Noctural enuresis

Presentation

• This is bedwetting in those >5yrs old.
• Daytime bladder symptoms may require further assessment.
• All children have difficulty in waking response to pass urine.
• Some children may have:
  • Nocturnal polyuria, heavy wetting most/every night, never been dry, family history – likely lack of vasopressin.
  • Bladder storage problems – variable wetting in volume and frequency, small bladder capacity – possibly overactive bladder.
  • Combination of all factors.

Red flags

• Possible diabetes – weight loss, excessive thirst – check blood glucose and dip urine for glucose.
• Lower limb weakness, sacral abnormality or abnormal lower limb reflexes.
• Intractable day and night-time wetting and soiling.
• Persisting nocturnal enuresis despite conservative measures and non-response to alarm or desmopressin.
• Accompanying daytime bladder issues.
• Persistent constipation and/or soiling.
• Developmental difficulties.
• Secondary enuresis with no identifiable cause. 

Referrals to Paediatrics should be made via the SCI Gateway.

Please note, these are vetted in a timely manner so the priority status of a referral may change upon review.

Initial management

• Encourage good fluid intake and good toileting habits.
• Ensure bowels motions are passed daily and are soft – see Constipation section in resources below
  • Adequate fluid intake
    • Age 4-8 years: 1000-1400mls (girls and boys)
    • Age 9-13 years: 1200-2100mls (girls), 1400-2300mls (boys)
    • Age 14-18 years: 1400-2500mls (girls), 2100-3200mls (boys)
  • Regular voiding throughout day, double void before bed.
  • Avoid irritant drinks e.g. caffeine, fizzy drinks, blackcurrant.
  • Avoid excessive fluid late afternoon/evening but do not restrict overall fluid.
  • Avoid salty or dairy snacks later into the evening (may increase volume of urine overnight)
  • Avoid screen time before bed – to promote healthy sleep routines.
  • Enuresis alarms are available to buy online.
• If previously dry >6 months, this is secondary enuresis and likely to be due to a trigger e.g. UTI, constipation, emotional change.
• Desmopressin and alarms can be trialled in Primary Care, as per NICE guidance.

Treatments

Alarms

• May be used from age 5; they are 75% effective for motivated families.
• May not be appropriate if child not willing/has sensory issues/shares a room with a sibling.
• Must be used consistently and can take weeks for an improvement to be seen; reassess after 4 weeks of use and continue until at least 2 weeks continuous dry nights have been achieved.
• Can be used again if wetting recurs, or if more than a year since last attempt.

Desmopressin

• Desmomelts – dose as per BNFc.
• Continue treatment for 3 months, then take a week off to see if child drier while off medication; if not, restart on dose given before break.
• No fluids for an hour before or 8 hours after medication.
• Avoid with regular NSAIDs due to potential risk of hyponatraemia.
• Withhold if unwell with diarrhoea and vomiting.
• Can have combined treatment with medication and alarm.

NICE. Bedwetting in under 19s. CG111. Published 27 October 2010.

Carer information - NHS Ayrshire and Arran Paediatric Training App – Continence section.

ERIC. Carer information.

Bladder & Bowel UK. Carer information.