Many children wet the bed, and the process of achieving nighttime dryness is largely determined by ADH regulation, which relies on maturation. There is often a family history of delayed nighttime dryness. The cut off for seeing children in clinic is usually 7 years of age, before which there is a good prospect of them achieving dryness without intervention. Most children will have never been dry at night (primary enuresis); however, some will have been dry for 6 months or more, then start wetting. This is secondary enuresis and is much more likely to have an organic cause. The NICE guideline can be found here:
https://cks.nice.org.uk/bedwetting-enuresis#!topicSummary
Medical assessment should include:
• Lower limb neurology, including gait – is there any evidence for spinal cord tethering, dysraphism or previously undiagnosed neurological problem?
• Assessment for constipation – are stools palpable in abdomen? Is there a history of constipation, or overflow diarrhoea?
• Urine analysis – has a urine dipstick been performed and is it normal? Is there a history of previous UTIs or vulvovaginitis?
•Weight – and document BMI on appropriate centile chart
• Abnormal lower limb neurology (abnormal tone, brisk reflexes, abnormal gait, reduced sensation)
• Clinical examination shows previously undiagnosed sacral pit, hairy patch or naevus at base of spine
•Allegations or suspicion of child sexual abuse
•Recent onset enuresis following a period of night-time dryness (>6 months), in the context of weight loss, polyuria and polydipsia
Urine dipstick to exclude urinary tract infection should be performed. This should be collected by a clean catch method. Urine MC&S should be sent if urine dipstick suggests UTI likely.
If there are symptoms of type 1 Diabetes Mellitus (polyuria, polydipsia), perform a urine dipstick and blood sugar. Refer URGENTLY if abnormal.
The following should be discussed and managed with the parents prior to referral.
1.Drinking – most children do not drink enough daytime fluids. They should be encouraged to increase fluid intake throughout the day.
Recommended adequate daily fluid intake from drinks are:
At 5–8 years of age — 1000–1400 mL (girls); 1000–1400 mL (boys).
At 9–13 years of age — 1200–2100 mL (girls); 1400–2300 mL (boys).
At 14–18 years of age — 1400–2500 mL (girls); 2100–3200 mL (boys).
• Avoid drinking caffeine-based drinks (such as colas, coffee, and tea), fizzy or blackcurrant drinks.
• Drinks can be stopped 1 hour before bedtime if sufficient fluids have been taken during the day.
Here is a leaflet from ‘Bowel and Bladder UK’ for parents about encouraging fluids and why it’s important.
https://www.bbuk.org.uk/wp-content/uploads/2016/12/Promoting-Healthy-Bladders-1.pdf
A downloadable drinking reward chart can be found on the link below
https://www.eric.org.uk/pdf-drinking-reward-chart
2. Children should be encouraged to ‘double void’ prior to bedtime.
3. Some parents choose to ‘lift’ their child – where they encourage them to pass urine late in the evening. This is OK provided the child is awake enough to realise that they are going to the toilet and why.
4. If the child is afraid of the dark, ensure there is a nightlight available in case they need to get up and go to the toilet overnight.
5. The Eric website has lots of useful information and practical tips for parents. https://www.eric.org.uk/Pages/Category/bedwetting
Once the above have been addressed, if there is no resolution in symptoms, we consider treating. Bedwetting is usually treated by a combination of an alarm system and medication (desmopressin)
– Bedwetting alarms are not currently available in the hospital but can be purchased online or via the ERIC website or through some community nurse led enuresis clinics. They work best if both parents and child are absolutely committed to getting up when they sound, changing bedding together etc.
– Desmopressin can be prescribed either short term (eg: to cover a residential stay) or longer term. Dosing should be as per the Children’s BNF. Medication does not need to be commenced in secondary care (for latest version of this NICE Pathway see: http://pathways.nice.org.uk/pathways/bedwetting-in-children-and-young-people
For detailed information suitable for parents, please look at the ‘Medicines for Children’ website.
https://www.medicinesforchildren.org.uk/desmopressin-bedwetting-0
For children with secondary enuresis (dry previously for > 6 months), there may be an organic cause. Some important things to consider and exclude are:
– Type 1 Diabetes Mellitus (urine dip, blood sugar as relevant)
– Urinary tract infection (urine dipstick)
– Constipation
– Anxiety especially if significant recent life events eg: bereavement, family loss, change in home or school circumstances, bullying
– Safeguarding concerns including sexual, emotional and physical abuse
All referrals for primary enuresis from Kingston GPs will be seen in general paediatric clinic first and then referred to our Nurse led Enuresis Clinic as appropriate. Please refer to General Paediatrics via ERS only once the above measures have been implemented and trialled. For non-Kingston GPs please refer to your local enuresis service since many are nurse-led, often through community nursing services, and for primary enuresis do not require a paediatric medical review.
If an underlying cause for secondary enuresis is suspected, referral should be via the appropriate pathway.
– For children with a positive urine dipstick for glucose +/- ketones, please refer urgently to our Paediatric Assessment Unit on the same day
– For safeguarding concerns, please follow the ‘Safeguarding referral flowchart’ https://swlondonccg.nhs.uk/about/governance/safeguarding/
– Treat any urinary tract infection as per NICE guidelines for UTI and local antibiotic policy https://cks.nice.org.uk/urinary-tract-infection-children
There are a number of resources for helping children manage anxiety, which can be found in our ‘Resources’ tab under ‘Information for Parents’. Consider CAMHS referral via SPA (Kingston).
Below are a list of resources for parents and carers:
https://www.eric.org.uk/Pages/Category/bedwetting
https://www.bbuk.org.uk/children-young-people/children-resources/
https://www.medicinesforchildren.org.uk/desmopressin-bedwetting-0
NICE Pathway: http://pathways.nice.org.uk/pathways/bedwetting-in-children-and-young-people
