Bedwetting

 

Bedwetting (nocturnal enuresis) is involuntary wetting during sleep, without any inherent suggestion of frequency or pathophysiology.  It is generally considered to be normal in children younger than 5 years of age.  Bedwetting can be classified as:

  1. Primary bedwetting without daytime symptoms — the child has never achieved sustained continence at night and does not have daytime symptoms
  2. Primary bedwetting with daytime symptoms — the child has never achieved sustained continence at night and has daytime symptoms such as urgency, frequency, daytime wetting, abdominal straining, or poor urinary stream, or pain passing urine
  3. Secondary bedwetting — bedwetting occurs after the child has been dry at night for more than 6 months

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Assessment

Determine the type of bedwetting by asking:

  1. Are there any daytime symptoms, such as urgency, frequency (more than seven times a day), daytime wetting, abdominal straining or poor urinary stream, pain passing urine, or passing urine infrequently (fewer than four times a day)?
  2. Has the child previously been dry at night without assistance for 6 months?

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In all cases:

  1. Assess the child's fluid intake throughout the day, and ask whether the child or the parents or carers are restricting fluids
  2. Consider asking the parents or carer to keep a diary of the child's fluid intake, bedwetting, and toileting patterns for 2 weeks
  3. Include the child in the assessment (where appropriate), ask:
    1. Whether the child thinks there is a problem
    2. What the child thinks is the main problem
    3. What the child hopes the treatment will achieve

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Without daytime symptoms:

  1. Assess the pattern of bedwetting — frequent bedwetting is less likely to resolve spontaneously than infrequent bedwetting. Ask:
    1. How many nights a week does bedwetting occur?
    2. How many times a night does bedwetting occur?
    3. Does there seem to be a large amount of urine?
    4. At what times of night does the bedwetting occur?
    5. Does the child wake up after bedwetting?
  2. Assess whether the child and parents or carers are willing or able to take part in behavioural interventions, such as using an enuresis alarm

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With daytime symptoms:

  1. Assess the pattern of daytime symptoms, ask if:
    1. Daytime symptoms occur only in some situations.
    2. The child avoids toilets at school or other settings.
    3. The child goes to the toilet more or less frequently than his or her peers
  2. Assess the child for:
    1. Chronic constipation — undiagnosed chronic constipation is a common cause of wetting and soiling in younger children
    2. Chronic urinary tract infections

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Secondary bedwetting:

  1. Ask when bedwetting started — bedwetting that has started in the last few days or weeks may be a presentation of a systemic illness (for example urinary tract infection), or a change in the child's environment (for example bullying or abuse)
  2. Assess for an underlying cause which may have triggered bedwetting, for example:
    1. Constipation (and/or soiling) — a common comorbidity than can cause bedwetting
    2. Diabetes
    3. Urinary tract infection
    4. Behavioural problems and emotional problems — these may be a cause or a consequence of bedwetting
    5. Family problems — a difficult or stressful environment may be a trigger for bedwetting
    6. Child maltreatment
  3. Assess pattern of bedwetting, ask:
    1. How many nights a week does bedwetting occur?
    2. How many times a night does bedwetting occur?
    3. Does there seem to be a large amount of urine?
    4. At what times of night does the bedwetting occur?
    5. Does the child wake up after bedwetting?

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Investigations

Consider performing urinalysis particularly if:

  • Bedwetting started in the past few days or weeks
  • The child has daytime symptoms
  • The child has any signs of ill health
  • There are a history, symptoms, or signs suggestive of urinary tract infections
  • There are a history, symptoms, or signs suggestive of diabetes mellitus

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Management of primary bedwetting (without daytime symptoms)

  1. For children younger than 5 years of age:
    1. Reassure the parents or carers that many children younger than 5 years of age wet the bed, and this usually resolves without treatment — reassurance maybe all that is required
    2. Ensure easy access to the toilet at night — consider a potty by the side of the bed if the toilet is not easily accessible
    3. Encourage the child to empty their bladder before sleep
    4. If the child has been toilet trained by day for longer than 6 months, consider a trial of at least 2 nights in a row without nappies or pull ups (appropriate waterproof mattress protection will be required)
  2. For children older than 5 years of age:
    1. If bedwetting is infrequent (less than twice a week), reassure the parents or carers that bedwetting may resolve without treatment and offer the option of a wait-and-see approach
    2. If long-term treatment is required, offer treatment with an enuresis alarm (first-line treatment) in combination with positive reward systems (for example star charts)
      1. Desmopressin is less preferred but may be considered if the child, parents, or carers do not want to use an alarm or are unable to use an alarm
  3. If bedwetting recurs after being treated successfully, consider:
    1. Restarting treatments which have been previously successful
    2. Offering combination treatment with desmopressin and an enuresis alarm
  4. Seek specialist advice before initiating tricyclic antidepressants (such as imipramine) or antimuscarinics (such as oxybutynin)
  5. Refer if bedwetting has not responded to at least two complete courses of treatment with either an alarm or desmopressin (this may be one course of each treatment, or two of the same), refer to secondary care, an enuresis clinic, or a community paediatrician, depending on local protocols and availability

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Management of primary bedwetting (with daytime symptoms)

  1. Refer all children with primary bedwetting and daytime symptoms (urgency, frequency, daytime wetting, abdominal straining or poor urinary stream, pain passing urine, or passing urine fewer than four times a day) to secondary care or an enuresis clinic (if available) for further investigations and assessment
  2. Consider referring younger children (older than 2 years of age) who are struggling to not wet themselves during the day as well as during the night, despite awareness of toileting needs and showing appropriate toileting behaviour

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Management of secondary bedwetting

  1. Manage the following underlying causes of secondary bedwetting in primary care:
    1. Urinary tract infections
    2. Constipation
  2. If an underlying cause has been identified and is generally not managed in primary care, refer the child to a paediatrician or an enuresis clinic:
    1. Diabetes — refer immediately (same day) to a multidisciplinary paediatric diabetes care team
    2. Recurrent urinary tract infection — refer to a paediatric specialist
    3. Psychological problems (behavioural or emotional problems)
    4. Family problems (vulnerable child or family)
    5. Developmental, attention, or learning difficulties
    6. Known or suspected physical or neurological problems
  3. If an underlying cause cannot be clearly identified, refer the child to an enuresis clinic or equivalent

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Advice and information

  1. Explain to the child and their parents or carers that bedwetting is not the child's fault and the child should not be punished
  2. Reassure the child and their parents or carers that almost all children (99%) become dry given time
  3. Advise that:
    1. During the day the child should use the toilet to pass urine at regular intervals and before sleep
    2. Caffeine-based drinks (such as colas, coffee, and tea) should be avoided before going to bed
    3. Recommended adequate daily fluid intake from drinks are:
      1. At 4–8 years of age — 1000–1400 mL (girls); 1000–1400 mL (boys)
      2. At 9–13 years of age —  1200–2100 mL (girls); 1400–2300 mL (boys)
      3. At 14–18 years of age  — 1400–2500 mL (girls); 2100–3200 mL (boys
    4. There should be easy access to a toilet
    5. A waterproof mattress and duvet cover, absorbent quilted sheets, and bed pads can be used
    6. Rewards may be given for:
      1. Drinking recommended levels of fluid during the day
      2. Using the toilet before going to bed
      3. Engaging in management (for example taking medication or helping to change sheets)
  4. Provide information on sources of support, e.g. the Education and Resources for Improving Childhood Continence (ERIC) and the Bladder and Bowel Foundation

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Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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