Enuresis
Disclaimer
These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.
|
Introduction
Enuresis or nocturnal enuresis, commonly known as “bed wetting”, refers to ≥5 years of age. 1, 2, 3
Enuresis is divided into mono-symptomatic and non-mono-symptomatic forms.
- Mono-symptomatic enuresis (MSE) is defined as nocturnal urinary incontinence without any other lower urinary tract symptoms or history of bladder dysfunction. MSE is further classified into primary and secondary categories.
- Primary enuresis is when a child has never achieved a period of night-time dryness, and results from uncommon underlying causes.
- Secondary enuresis is when urinary incontinence develops after a dry period of at least six months, and results from more common underlying causes.
- Non-mono-symptomatic enuresis is defined as urinary incontinence with other, mainly daytime, lower urinary tract symptoms such as abnormal urine stream, hesitancy, urgency, dribbling or pain2.
Pre-referral management
Patient assessment should include:
Clinical History
- Urinary symptoms (frequency, dribbling, stream etc.)
- Bowel habits
- Fluid intake and diet
- Sleep pattern
- Medical and family history
Physical examination
- Weight, height, blood pressure
- Abdomen
- Spine and lower limb neurology
- Perineum and perianal area
Differential diagnoses/comorbidities
- Chronic constipation with reduced functional bladder capacity or detrusor instability
- Urinary tract infection or acute illness affecting ability to maintain continence
- Conditions causing polyuria (renal failure, diabetes insipidus or diabetes mellitus)
- Abnormal or infrequent voiding pattern
- Congenital abnormality of urinary tract (rare)
- Neurological disorder e.g. spina bifida
Investigations
- Urine dipstick and culture to exclude urinary tract infection
- Further imaging or blood tests are not routinely recommended in enuresis
- Consider investigations if other conditions need to be ruled out
Treatment options
- Treat Constipation if present
- Treat Urinary Tract Infection if present
- Daytime urinary symptoms need to be addressed first before addressing enuresis
- Children older than 5½ years of ages with primary mono-symptomatic enuresis are generally suitable for an enuresis alarm.
Enuresis Alarm
- Recommended for children above 5½ years of age. It is associated with good long-term success and fewer relapses than medication
- Continue treatment until 21 days of uninterrupted dry nights are achieved
- Discontinue if no early signs of response within 4 weeks
- If unsuccessful after first treatment, consider a retrial in 6 months
Medication
Medication should be considered as a temporary measure only, and focus on improving short-term goals such as, increased continence during school camps and sleep overs.
Desmopressin
- Reduces the volume of urine produced and is recommended for short term use only (up to 3 months)
- Relapse rates are high when medication withdrawn
- Restrict fluids from 1 hour before until at least 8 hours after the dose3
- Intranasal route is not recommended due to higher risk of hyponatraemia
- Monitor children with increased risk of hyponatraemia e.g. systemic infections, gastroenteritis, syndrome of inappropriate antidiuretic hormone secretion (SIADH)
- Treat for 1 to 3 months then withdraw desmopressin for at least 1 week to assess for relapse and ongoing need for medication.
Dosing for children age 6 years and above3
| Oral tablet |
200 micrograms daily at bedtime |
Increase to a maximum of 400 micrograms daily at bedtime |
| Sublingual wafers |
120 micrograms daily at bedtime |
Increase to a maximum of 240 micrograms daily at bedtime |
Avoid use with:
- Medications known to induce SIADH – including tricyclic antidepressants, selective serotonin reuptake inhibitors, chlorpromazine, and carbamazepine.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), which can increase water retention.
When and how to refer
Available clinics dedicated to enuresis in Western Australia are outlined below.
Please read the criteria carefully and choose the service that best suits the needs of your patient.
Bedwetting program - CAHS Community Health
Criteria:
- aged 5½ to 18 years
- has mono-symptomatic or non-mono-symptomatic enuresis
- has daytime urine and bowel continence
- no ongoing issues relating to constipation or other comorbidities
- a nocturnal enuresis bedwetting pattern of more than twice weekly
- there is adequate family/caregiver support to engage with the program.
Referrals
Referrals to the CAHS Community Health Bedwetting Service are on the CAHS website.
