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 

The term enuresis is used to describe lack of bladder control overnight in a person who has reached an age at which control is expected (usually 5 – 6 years).1

Monosymptomatic nocturnal enuresis refers to children with normal daytime voiding patterns and night time wetting only. Non-monosymptomatic enuresis refers to enuresis in children with daytime wetting and / or additional lower urinary tract symptoms (such as abnormal urine stream, hesitancy, urgency, dribbling or pain.1

Enuresis can be primary or secondary.

Monosymptomatic (nocturnal) enuresis

  • Bed wetting is a common childhood problem. 
  • Dryness at night occurs at different ages in children. It is a normal developmental process that occurs as the parts of the body in charge of bladder control mature. It does not depend on special training. 16% of children at 5 years of age will still wet the bed at night.2 The percentage of children with nocturnal enuresis gradually decreases with age to 6% at 8 years of age and 2% at 19 years of age.2
  • Children do not wet the bed because they are being lazy or naughty. Children are not conscious of bed wetting; from the child’s point of view they have no recollection of passing urine.
  • In most children who wet the bed, there is a family history of bed wetting.3
  • Bed wetting is a problem that can cause stress for both children and parents. The child may experience loss of self-esteem and / or lack confidence.4,5 
  • Not all nocturnal enuresis or daytime incontinence resolves with age. 6,7 Treatment for nocturnal enuresis is recommended beyond the age of 5 ½  years.
  • Bed wetting alarms are the safest and most effective way to treat monosymptomatic nocturnal enuresis.8
The Perth Children’s Hospital Continence/Enuresis Nursing Service employs education, counselling, support and advice to manage both their clients and their families in conjunction with a mat and alarm system. The programme takes 6-8 weeks and the appointments are fortnightly. 

Please note that it is standard protocol within the Western Australian Enuresis Clinics that the medication Minirin© will be ceased pro tem whilst the child is receiving treatment with the Perth Children’s Hospital Continence/Enuresis Nursing Service. The protocol has been determined to comply with safe administration of medications. 

Pre-referral investigations and assessment 9,10

If the child is dry during the day and passes urine normally, bedwetting is unlikely to be due to any underlying bladder or kidney disease.11
  • Abdominal and perineal examination.
  • Growth parameters and blood pressure.
Assess for urinary urgency, urinary frequency or infrequency, urinary dribbling, poor stream, polydipsia, polyuria, dysuria, backache or unexplained fevers, constipation.
  • Urinalysis and MC&S of urine.
An ultrasound of the kidneys, ureters and bladder is recommended if the child has any daytime urinary/bladder problems and before referral for Specialist Medical Services.

Pre-referral management 9,10

  • Explain natural history and genetics
  • Cease night time fluid restriction
  • Explain that waking the child to toilet during the night is not curative
  • Manage constipation if present
  • Discourage punitive responses to bed wetting
Refer to local enuresis service for a nocturnal enuresis treatment programme if the child has no daytime bladder or bowel symptoms. 

When to refer to specialist medical services 9,10

  • Non-monosymptomatic enuresis (day time urinary urgency, frequency, urinary incontinence or constipation and/or faecal incontinence)
  • Persistent enuresis after treatment of constipation / UTI
  • Children greater than 5.5 years with monosymptomatic nocturnal enuresis that have failed the nocturnal enuresis treatment programme twice
  • Secondary enuresis.

How to refer

Referrals are through the Central Referral Service. Please include the completed clinical referral form with your referral (Word 130kb).

References

  1. Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W, Jørgensen TM, Rittig S, Walle JV, Yeung CK, Djurhuus JC. 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 Jul;176(1):314-24.
  2. Yeung CK, Sreedhar B, Sihoe JD, Sit FK, Lau J. Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int. 2006 May;97(5):1069-73.
  3. Fatouh AA, Motawie AA, Abd Al-Aziz AM, Hamed HM, Awad MA, El-Ghany AA, El Bassyouni HT, Shehab MI, Eid MM. Anti-diuretic hormone and genetic study in primary nocturnal enuresis. J Pediatr Urol. 2013 Dec;9(6):831-7. 
  4. Hägglöf B, Andrén O, Bergström E, Marklund L, Wendelius M. Self-esteem in children with nocturnal enuresis and urinary incontinence: improvement of self-esteem after treatment. Eur Urol. 1998;33 Suppl 3:16-9.
  5. Kanaheswari Y, Poulsaeman V, Chandran V. Self-esteem in 6- to 16-year-olds with monosymptomatic nocturnal enuresis. J Paediatr Child Health. 2012 Oct;48(10):E178-82.
  6. Fitzgerald MP, Thom DH, Wassel-Fyr C, Subak L, Brubaker L, Van Den Eeden SK, Brown JS; Reproductive Risks for Incontinence Study at Kaiser Research Group. Childhood urinary symptoms predict adult overactive bladder symptoms. J Urol. 2006 Mar;175(3 Pt 1):989-93.
  7. Nappo S, Del Gado R, Chiozza ML, Biraghi M, Ferrara P, Caione P. Nocturnal enuresis in the adolescent: a neglected problem. BJU Int. 2002 Dec; 90 (9): 912-7
  8. Glazener CM, Evans JH, Peto RE. Alarm interventions for nocturnal enuresis in children. Cochrane Database Syst Rev. 2005;(2):CD002911.
  9. Nocturnal Enuresis. The management of bed-wetting in children and young people. October 2010.  NICE clinical guideline 111. http://guidance.nice.org.uk/cg111
  10. Vande Walle J, Rittig S, Bauer S, Eggert P, Marschall-Kehrel D, Tekgul S; American Academy of Pediatrics; European Society for Paediatric Urology; European Society for Paediatric Nephrology; International Children’s Continence Society. 
  11. Kawauchi A, Kitamori T, Imada N, Tanaka Y, Watanabe H. Urological abnormalities in 1,328 patients with nocturnal enuresis. Eur Urol. 1996;29(2):231-4.

Reviewer/Team: Dr Andrew Martin, Mr Ian Gollow, Kerry Murphy, Continence CNC, Charlotte Allen DGP CNS, Suret Nel, Shalini Kassam (Pharmacy Department) Last reviewed: Jan 2020


Review date: Jan 2022
Endorsed by:

Medical Advisory Committee (MAC) Date:  Jan 2020


This document can be made available in alternative formats on request for a person with a disability.