Nocturnal enuresis (Bedwetting in children)
Nocturnal enuresis is a common issue in children, defined as involuntary wetting at night after the age of 5. The management in the UK, as guided by the National Institute for Health and Care Excellence (NICE), focuses on a stepped approach that starts with reassurance and education before moving on to specific treatments.
Causes
Primary Nocturnal Enuresis
This is the most common type, where the child has never achieved a sustained period of dry nights. It is often multifactorial, caused by:
Sleep Arousal Difficulties: The child does not wake up to the sensation of a full bladder.
Nocturnal Polyuria: The kidneys produce an excessive amount of urine at night. This is often due to a lack of nocturnal secretion of antidiuretic hormone (ADH).
Bladder Dysfunction: The bladder has a reduced functional capacity.
Genetic/Hereditary: There is a strong familial link.
Secondary Nocturnal Enuresis
This occurs when a child who has been dry for at least 6 months starts bedwetting again. It may be a sign of an underlying medical or psychological issue, such as:
Medical: Urinary tract infection (UTI), diabetes mellitus.
Psychological: Emotional stress, anxiety, or child abuse.
Clinical Assessment
A comprehensive assessment is essential to determine the type of enuresis and rule out any underlying causes.
History: A detailed history is crucial. Ask about:
Fluid intake: What types of fluids and how much the child drinks, and when they stop drinking in the evening.
Bedwetting patterns: The frequency of bedwetting (e.g., nights per week) and whether the child ever wakes up after wetting the bed.
Daytime symptoms: Enquire about any daytime wetting, frequency, or urgency, as this may suggest a bladder dysfunction.
Associated symptoms: Ask about constipation, which can put pressure on the bladder, and behavioural or emotional issues.
Examination: A physical examination should focus on ruling out underlying organic causes. This includes a full abdominal examination, palpating for a full bladder, and a neurological examination of the lower limbs and spine.
Investigations: In most cases, a urinalysis is the only investigation required to rule out a UTI or diabetes. A bladder diary for 48 hours is also very useful for assessing fluid intake and urine output.
Management
Management follows a stepped-care approach, with a focus on non-pharmacological interventions first.
Non-Drug Management: This is the first-line treatment for all children.
Education and Reassurance: Provide clear information to the child and family, explaining that it is a common condition and not the child’s fault.
Lifestyle Advice: Advise on adequate fluid intake throughout the day but limiting fizzy and caffeinated drinks, especially in the evening.
Toileting Habits: Encourage regular trips to the toilet every 3-4 hours during the day and before bedtime.
Reward Charts: Reward systems can be used to reinforce positive behaviours, such as using the toilet before bed, but not for dry nights.
Enuresis Alarms: An enuresis alarm is recommended as a first-line treatment for children over the age of 7 who have not responded to initial advice. They work by training the child to wake up to the sensation of a full bladder.
Pharmacological Management: Medications are considered for children over the age of 7 where alarms are not suitable or have been ineffective.
Desmopressin: This is the first-line medication. It is an analogue of ADH and works by reducing nocturnal urine production. It is particularly effective in children with nocturnal polyuria. The drug is often prescribed for 3-month blocks, with a treatment-free period to assess for a sustained response.
Oxybutynin: This is an anticholinergic drug that works by reducing bladder contractions. It may be used in combination with desmopressin for children with a small bladder capacity.