Enuresis Service - Perth Children's Hospital
This service runs a 6-8 week nurse-led nocturnal enuresis treatment program with fortnightly appointments. The program combines education, counselling, support and advice to manage patients and families in conjunction with an enuresis mat and alarm system.
Eligibility criteria
Child aged 5 ½ to 16 years experiencing enuresis without daytime bladder or bowel dysfunction.
Non-urgent referrals
Complete the Continence and Enuresis Service referral form and send to the Central Referral Service.
Urgent referrals
Phone the PCH switchboard on 6456 2222 and ask to speak to speak to the on-call general paediatrician to discuss the referral. Email referral to pch.referrals@health.wa.gov.au.
Download
Complete the Continence and Enuresis Service referral form (Word 347kb).
Paediatrician in the appropriate catchment
Eligibility criteria
Child aged 5½ years and over, and has:
- Failed enuresis treatment program twice
- Non-mono-symptomatic enuresis (daytime urinary urgency, frequency, urinary incontinence or constipation and/or faecal incontinence)
- Persistent enuresis after treatment of constipation or urinary tract infection (UTI).
- Secondary enuresis
- The child is still bedwetting at night after 6 months of trialling enuresis alarm training and desmopressin.
- Significant psychosocial impact, developmental, or family problems exist
Non-urgent referrals
Send via the Central Referral Service.
Urgent referrals
Phone the relevant hospital switchboard and ask to speak to the on-call general paediatrician to discuss the referral and email relevant referral email.
Daytime Bladder Dysfunction Clinic - Perth Children's Hospital
A multidisciplinary service where all patients are seen jointly by a paediatrician, specialist continence physiotherapist, and specialist continence clinical nurse consultant. Follow up will primarily be face-to face and it is preferred that families have English proficiency and internet access in order to fill in the questionnaires provided.
Eligibility criteria
- Aged <16 years with daytime urinary incontinence.
Exclusions
- Developmental delay, autism spectrum, or behavioural disorders
- Constipation and soiling
- Neurogenic bladder
- Patients already known to a urologist or incontinence service
- Nocturnal enuresis without daytime symptoms.
Referrals
Send via the Central Referral Service.
Include results:
- Renal ultrasound with measurement of bladder wall thickness, rectal diameter, and post‑void residual volume
- MSU.
Continence Service - Perth Children's Hospital
The continence service provides clinical care to children and families with daytime bladder and/or bowel dysfunction. Referrals to this service must come from a Paediatrician.
Non-urgent referrals
Send via the Central Referral Service.
Urgent referrals
Phone the PCH switchboard on 6456 2222 and ask to speak to speak to the on-call general paediatrician to discuss the referral. Email referral to pch.referrals@health.wa.gov.au.
Essential information to include in your referral
- Relevant medical history
- Details of treatments previously tried and current treatment plan.
Useful resources
References
- Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, et al. The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Update Report from the Standardization Committee of the International Children′s Continence Society. J Urol. 2014. [cited 2022 July 8]. Available from: TThe standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society - PubMed (nih.gov)
- Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: Report from the Standardisation Committee of the International Children′s Continence Society. J Urol. 2006;176:314–24. [cited 2022 July 8]. Available from: The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society - PubMed (nih.gov)
- The Royal Children’s Hospital Melbourne. Clinical practice guidelines : Enuresis - bed wetting and monosymptomatic enuresis [Internet]. Org.au. 2019 [cited 2022 Jul 12]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Enuresis_-_Bed_wetting_and_Monosymptomatic_Enuresis/
- Neveus T, Eggert P, Evans J, Macedo A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L; International Children's Continence Society. Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the International Children's Continence Society. J Urol. 2010 Feb;183(2):441-7.
- Australian Medicines Handbook Children’s Dosing Companion Online [internet]. Desmopressin. Australia: Australian Medicines Handbook Pty. Ltd.; 2022 [cited 2022 Mar 16]. Available from:Desmopressin - AMH Children's Dosing Companion (health.wa.gov.au)
- Children’s Health Queensland Hospital and Health Service [Internet]. Primary care management and referral guideline- Enuresis in Children-Management and referral guideline. [cited 2022 March 8]. Available from: Enuresis in Children - Management and referral guideline (health.qld.gov.au)
| Reviewer/Team: |
General Paediatrics / Enuresis and Continence Service |
Last reviewed: |
Jul 2020 |
|
|
Next review date: |
Jul 2023 |