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Nocturnal enuresis: diagnosis and treatment

Jonathan HC Evans
FRCP FRCPCHConsultant Paediatric Nephrologist
Children and Young People's Kidney Unit
Nottingham City Hospital NHS Trust

Nocturnal enuresis (NE) is defined as voiding at night while asleep in a child over the age of five who does not have other urinary symptoms or disorders affecting the urinary tract. Bedwetting in children with daytime symptoms is usually caused by detrussor instability and dysfunctional voiding. Psychological problems are often present in this group, and constipation or soiling may coexist.

Differential diagnosis
The following are signs for differential diagnosis of NE:

  • Bladder disease - detrussor instability, urinary tract infection (UTI), neurogenic bladder, ­posterior ­urethral valves.
  • Polyuria - chronic renal failure and diabetes.
  • Nervous system disorders - such as cerebral palsy and sedative medications.

Investigation
For NE, only urinalysis (including protein, nitrite and leucocytes) is necessary. If significant daytime wetting or UTI is present, an ultrasound scan of the kidneys and bladder is needed. Invasive investigations such as urodynamics or an intravenous urogram are rarely needed.

Treatment

Under-fives
For the under-fives, explanation and advice about potty training is advised. Punishment should be avoided.

Between five and seven years
For children between five and seven years use star charts and rewards; encourage daytime fluids (avoid caffeine); treat constipation and daytime wetting before bedwetting. If the child is distressed and motivated towards treatment, manage as if over seven years old.

Over-sevens
For the over-sevens enuresis alarms (worn on the body or placed on the mattress) are most effective but require a motivated and determined child and parent.
Desmopressin (10-40mg nasal spray or 200-400mg tablet) is rapidly effective but does not usually cure the underlying condition. It is good for short-term relief of wetting or where the use of an alarm is not possible or effective. There are few adverse effects.
Imipramine may be effective, but the high incidence of adverse effects and the danger of overdose limit its usefulness.
Oxybutinin may help the child with symptoms of bladder instability.

Referral indications
Indications for referral to a specialist include: for evaluation and treatment in a community-based enuresis ­clinic; when there are indicators of urinary tract disease; on treatment failure; and where there are behavioural or psychological problems, with possible referral to ­community paediatrics or child mental health.

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References

  1. Rodgers J. Daytime wetting in school-age children. J Community Nurs 2000;14:4-6.
  2. Lister-Sharp D, O'Meara S, Bradley M, Sheldon TA. A systematic review of the effectiveness of interventions for managing childhood nocturnal enuresis (CRD report 11). York: NHS Centre for Reviews and Disseminations; 1997.
  3. Evans JHC. Bedwetting: a good ­practice guide. Ambulatory Child Health 1997;3:130-6.

Resource
Enuresis Resource and Information Centre
Provides advice, literature, enuresis alarms and ­continence products for parents, children and professionals
T:0117 9603060
E:enuresis@compuserve.com
W:www.enuresis.org.uk