Dr Claire Strauss | Dr Cheentan Singh

Not taking the P: How to manage Bedwetting

Bedwetting is one of those absolutely classic paediatric outpatient clinic problems, causing children and their families a whole lot of distress (and if you are new to outpatient clinic settings, it can be difficult to know where to start in addressing the issue). So here, we’re going to break down how to assess and manage a young person with enuresis.

Obviously let’s start with a definition or two…

Nocturnal enuresis: When a child of 5 years and over involuntarily bed wets during sleep, at least once a month over 3 months or more, without an underlying medical problem (BMJ 2013)

Primary nocturnal enuresis is when a child has never previously been dry at night for a period of at least 6 months

Secondary nocturnal enuresis is when a child has previously been dry at night for at least 6 months (this is when there is more likely to be an underlying medical problem).

And some motivation – why is it important to sort this out?

To exclude any underlying serious medical problems

Bedwetting can cause a lot of stress and anxiety in the family and is embarrassing especially for older children. It can affect the whole family’s sleep, and just think of all the laundry…

Managing and treating bedwetting is helpful for children and young people’s self-esteem.

What is ‘normal’ anyway?

Developmentally speaking, most children are expected to be dry at night by the age of 5 years. Traditionally treatment has only been considered for children over 7 years but NICE now recommends that you can start it at any age.

Age	Frequency of bedwetting on average twice a week
5y	15-20%
7y	7%
10y	5%
12-14y	2-3%
>15y	1-2%

Glazener and Evans (2004)

Children under 5 years who wet the bed

The first thing to say is that bedwetting is very common in children under 5 years old, (table above!) so parents can be reassured that there is unlikely to be a serious problem. The first thing they should do is to start toilet training if not already done so – as this will help the child to learn what it feels like to have a full bladder and to hold their urine. Other useful advice is as follows –

• If a child has been dry by day for 6 months, advise to try at least 2 months without nappies. This may be longer if children are older, there is some success and family circumstances allow.
• If a child wakes at night parents should take them to the toilet.
• Consider constipation as a cause and treat it if found.
• Consider assessing for a medical cause in children over 2 years who have appropriate toileting behaviour but are having difficulties with enuresis in the day and night.

Why does bedwetting happen?

We don’t fully understand the causes, but there is probably a mixture of things going on including sleep arousal difficulties, bladder dysfunction and polyuria. It sometimes runs in families.

Noturnal Enuresis – ‘Simple bedwetting’(i.e. there is no underlying physical problem)	Nocturnal Enuresis with an underlying cause
Excessive fluid intake	Constipation
Limited facilities e.g. distance and cleanliness of toilets	Overactive Bladder
Poor toileting habits	Emotional, behavioural or social problems
	Urinary tract infection
	Diabetes Mellitus
	Diabetes Insipidus
	Neurological (spinal pathology?)

HISTORY

Your consultation (and all paediatric clinic consultations!) should be child focused. Ask what the child thinks – they are the patient! What does the child think is the main problem? Do they think the problem needs treating? Are there any immediate needs or short / long term goals (e.g. holiday dryness or going on a school trip?)

Now we can get into the details.

CLUE: ‘Simple bedwetting’ is usually large volumes early on, but in bladder instability the volume and timing varies and can be multiple times per night

What happens in the daytime?

As a baseline, a child should wee 5-7 times a day including just before bedtime.

Does the child wet themselves during daytime? Or do they have frequency or urgency? Ask about what happens in different settings – is it also a problem at school? Any daytime symptoms make simple bedwetting less likely. Daytime behaviours which are important to note include avoiding toilets, particularly in certain environments (do they only like to use the toilet at home?), frequency of urination and unhelpful patterns of fluid intake.

Let’s talk about fluid intake. Enuresis can be due to the child drinking too much OR too little (as concentrated urine can stimulate the bladder to void), and exactly what they are drinking is also important (remember caffeine is a diuretic! Children should never drink energy drinks!) Ask about the total daily fluid intake and the type of fluids they drink as well as whether drinks are restricted in the evening before bedtime.

If the child is drinking huge amounts and also weeing all the time, you are obviously going to have to rule out diabetes mellitus or diabetes insipidus. Don’t let them leave clinic without doing a finger prick blood glucose (you will kick yourself if they are in early stages of DKA!)

Underlying causes

Rarer causes of secondary enuresis are the ones you don’t want to miss. We’ve already mentioned some endocrine causes including – be sure to ask about polyuria, polydipsia and weight loss. Spinal pathology can be a rare cause of constipation and enuresis. All aspects of toileting can be affected by developmental delay or learning, attention, behavioural or emotional difficulties – also, social and family problems can have a huge effect on wetting at night. Lastly, please rule out a UTI!

Could bedwetting be a sign of abuse? Get your protection hat on – these are red flags… 

The parents tell you that the child is deliberately bedwetting; parents punish a child or young person for bedwetting even though they have been told that it is not deliberate; or there is secondary daytime or bedwetting (without a medical or social reason) that doesn’t respond to treatment.

