Effective Healthcare
Bulletin on the effectiveness of health service interventions for decision makers
Source: Centre for Reviews and Dissemination, University of York
- Nocturnal enuresis in children (bedwetting) is the involuntary loss of urine at night, in the absence of physical disease, at an age when a child could reasonably be expected to be dry (by consensus, at a developmental age of five years).
- Nocturnal enuresis in children (bedwetting) affects many families. Although it has a high rate of spontaneous remission, bedwetting may bring social and emotional stigma, stress and inconvenience to both the child and their family.
Management of enuresis
- A wide variety of interventions are used to treat nocturnal enuresis. These include enuresis alarms, drugs such as desmopressin, simple behavioural methods such as star charts and more complex behavioural methods including dry bed training. Other less common interventions include psychotherapy, surgery, fluid deprivation and complementary therapies.
- Treatment for children who wet the bed is often carried out by health professionals in general practice.
- Bedwetting may be discovered when a child is seen for a complaint other than enuresis.
- Having established that the child is at an age where one could reasonably expect a dry bed (at least five years old) and wants to become dry, consensus is that a thorough assessment should be undertaken, including a general physical examination, urinalysis and investigation of attitudes.
- In keeping with the objectives of the NSF for children, any intervention should be centred on the needs of the child.
- The Enuresis Resource and Information Centre (ERIC) has produced guidelines on minimum standards of practice in the treatment of enuresis.
Acceptability of drugs
- Current thinking suggests that drug therapy is not usually appropriate for children under seven years of age and is reserved for when alternative measures have failed.
Adverse effects of drugs
- Fluid overload is potentially the most serious complication with desmopressin. It is associated with over-drinking at bedtime and its symptoms include headache, nausea, hyponatraemia, cerebral oedema and convulsions.
- Tricyclics have significant adverse effects, including cardiotoxic and hepatotoxic effects in overdose. Minor side-effects related to their anticholinergic actions include postural hypotension, constipation, dry mouth, perspiration, tachycardia, nausea, lethargy and insomnia.
- Possible side-effects of the various drugs should be considered, and that any prescription should not be continued for longer than three months without stopping for a full re-assessment.
Interventions used to treat nocturnal enuresis
Behavioural interventions
- Lifting: involves taking the child to the toilet during the night, usually before the time that bedwetting is expected, without necessarily waking the child.
- Waking: involves waking the child to allow them to get up and urinate.
- Reward systems (for example, star charts): the child might receive a star for every dry night, and a reward after a preset number of stars have been earned.
- Retention control training: this involves attempting to increase the functional bladder capacity by delaying urination for extended periods of time during the day.
- Stop-start training: this involves teaching children to interrupt their stream of urine in order to strengthen their pelvic floor muscles.
- Dry bed training: this can include enuresis alarms, waking routines, positive practice, cleanliness training, bladder training, and rewards.
Enuresis alarms
- Enuresis alarms wake the child in the night at the onset of wetting. When a child begins to urinate, a sensor (either a bed pad or one worn inside pyjamas) is moistened, and the alarm is triggered.
- Over-learning may be initiated after successful alarm treatment (for example, achievement of 14 consecutive dry nights). Extra drinks are given at bed-time to cause additional stress to the detrusor muscles in the bladder. Alarm treatment is then continued until 14 consecutive dry nights are once again achieved.
Pharmacological interventions
- Drugs include desmopressin and, less commonly, tricyclic drugs such as imipramine, amitriptyline and nortriptyline.
The Effective Health Care bulletins are based on systematic review and synthesis of research on clinical effectiveness, cost effectiveness and acceptability of health service interventions. This is carried out by a research team using established methodological guidelines, with advice from expert consultants for each topic. Great care is taken to ensure that the work, and the conclusions reached, fairly and accurately summarise the research findings. The University of York accepts no responsibility for any consequent damage arising from the use of Effective Health Care.
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Treating Nocturnal Enuresis in Children. Effective Health Care, 2003, Volume 8, Number 2. ISSN: 0965-0288
