Enuresis

• Nocturnal enuresis:

  • Involuntary wetting during sleep
  • Generally considered to be normal in children younger than 5
• Diagnostic criteria:

  • occurs at lease twice weekly for 3 consecutive months, or
  • Causes significant distress, or
  • Leads to impaired social, academic, or other impairment of functioning
• Can be classified as:

  • Primary enuresis without daytime symptoms - never achieved sustained continence at night as does not have daytime symptoms
  • Primary enuresis with daytime symptoms - never achieved sustained continence at night and has daytime symptoms such as urgency, frequency, daytime wetting
  • Secondary enuresis - occurs after the child or young person has been previously dry at night for more than 6 months
• Causes of primary enuresis without daytime symptoms:

  • Sleep arousal difficulties - unable to wake to noise, sensation of a full bladder
  • Polyuria
  • Bladder dysfunction - overactive bladder or small bladder capacity
• Causes of primary enuresis with daytime symptoms:

  • Overactive bladder
  • Structural abnormalities
  • Neurological disorders e.g. neurogenic bladder secondary to spinal disorders
  • UTI
  • Chronic constipation
• Secondary bedwetting often has an underlying cause:

  • Diabetes
  • UTI
  • Constipation
  • Psychological problems
  • Family problems
• Most children have daytime control by 3 years and nighttime control by 4 years.
• Risk factors:

  • Family history
  • Male sex
  • Developmental delay
  • Constipation or faecal incontinence
  • Psychological or behavioural disorders e.g. ADHD and autism
  • Sleep apnoea
• Determine the pattern of bedwetting, including:

  • When bedwetting started — bedwetting that has started in the last few days or weeks may be a presentation of a systemic illness (for example UTI), or a change in the child's environment (for example bullying or abuse).
  • How many nights a week, and how many times a night, bedwetting occurs — frequent bedwetting is less likely to resolve spontaneously than infrequent bedwetting.
  • How many times a night bedwetting occurs.
  • The quantity of urine passed.
  • The times of night that bedwetting occurs.
  • Whether the child or young person wakes up after bedwetting.
• A bladder diary (recording fluid intake, urine output, and wetting episodes) can help establish patterns and determine the cause (e.g., too much fluid before bed).
• Management of primary nocturnal enuresis:

  • Reassurance if under 5 years - likely to resolve without any treatment
  • Lifestyle changes - reduce fluid intake in the evenings, passing urine before bed and ensuring easy toilet access
  • Encouragement and positive reinforcement
  • Treat underlying causes e.g. constipation
  • Enuresis alarms
  • Pharmacological treatment
• Offer treatment to children and young people with primary bedwetting and has not responded to advice on fluids, toileting, or an appropriate reward system.

  • If rapid or short-term control of bedwetting is required (for example for sleepovers or school trips), offer treatment with desmopressin.
  • If long-term treatment is required, offer treatment with an enuresis alarm (first-line treatment). 
• other pharmacological treatments that can be started in secondary care:

  • Oxybutynin - anticholinergic useful for overactive bladder
  • Imipramine - tricyclic antidepressant, unclear how it works
• Secondary enuresis management:

  • Manage any identified underlying cause in primary care - UTI and constipation are common
  • Same day referral if suspected T1DM
  • Consider referring to secondary care or enuresis clinic for further assessment
  • If child maltreatment is suspected, safeguarding should be contacted