Nocturnal Enuresis (Bedwetting)

Last updated 25.08.13

   

Definition

-    Nightime urinary incontinence in children

-     Monosymptomatic enuresis: enuresis without other urinary tract symptoms & no history of bladder dysfunction

-    Primary: never achieved satisfactory period of nighttime dryness

-    Secondary: enuresis develops after >6 months of dryness

 

Features

-    Very common

-    Emotional & social effects in children: embarrassment, low self esteem, poor sleep

-    Day time control of bladder preceeds nocturnal control

-    Most children dry during day by 3yrs old & dry at night by 6yrs

-    Tend to run in famililes

-    Indications for medical review

-     Dry child suddenly wet at night

-     Frequent wetting after school age

-     Bedwetting bothers child making them upset or angry

-     Child wishes to become dry

 

Incidence

 

Causes

-      Inability to waken to a full bladder

-      Overactive bladder at night

-      Increased production of urine at night

-      Medical illness

-     DM

-     Diabetes insipidis

-     ARF, CRF

-     OSA

-     Chronic constipation

-     Congenital abnormality

-     Neurological disorder: spinda bifida

-      NOT associated with

-     Laziness

-     Bad behavior

-     Drinking after dinner

 

Associated S/S

-      Snoring: OSA as cause

-      Family Hx

-      Monosymptomatic enuresis is not associated with

-     Urinary frequency

-     Daytime incontinence

-     Urinary urgency

-     Genital or lower tract pain

 

Ix

-      Abdominal, spine & lower limb exam +/- perineal exam

-     Spinda bifida

-     Neurological disorder

-      FWT & Urine MCS: to exclude UTI

-      +/- BSL: DM

-      Renal US indicated if Daytime enuresis, UTI or refractive to Mx

 

Mx

-    Dont punish or shame child for bedwetting

-    Address issues which may be preventing child to toilet at night: light, fear, social setting

-    Most children will cease bedwetting on their own but if >9yrs old my require intervention

-      Chart of wet & dry nights: calendar with stickers, etc.

-      Best to cease using nappies (cannot be used with alarms)

-      Mattress protection: pads, covers

-      If child <6yrs old and monosymptomatic reassure & educate

-      Night alarms

-     Teach child to waken when they wet the bed

-     Used on the wet in in the pants

-     Most useful & successful method: works in majority of children, 80%+

-     Typically takes 6-8 weeks to work

-     Mattress alarm

-    Pad in the bed where childs bottom will rest

-    Underpants only, no pyjama pants

-    Alarm rings then pad gets wet

-    Child should get out of bed & go to the toilet

-     Pant alarm

-    Vibrating alarm worn on pants

-    Child should get out of bed & go to the toilet

-      Medication: Desmopressin (DDAVP, Minirin)

-     Generally if child >6yrs old

-     Assists in times when acute control required: school camps, sleep overs, etc.

-     Synthetic ADH

-     Taken at night to reduce the amount of urine produced

-     Also used if alarm fails, then use for 3 months

-     20-40mcg intranasal Nocte

-     200-400mcg PO Nocte

-     Reduce oral intake late in evening to avoid dilutional hyponatraemia

-     Reduce oral intake late in evening to avoid dilutional hyponatraemia

-    +/- Referral

-     Continence nurse (online search) or helpline (Continence Australia) 1800 330 066

-     General Paediatric Enuresis Clinic

-    Indicated if refractory to treatment, non-monosymptomatic, developmental or behavioural problems, neurological disorders

-    Royal Childrens Hospital, Parkvile 3052

-    Fax (03) 9345 5034

-    Phone (03) 9345 6180

 

 

Alarm

 

 

 

References

 

Continence Foundation of Australia

RCH Kid Health Information

UpToDate: Management of nocturnal Enuresis in Children

Paediatric Society of New Zealand: Nocturnal Enuresis 2005

NICE Guideline: Nocturnal Enuresis 2010