Management for cases of bedwetting

Bedwetting is usually entirely manageable in the primary care setting, says Dr Julia Markham

Bedwetting is usually entirely manageable in the primary care setting.

If not managed properly it can result in a variety of problems. For the child these may include low self-esteem and a reduction in social interactions. Parents may experience feelings of guilt and inadequacy, family and relationship tension and tiredness from disturbed nights.

Nocturnal enuresis is the most common cause of bedwetting. It is recognised by the absence of other urinary symptoms or signs of disease.

Other causes include urinary tract infection, urge syndrome, dysfunctional voiding, diabetes mellitus and structural urinary abnormalities, but these usually present with daytime symptoms in addition to bedwetting.

Bedwetting is not considered to be a problem until the age of five. One in six five-year-olds, one in 11 nine-year-olds and up to 2 per cent of people over 15 wet at night.

The condition often runs in families, so a positive history in parents is common. It is more common in boys.

There is also evidence for the presence of physiological disturbances such as nocturnal polyuria, small functional bladder capacity and decreased arousal response to full bladder.

The decision to treat is based on the age of the child and is indicated for children and families who are adversely affected by the wetting.

It is vital to take a good history to ensure that there is no underlying urological or psychological illness, and to assess the impact of the bedwetting on the child and family.

Routine tests should include urine dipstick and midstream urine to rule out infection. Explanation and education are vital so that parents or carers understand that the problem is common and that the child should not be labelled as naughty or managed with punishments.

Waterproof mattress covers are useful. Star charts can be used as a reward and incentive scheme and may give encouragement to a child although there is not much evidence confirming their usefulness.

Enuresis alarms are a form of conditioning. The alarm is triggered to sound when urine comes into contact with a pad placed under the bedsheets. If a child is sharing a room, a silent vibrating alarm can be obtained. Using an alarm makes a child 13 times more likely to become dry. Alarms are effective and safe, but require several months of continuous use.

Desmopressin is a synthetic analogue of antidiuretic hormone and reduces nocturnal output of urine. It has a rapid onset of action. It improves bedwetting, but there is little evidence of long-term benefit.

It is available as a tablet and is particularly useful for sleepovers or school trips. It does, however, have the potential to cause water intoxication leading to coma and seizures.

Imipramine is a tricyclic antidepressant, and the mechanism of its action in enuresis is not fully understood, but it has anticholinergic and antidiuretic actions and effects on the CNS.

Although a child is four times more likely to become dry, imipramine has a high incidence of serious adverse affects and the long-term benefits are uncertain. It is rarely prescribed for children.

Oxybutynin may sometimes be used if there is detrusor overactivity, but data are not available to support its use routinely, and it is more likely to be initiated from the urology clinic.

If a physical cause is suspected, referral to a paediatrician or paediatric urologist may be required.  

Dr Markham is a GP in Solihull, West Midlands 

Key points

  • Bedwetting is a common condition resulting in significant morbidity.
  • The most common cause is nocturnal enuresis; other causes are associated with daytime symptoms.
  • It is more frequent in boys.
  • Good history taking is vital and should include physical, social and psychological factors.
  • Simple tests are required: midstream urine and urine dipstick. 
  • Treatment involves explanation of the condition with reassurance, advice on fluids, practical advice, reward systems, dealing with underlying stresses, medication — most commonly short-term desmopressin — alarms and referral to specialist services.

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