to liaise with the school to ensure access to drinks and the toilet during the school day.

If the child or young person wears pull-ups or nappies at night but is toilet trained during the day, a trial of at least two nights in a row without pull-ups or nappies can be suggested. This can be done at regular intervals to see if it promotes dry nights. It is not worth suggesting that these should be removed permanently if the child remains wet and the parents or carers are against this, as they can still be used with any treatment option.

There is no evidence to suggest that lifting or waking a child helps to promote long-term dryness. Lifting (carrying the child to the toilet while they are still asleep) means that no effort is made to ensure the child is fully woken. Waking (waking a child from sleep to take them to the toilet) at regular times or randomly during the night will promote dryness, but may be used as a practical measure in the short term only. Some young people who have not responded to treatment may find self-instigated waking a useful management strategy.

Reward systems with positive rewards for agreed behaviour, rather than dry nights, should be used either alone or alongside other treatments. The agreed behaviour could be for drinking recommended levels of fluid during the day, using the toilet before sleep or engaging in treatment. Systems that penalise or remove previously gained rewards should not be used.

Planning management

It is important that practitioners involve the family and child in the discussion about treatment options. The child's views should also be explored, as should the ability of the family to cope with an alarm as a treatment option. It is essential to know what the family hopes to achieve from treatment--long-term success or whether in the first instance they require rapid-onset, short-term improvement in order for the child to go on a residential trip or holiday (see Figure 1).

If the family chooses to use an alarm, it is important that their specific circumstances and needs are considered, such as the child's sleeping arrangements. For a child sharing a bedroom with a sibling, a bodyworn alarm that vibrates may be more appropriate. A child with a hearing impairment will also find the vibrating alarm effective. Parents should be informed about the benefits of using an alarm combined with reward systems. Advice should also be given to the parent or carer to use positive rewards for desired behaviour, such as waking to the alarm or going to the toilet when the alarm goes off.

If rapid-onset or short-term improvement is required or the family cannot use an alarm at this moment in time, they may want to consider desmopressin medication. It is important that the family is given accurate written information with regard to fluid restriction and contraindications.

For children and young people being treated with desmopressin, the following should not be measured routinely:

* Weight

* Serum electrolytes

* Blood pressure

* Urine osmolality.

With all treatment options, it is necessary for the family and child to feel well supported. Regular evaluation--at a minimum of every four weeks--is required in order to assess progress. This may improve compliance and eventual outcomes. Phone contact should also be available for advice and support between appointments.

Lack of response to initial treatments

If there is a lack of response to first-line treat- ments or if children relapse, it may be necessary to refer the child and family to an enuresis specialist for further review. Factors associated with poor response include an overactive bladder, underlying disease and social and emotional factors. Treatment options for these children may include combination therapy of desmopressin and alarm, desmopressin and an anticholinergic, or the use of tricyclic antidepressants.

Alongside the clinical guideline, NICE has provided a costing tool to help NHS organi- sations in England, Wales and Northern Ireland plan for the financial implications of implementation. It is not thought that the guideline will have a significant impact on the use of NHS resources at a national level. However, due to variations in practice, some may incur costs or savings depending on their circumstances (NICE, 2010a).


The most significant change for many organisations may be the provision of service for five- to seven-year olds. Additional costs may be related to patient referrals, but also for alarms and pharmological treatments. However, the actual number of children aged five to six years who might be eligible for an alarm or desmopressin is likely to be low. Treating people when they are younger may also resolve issues earlier and remove the need for them to be treated when they reach seven years. Staff training may be an issue for some authorities if in-house training is not available. In these cases, ERIC (the Education and Resources for Improving Childhood Continence charity) may be able to provide training days (see:


Treatment of nocturnal enuresis has a positive effect on the self-esteem of children. For most children, bedwetting treatment is effective and successful.

Healthcare professionals should persist with treatment options if these are not successful at first. Referrals should be made to a specialist enuresis practitioner when there are comorbidities or if first-line treatments do not work.

