Enuresis - night wetting

Pre-referral guidelines for primary care providers

Terminology for children with bowel and bladder dysfunction is confusing, and only in the last decade has there been consensus regarding these terms. This is divided into:

  • Lower urinary tract dysfunction
    • Daytime urinary incontinence (DUI) - see Enuresis - day wetting pre-referral guideline.
    • Enuresis or nocturnal enuresis.
  • Bowel dysfunction (encopresis) - see Encopresis pre-referral guideline.

Diagnosis

Urinary Incontinence is defined as involuntary leaking of urine, whether continuous or intermittent. 10% of normally developing children still have nocturnal enuresis. Unlike in adults, where night wetting is always pathological, toilet training occurs at varying ages for different children (20% of 5 year olds, 10% of 7 year olds and 2% of 15 year olds still wet the bed). However, any child who wets the bed beyond age 7 is diagnosable with nocturnal enuresis, and should be further examined and investigated.

Nocturnal enuresis is caused by the triad of:

  • poor arousal from sleep
  • small nocturnal bladder capacity
  • nocturnal polyuria (increased urine production at night)

Differentials

Constipation - take a history and perform an abdominal examination to exclude constipation. Any rectal overload puts pressure on the bladder, decreasing its capacity, and increasing urinary symptoms. See Constipation for more details.

Nerve involvement or structural problems - examination of the spine (back) and the bladder opening to exclude any nerve involvement or structural problems.

UTI and diabetes - urine culture and urinary glucose to exclude these causes of urinary frequency.

Practice points

  • Night time wetting is developmentally normal for many children!
  • 20% of 5 year olds, 10% of 7 year olds and 2% of 15 year olds still wet the bed, however, any child who wets the bed beyond age 7 should be further examined and investigated.
  • Nocturnal enuresis is caused by the triad of poor arousal from sleep, small nocturnal bladder capacity and nocturnal polyuria (increased urine production at night).
  • The three mainstays of treatment that target these issues are bell and pad alarm, desmopressin (Minirin) and oxybutynin (Ditropan).
  • It is important to differentiate whether there are any daytime symptoms (wetting or urgency) in association with the night wetting, as the treatment is different.

Management

Simple management steps should include:

  • demystify and educate - wetting is a developmentally normal process for many children.
  • remove blame - there is nothing voluntary about night wetting, it is entirely caused by inability to wake from deep sleep state.
  • unrestricted fluid intake - despite what seems logical, there is no evidence that fluid restriction helps, and may lead to dehydration and increased risk of UTI.
  • an enuresis diary for at least one week is always help to clarify the pattern of wetting.

For children 7 years and older:

  • Night wetting only
    • Bell and pad alarm - used for 8-12 weeks, available through Continence Clinic, UFS pharmacies or some GP clinics, can be re-trialed every 6 months.
    • Body worn ('clip on') alarms - there is a current trial comparing these with bell and pad alarms, available through Continence Clinic
    • Desmopressin (Minirin) - used when alarms fail, start 120 mcg sublingual wafer at night, increase to 240 mcg if needed, restrict fluids 1 hour prior to bed (to avoid hyponatraemia), trial off after 3 months
    • Oxybutynin (Ditropan) - used if concerns regarding overactive bladder (see Enuresis - day wetting).
  • Day and night wetting

Referral pathways

  • Paediatrician
    • generally a non-urgent referral to paediatric outpatient services to i) confirm diagnosis, ii) discuss management strategies and iii) consider appropriateness of medication.
    • Information to bring to any appointments:
      • Enuresis diary - at least 7 nights recording is needed, but the more the better.
  • Paediatric Continence Service
    • referrals to Dr Mark Nethercote, Queen Elizabeth Centre, 102 Ascot Street South, Ballarat 3350, fax 53203737
    • All patients are seen by a Continence Nurse initially, who performs and intake assessment and management plan.
    • If deemed necessary, the Continence Nurse will on-refer to Dr Mark Nethercote, the Paediatrician attached to the Continence Service.