GP with an interest in child health Dr Margaret Morris offers her hints on managing bedwetting
1. Reassure children and parents that nocturnal enuresis is very common and can be treated.
Bedwetting less than two nights a week has a prevalence of 21% by about four and a half years and 8% by nine and a half years.1
2. Advice and treatment should be available for all children, including the under-sevens.
Traditionally children have only been considered for treatment at seven. But the new NICE guidance on nocturnal enuresis applies to all children and young people up to the age of 19.2
3. Find out if bedwetting started after a period of the child being dry at night.
If it started in the past few days or weeks, exclude other problems such as urinary tract infection.
4. Establishing the pattern of bedwetting can be very useful.
Wetting the bed several nights a week is less likely to resolve without intervention than less frequent bedwetting. Wetting more than once during the night is typical of children who also have daytime urinary symptoms.
5. Tackle problems with fluid intake or toileting patterns before other interventions.
Is fluid intake being restricted during the day for some reason? Is the child avoiding going to the toilet at school? If you think there might be problems, recommend they keep a record of fluid intake, toilet use, bedwetting and so on.
6. Reward systems work better if offered for changes in behaviour rather than dry nights.
Ideas for rewarded behaviour include:
• drinking enough fluid during the day
• passing urine in the toilet before going to sleep
• taking part in management, such as helping to change sheets, checking the alarm and so on.
7. Urine analysis or M&C testing are not normally needed.
The exceptions are if:
• bedwetting started in the past few days or weeks
• there are daytime urinary problems
• you suspect another problem – such as diabetes or a UTI.
Consider further tests or a referral for:
• severe daytime symptoms
• a history of UTIs
• a physical abnormality, such as posterior urethal valves, or neurological problems
• developmental or learning difficulties
• behavioural or emotional problems.
8. Suggest an alarm as an initial intervention if advice on fluid intake and toileting – or a reward system – hasn't worked.
Alarms aren't generally appropriate if the bedwetting is fairly infrequent or for children whose parents are blaming the child for the problem. Assess response at four weeks.
9. If an alarm treatment doesn't help on its own, offer desmopressin as well as the alarm.
Offer desmopressin alone if the child or parent doesn't want to keep trying with the alarm or if rapid, short-term improvement is a priority. Initial dose for children five years and over is 200µg for Desmotabs or 120µg for DesmoMelt.
10. Refer children who have not responded to the above.
A specialist might consider offering an anticholinergic like tolterodine or oxybutynin to take with desmopressin.
Dr Margaret Morris is a GP in Edinburgh and a former paediatrician
References
1 Butler RJ and Heron J. The prevalence of infrequent bedwetting and nocturnal enuresis in childhood: a large British cohort. Scand J Urol Nephrol 2008;42:257-64
2 NICE. Nocturnal enuresis: the management of bedwetting in children and young people CG111. October 2010
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