- Primary or secondary – have they ever been dry? Only considered secondary if consistently dry for at least 6 months
- Neurology – dribbling, ankle jerks, anal tone
- Daytime or night time
Nocturnal wetting is considered normal up to the age of 7. Quantify daytime wetting – pants only, patch on clothes, or puddle.
Diagnoses to consider: (not mutually exclusive)
- Spinal lesion
- Excessive urine production – diabetes, lack of mature pattern of ADH production at night
- Excessive bladder tone/poor bladder volume – urgency, posturing
- Abnormal voiding – straining, intermittent or poor stream. Could be a bladder neck problem, or else incomplete emptying.
- Inadequate nocturnal awareness
Diaries of input/output, wetting/waking and measuring overnight urine output may be helpful. The expected bladder capacity is (Age + 1)x 30, max 390ml. If night time urine output is substantially greater than this eg 130% of expected, then suggests nocturnal polyuria. Similarly, day time voiding of consistently less than 65% of expected capacity suggests a small bladder. Going 8x a day or more (with a normal fluid intake) is another clue.
Recommended fluid intake (NICE):
- 4-8 yrs: 1000–1400 ml
- 9–13 years: 1200–2100 ml (boys sl more!?)
Incomplete bladder emptying can be defined as post void residual urine volume of greater than 20 ml, on more than one ultrasound, without excessive bladder distension before hand.
For bladder problems, exclude UTI/diabetes by urine dipstick testing.
For bladder or bowel problems, look for any signs of constipation, not just hard/painful stools.
Daytime wetting or urinary urgency/frequency
Ensure adequate fluid intake. Aim for at least 6-8 cups of appropriately sized water-based drinks spread throughout the day (e.g. 200ml for a 7 year old, about a teacup full; 250ml for an 11 year old, about a mug full). Start with 8 small drinks every day and increase the amount gradually so the bladder gets used to being stretched.
Try avoiding fizzy drinks, blackcurrant, orange, and drinks containing artificial colourings, flavourings and sweeteners, tea/coffee/hot chocolate for a few weeks, then introduce them one at a time to see what effect they have on the bladder.
Aim for 4-7 voids per day. If child tends to hang on for prolonged periods, ensure adequate fluid intake as above, then consider an alarm to remind them to go (vibrating watch available, £40+). Do not encourage excessively frequent voiding – bladder will then become less able to contain normal volume.
Check child is properly relaxed going to the toilet. Feet should be supported if sitting, use child toilet seat if tending to slip through. Boys should try sitting for some pees each day, as well as standing. “Don’t push your pee out. When you think you’re finished, count to 10 and start again. Tell your teacher if no toilet paper/soap or broken seat/locks etc.” (Snakes and ladders booklet, Kidney Kids Scotland).
Oxybutinin for small bladder (Desmopressin may work but less rational). Tolerterodine, Solifenacin are alternatives but still antimuscarinic, so same side effects.
Night time wetting
Deal with daytime wetting or urgency/frequency first.
Ensure adequate fluid intake through the day, spread evenly through the morning and afternoon/early evening. Stop drinking an hour before bed time.
Fully empty bladder before bed time. Try going twice!
Make toilet easily accessible in night – lower bunk, night light, bucket etc
Do not encourage regular or random lifting/waking – there is no evidence that this promotes long term dryness! Should only be used as temporary short term measure. Where night time wetting has not responded to management, a young person may find it useful to set an alarm for themselves.
Establish reward system for drinking well through day and helping to change bedding/pyjamas (rather than for staying dry, which is beyond their control). Choose appropriate goals, choose appropriate reward (choices/time, not necessarily monetary/dietary), choose appropriate format. Dot to dot picture rather than calendar?
Think positively – say “I can wake up and go to the toilet if I need to in the night!” before going to sleep. Try without nappies/pull-ups from time to time.
Get bed pads or waterproof mattress protector
Consider bed wetting alarm – bedpad or pant sensor? Buzzer or beeper? Alarms from ERIC cost £50-150! NICE says avoid alarms if doesn’t suit household, emotional stress esp parental blaming, or if infrequent wetting. Will disrupt sleep, of course! Parents may need to help child wake to alarm, need to do consistently and chart progress.
Offer trial of desmopressin if child over 7yrs, especially if rapid short-term improvement a priority, or if alarm not suitable. Consider from age 5yrs. Response rate low for those without obvious polyuria.
Refer to ERIC website (www.eric.org.uk) or helpline (0845 370 8008) for further support/information
Although primary nocturnal enuresis is still reasonably common up to the age of 7yrs, addressing the issues above should nonetheless be considered in children younger.
Refer to Secondary Care:
- Bladder dysfunction: straining to pass urine, intermittent or poor stream
- Abnormal neurology or lumbosacral spine (naevus, hairy patch, pits, asymmetry)
- Social/emotional factors that are affecting likelihood of improvement
- Bedwetting not responding to alarm or trial of desmopressin
- History of recurrent urinary tract infection
- Day time wetting not improving with first line advice as above
See ERIC (Childhood continence) website for parent information. Hjalmas, J Urol 2004 International evidence based strategy for nocturnal enuresis. International Children’s Continence Society. NICE guideline 111 nocturnal enuresis