Support should be available when relapse occurs so that reassessment and treatment can be started again. Practitioners should take into account the family's circumstances and they should explain all the treatment and management options clearly so that the child and young person with their family can make an informed decision. Written information should be made available to families that is evidence based.


* Bedwetting (nocturnal enuresis) is a common and distressing condition among children and young people, and NICE has produced new guidance on its assessment and treatment

* Treatment options to consider include provision of advice, use of a reward system and/or an alarm and desmopressin medication, depending on individual needs

* Practitioners should persist with treatment options, but referrals may be made to a specialist enuresis practitioner where necessary

Further information

For all guideline documents--including a quick reference guide for professionals and guidance written for patients and carers--see: uk/CG111

No potential competing interests declared.


Butler RJ, Heron J. (2008) The prevalence of infrequent bedwetting and nocturnal enuresis in childhood: a large British cohort. Scandinavian Journal of Urology and Nephrology 42(3): 257-64.

National Institute for Health and Clinical Excellence/NICE. (2004) Diagnosis and management of type 1 diabetes in children, young people and adults. London: NICE.

NICE. (2007) Diagnosis, treatment and long-term management of urinary tract infection in children. London: NICE.

NICE. (2009) When to suspect child maltreatment. London: NICE.

NICE. (2010a) The management of bedwetting and nocturnal enuresis in children and young people. London: NICE.

NICE. (2010b) Diagnosis and management of idiopathic childhood constipation in primary and secondary care. London: NICE.

Janet Wootton DipHE, ENB 405, RM, RGN Specialist enuresis nurse and school health nurse, York Teaching Hospitals NHS Foundation Trust

Sally Norfolk BSc, SNCert, RGN Operational lead school nursing, Children and Family Services, NHS Leeds Community Healthcare
Table 1. History taking (NICE, 2010a)

Patterns and symptoms

Pattern of bedwetting

* How many nights a week does it occur?

* How many times a night does it occur?

* Does there seem to be a large amount
of urine?

* At what times of night does it occur?

* Does the child or young person wake
up after bedwetting?

Daytime symptoms

* Does the child or young person need to
pass urine frequently (more than seven
times) or infrequently (less than four
times) during the day?

* Does they need to pass urine urgently
during the day?

* Are they wetting during the day?

* Do they have abdominal straining when
passing urine or a poor urinary stream?

* Do they have pain passing urine?

Toileting patterns

* Does the child or young person
avoid using certain toilets, such as
school toilets?

* Do they go to the toilet more or less
often than their peers?

* Do daytime symptoms happen only in
certain situations?

Pattern of bedwetting

* How much does the child or young
person drink during the day?

* Are they drinking less because of
the bedwetting?

* Are the parents or carers restricting
drinks because of the bedwetting?

Interpretation or action

Bedwetting that occurs every night is severe
bedwetting, which is less likely to resolve
spontaneously than infrequent bedwetting

A large volume of urine in the first few hours
of the night is typical of bedwetting only

A variable volume of urine, often more than
once a night, is typical of bedwetting and
daytime symptoms with possible underlying
overactive bladder

Daytime symptoms may indicate a bladder
disorder such as overactive bladder

Pain passing urine may indicate a UTI

Perform urinalysis

If daytime symptoms are severe:

* Consider assessment, investigation
and/or referral

* Consider investigating and treating
daytime symptoms before bedwetting

* This may rarely indicate an underlying
urological disease

Give advice about encouraging normal
toileting patterns

Inadequate fluid intake may mask an underlying
bladder problem and may impede
development of adequate bladder capacity
Give advice on fluid intake

Table 2. Suggested daily intake of drinks for children and young people
(NICE, 2010a)

Age Sex Total drinks per day

Four to eight years Female 1000ml to 1400ml
 Male 1000ml to 1400ml
Nine to 13 years Female 1200ml to 2100ml
 Male 1400ml to 2300ml
14 to 18 years Female 1400ml to 2500ml
 Male 2100ml to 3200ml
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Title Annotation:CLINICAL
Author:Wootton, Janet; Norfolk, Sally
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Dec 1, 2010
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