EXAMINATION

Investigations

Should be determined by the examination.  The simplest are a blood sugar and a urine dip if there are symptoms of a urinary tract infection or diabetes, if bedwetting has started recently (days/ weeks), if there are daytime symptoms or if the child appears unwell. Imaging is not normally helpful in the first instance.

Management

We’re not going to talk about management of enuresis with an underlying cause – treating the cause will normally resolve the enuresis.

This section is about management of SIMPLE ENURESIS without any other medical explanation.

Enuresis is not a problem which has a quick fix, and so families need to be totally on board with a long term plan. Be open about the options available and make sure that they understand that the problem is a physical, not behavioural one.

Emphasise that bedwetting is NOT deliberate. It is INVOLUNTARY, and their child will need a lot of support and encouragement, not blame, to stop bed wetting.

Think about the family’s individual circumstances that will affect the plan:

• What are the child’s sleeping arrangements? E.g. do they share a room?
• What is the impact of bedwetting on child and family? Is there any negativity towards the child or blame placed upon them?
• Are they still using nappies?
• How motivated are the child/family to change the situation?

Here’s an enuresis treatment overview:

Get the basics right

Reward systems

Alarms

Medication

Second line medication after specialist referral

 

Reward systems

Rewards should not be for dry nights but instead:

The next steps will generally take place following a review in an enuresis clinic. But it’s important for you to know the options so you can explain to families what to expect.

Alarms

The point of an alarm is to wake the child up before or as the bed is wet. They learn to associate the alarm with wetting, so it will gradually teach them recognise the need to wee, wake up and get to the toilet. It can take a few weeks to start working, and the parents need to be fully engaged – it’s up to them to help the child to wake up to the alarm and understand what it means. Alarms are definitely not for all families and some choose to go straight to medication.

An alarm is not appropriate if:

• The young person or their parents don’t want one or don’t think it would suit their situation
• Bedwetting happens less than 1–2 times a week
• Parents are having emotional difficulty coping with the burden of bedwetting
• Parents are expressing anger, negativity or blame towards the child or young person

Using an alarm

It can be helpful to use an alarm along with a reward system. Rewards shouldn’t be given for dry nights! Instead, the child should be rewarded for positive behaviours like

• Waking up when the alarm goes off
• Going to the toilet after the alarm has gone off
• Going back to bed and resetting the alarm.

Alarms do have a high long‑term success rate, but it can take several weeks to see early improvement (waking to the alarm, reduced frequency of the alarm going off) and totally dry nights take even longer to achieve.

Parents should be aware that the alarms disrupt sleep and that using an alarm means that they have to make a long term commitment to this method if they want to see progress (and they should keep a record of progress).

If, after a period of success, bedwetting restarts, the alarm can be used again.  Alarms can also be used in combination with desmopressin.

Desmopressin

This is an antidiuretic medicine, and is really for short term relief (for example if there is a short term goal like going on a sleepover) but it can be trialed up to 3 months. It’s taken at bed time to reduce urine output overnight. Children shouldn’t drink for 8 hours after taking the medication. Desmopressin may be appropriate in children with emotional or behavioural problems or developmental and learning difficulties if an alarm is inappropriate and they can comply with night‑time fluid restriction.

NOTE: Children with sickle cell disease should stop desmopressin during a sickle crisis as it can affect blood clotting.

If bedwetting starts again…

• Try repeated use of an alarm if previously successful.
• Try an alarm with desmopressin if a child has multiple recurrences following initial success with an alarm
• If desmopressin was successful it can be used again. Check for resolution of bedwetting by stopping it for a week at regular intervals.
• If the family haven’t used an alarm previously – maybe have a conversation about trying one

Further Management

When bedwetting doesn’t respond to simple fluid measures, an alarm and/or desmopressin, you might need some expert help. This is for an assessment of things like an overactive bladder, reconsidering underlying medical causes and social and emotional factors – all of these can mean that standard treatment is ineffective.

Other medical treatments of nocturnal enuresis (which are generally only used by specialists) include anticholinergic agents, especially useful if children also have daytime symptoms. A tricylclic agent like imipramine is another possibility.

Summary

• Children are usually dry at night by the age of 5
• Secondary nocturnal enuresis is more likely to be caused by an underlying medical problem which needs treatment e.g. constipation, diabetes mellitus or neurological problems
• Think about traumatic events or maltreatment as a cause
• First line management is adjusting fluid intake and toileting habits
• Alarms can be used, but families need to commit to them long term and it can take weeks to see a response
• Desmopressin is the first line medical treatment.
• If simple measures, alarms and desmopressin are unsuccessful, get an expert opinion.

Dr Claire Strauss, Paediatric registrar, and Dr Cheentan Singh, Consultant Paediatrician, North Middlesex Hospital, London

Further Reading:

Bedwetting in under 19s. NICE clinical guidance

Simple behavioural and physical interventions for nocturnal enuresis in children- Glazener and Evans

Management of nocturnal enuresis (BMJ)

ERIC, The Children’s Bowel & Bladder Charity: Bedwetting Advice