Bedwetting is a common and often distressing problem in older children. It is generally easily treated at an appropriate age. The resourses below provide the practitioner with a mechanism to tackle this problem and a diagnostic process to be reasonably sure that contributing problems if present are recognized. There are 5 components.
Bedwetting (primary enuresis) is a common childhood problem which in later childhood years can be extremely distressing. It is easily treated with modern biofeedback techniques which can produce excellent results.This usually involves the use of a bladder alarm.
Bedwetting is a common problem and affects 15-20% of 5 years olds, 7% of 7 year olds, 5% of 10 year olds and 1-2% of 15 year olds. As can be seen from these figures, once a child reaches 7 years of age there is only a slight chance of improvement from 7 to 10 years.. Because of the fact that most 7 year olds are reasonably mature in terms of coping with the demands of an alarm programme and also appreciate the social desirability of being dry, 7 is an appropriate age at which treatment is offered.
The gold standard treatment for bedwetting is a very good quality bedwetting alarm with therapy taking 8-10 weeks on average with appropriate programme support. Programmes offering this can provide up to 80-85% cure rates. Medication can be considered for children with bedwetting only after they have failed an alarm programme. No medication has been shown scientifically to be curative for bedwetting and many children on medication will wet as soon as it is stopped. Desmopressin or DDVAP is the only recognised medical treatment with support in the literature for symptomatic control only and again this is low in only about 40-50% of cases. As soon as the medication is stopped wetting returns.
Referral Guidelines for the Bedwetting Programme
Follow the diagnostic flow chart to apply these guidlines.
1. Treatment is for primary enuretics only.
2. The child must be 7 years or over to commence on the programme.
3. There must be no day-time urinary incontinence.
4. No day-time faecal incontinence.
5. The child must have 5 or more wet nights per week. The pattern of wetting must be suitable for an alarm programme rather than the technique of systematic awakening. (See Below)
6. Both the child and the parent/guardian must be motivated.
7. There must be no urological or physical abnormalities.
8. Behavioural problems must be minimal
9. An MSU must be normal.
Children with primary enuresis do not require an ultrasound or x-ray examination of any sort.
Children with medical conditions or behavioural problems should be referred to a paediatrician, urologist or services of the Child & Family Service in the first instance. Otherwise a referral letter should be sent to the Continence Nurse, Community Health Services, with a summary of findings including examination, MCU and a past history to admit the child to the programme. There may be a short wait for an alarm.
On completion of treatment a letter summarising the outcome will be sent to you.
Discussion around referral criteria
It has been shown that if there is any day-time wetting or soiling problems it will be very unlikely that a child will respond to a bladder alarm. Day-time wetting problems require assessment by a paediatric urologist or paediatrician with an interest in day-time wetting. If the child has faecal soiling this often compounds bladder instability, both during the day and at night, essentially because of a back pressure affect on the bladder and unless the bowel problem is fixed by appropriate therapy the child would be very unlikely to respond to an alarm.
Children need to be 7 years of age or over. It is at this stage they move into a more resistant phase of bedwetting and usually will have developed enough to cope with the demands of the programme. The child must have at least 5 or more wet nights per week.
Children having 4 wet nights per week at the age of 7 are likely to be in a phase where they may soon grow out of it. These children should be offerred encouragement and possibly a reward for a run of dry nights. The children must be motivated to become dry.
It is important to realise that if a child has tried an alarm previously without success they should still be referred. There are a large range of alarms available and they vary both in quality and sensitivity.
A considerable amount of research has been done on alarms and it is has been found that a very large, good quality, highly sensitive alarm is much better at producing a good result. If an alarm is of poor quality or small and fails to detect even a small amount of urine then the biofeedback effect will be lost very quickly. As such many children who have not achieved a result with a poor alarm can be expected to have a better outcome with a quality alarm.
Prior to referral an assessment needs to be done to determine the type of wetting that the child has. Generally there can be two patterns. That is, a child has one significant wet during the night or there are multiple small periods of wetness. The latter group require referral for an alarm service.
The assessment can be made by requiring the parent to assess the pattern by filling out a copy of the attached bedwetting chart If it is found after 2-3 nights of assessment that a children has one particular time at which they are wetting and this time approximates either the time they go to sleep or the time they wake up, then a technique should be used known as systematic wakening. Here the child is woken close to the time they are known to be wet when it would be presumed they would have a full bladder and they are taken to the toilet. This proceeds for one week. The next week the time at which they are woken is half an hour closer to the time at which they either go to sleep or wake up in the morning, depending when their primary wetting time. Gradually, over a period of several weeks the time can be weaned out to their normal bed-time. This technique should only be used if there is a specific time that can be clearly identified.
Other facts regards bedwetting.
Research has shown that excessive fluid restriction prior to going to bed makes no difference in terms of improving the problem.
There is often a family history.
Psychological problems do not directly cause bedwetting but stress may make it worse if a child has a tendency to wet.
Drug therapy does not cure bedwetting. The synthetic hormone DDVAP can provide symptomatic control in some children and has a role for children wetting infrequently who may be going to school camps or sleepovers etc.
Drugs such as imipramine should not be used for wetting. They have limited benefits and unpleasant side effects. If taken in overdose, it may be fatal