Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.

Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser

We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.
Learn more

Nocturnal enuresis: systems for assessment and treatment

  • Comment

VOL: 102, ISSUE: 12, PAGE NO: 49

Penny Dobson, MSc, RGN, CQSW, is director

Anne Weaver, RGN, is clinical adviser, Education and Resources for Improving Childhood Continence (ERIC)

Nocturnal enuresis in children aged five years or older is currently defined in the UK as being an involuntary voiding of urine during sleep - in severe cases at least twice a week - in the absence of congenital or acquired defects of the nervous system (American Psychiatric Association, 1995).

The International Children’s Continence Society is about to publish a definition based on the leakage of urine while sleeping, regardless of the presence or absence of daytime symptoms, such as urgency or frequency.

There are two sub-types of enuresis in children. These are as follows:

- Monosymptomatic enuresis (the children have other bladder symptoms);

- Non-monosymptomatic enuresis (there are other lower urinary tract symptoms).

About 90% of children with bedwetting have primary enuresis; that is, they have never been dry for a significant period. A smaller proportion (10%) have secondary or onset enuresis - they started bedwetting after six to 12 months or more of being dry.

Prevalence

Most prevalence studies include children who wet a few times a month as well as those who wet every night. The average from these studies is about one in six five-year-olds, one in seven seven-year-olds, one in 11 nine-year-olds and one in 50-100 teenagers and young adults (Butler, 1998).

The Avon Longitudinal Study of Parents and Children (ALSPAC) has been able to differentiate according to severity: in a sample of 1,260 children aged seven-and -a-half years, 15.5% wet the bed; most wet it once or less a week, but only 2.6% met the criteria of wetting it at least twice a week. Within the research sample, 3.3% had additional daytime wetting and 2.3% experienced additional wetting and soiling. A higher prevalence was reported in boys than girls (Butler et al, 2005).

The path to becoming dry

Most children become dry at night after achieving bowel control, in the following sequence:

- Bowel control during sleep;

- Bowel control when awake;

- Dry in the day;

- Dry at night after a variable interval from being dry during the day (Stein and Susser, 1967).

One study showed that 7.5% of children were dry at night by the age of two years; 57% by the age of three and 81% by the age of four. This suggests that children normally become dry around their third year (Fergusson et al, 1986).

The impact of bedwetting

Children who wet the bed often feel isolated and ‘different’, have a fear of public detection and avoid social activities that involve sleepovers (Butler, 2004). Most parents are concerned for their child and are aware that it is outside the child’s control. However, up to a third of parents believe, quite wrongly, that their children could become dry if they really wanted to, and are likely to punish their them for episodes of bedwetting (Butler et al, 1986). This can lead to a vicious circle of increased wetting and more punishment.

Causes of enuresis

There are some general predisposing factors to developmental delays in becoming dry at night:

- A genetic predisposition and family history;

- Daytime wetting;

- Constipation;

- A physical or learning disability;

- Changes in routine, such as moving house or a new baby in the family;

- Stress or anxiety.

The ALSPAC survey identified that only 31.9% of parents who had children aged seven-and-a-half with nocturnal enuresis had consulted a health worker (Butler et al, 2005). Possible explanations for this delay in seeking help, based on our experience on the ERIC helpline, may be due to a number of factors:

- Waiting for their child to ‘grow out of it’;

- Feelings of embarrassment and/or that they should try to deal with the problem themselves;

- A perception that the cause is emotional or behavioural;

- Fear they might be considered to blame or to have poor parenting skills;

- A belief that nothing can be done.

The three systems approach

Research indicates that tailoring the treatment to the system or systems that are an underlying cause of bedwetting results in a better outcome. The nurse can then provide a clear explanation to the child and family about the physical factors that are preventing the child from staying dry and suggest what can be done in partnership to try and improve matters (Butler, 2004). The three systems are outlined below.

System 1: Nocturnal polyuria as a result of low nocturnal vasopressin levels - The hormone arginine vasopressin is naturally produced in a circadian rhythm by the hypothalamus and stored in the pituitary gland. Its function is to increase the reabsorption of water in the kidneys. Normally, there is a higher release of arginine vasopressin at night compared to that during the day, resulting in a reduction in the volume of urine produced during sleep. In some children this circadian rhythm has not yet developed, and the amount of urine produced exceeds the bladder’s natural capacity (Devitt et al, 1999).

System 2: Bladder overactivity/low voided volume - Overactive or uninhibited bladder contractions may occur while the bladder is filling and result in wetting before it is full. The child’s natural voided volume may also be relatively low. Both may be associated with symptoms of urgency and signs of frequency in the day, but not always with daytime wetting (Yeung, 2002).

System 3: Lack of arousal from sleep - This is due to difficulty in responding to the sensation of a full bladder and waking up and/or ‘holding-on’ at night. Children who wet their bed have a problem with either System I or System 2 or a combination of both. All will have a problem with System 3 (Butler, 2004).

Assessing the child

Asking as routine the question ‘Is your child dry at night?’ in the school entry questionnaire or health interview gives the school nurse an opportunity to provide information and support. This often reassures parents and carers that there are known reasons why some children continue to wet the bed and that there is treatment available. Education and Resources for Improving Childhood Continence (ERIC) has information that can be displayed in surgeries and other community settings.

The school nurse, health visitor or general practitioner is often the first point of contact for the family, but there are also community-based enuresis/continence clinics around the country. The majority of them are nurse-led.

An initial assessment should cover a general history and the pattern of bedwetting over the past few weeks. Asking the child and parent to complete a record chart of urinary symptoms before the first appointment can be helpful.

When taking a history, questions on the following issues should be included:

- Any urgency, frequency or day-time wetting;

- How many and what type of drinks the child is having;

- Whether bowel function is regular;

- The average voided volume (the second void of the day is measured over two weeks). This will give information that can be compared with the expected bladder capacity (Butler, 2006).

A general medical examination is advised before treatment to rule out physical, congenital or neurological causes for the bedwetting. The examination usually includes

- Routine urinalysis, to detect whether or not the child has a urinary tract infection;

- Recording blood pressure to exclude kidney disease;

- Examining the abdomen and external genitalia to check for constipation and to exclude abnormalities of the urethra, including epispadius;

- Observing lower limb reflexes and the spine to exclude neurological problems, such as neuropathic bladder.

Referral to a specialist should be made if these routine tests suggest an abnormality. Any urinary tract infections, constipation or daytime wetting should be treated. A bladder scan (ultrasound), which is a non-invasive test that identifies abnormalities such as dilatation of the ureters and residual urine in the bladder, is recommended only when there are persistent urinary tract infections or wetting in the day.

Treatment

There are some simple self-help measures for children aged five to seven years that health professionals should make parents/carers aware of (Box 1). Treatment based on the three systems approach is described in Box 2.

Help for teenagers

One in 50 -100 young people reach their teens without resolving the problem of enuresis, and for one in 100 this continues into adult life (Butler 1981). Teenagers with nocturnal enuresis are often reluctant to seek advice (Lukeman, 2003), and those unsuccessfully treated in childhood sometimes believe no other help is available.

Feelings of isolation may affect their general sociability and motivation, while the fear of others finding out can prevent them from enjoying trips away from home or inviting friends to stay. Enuresis can be a worry for older teenagers and young adults when they plan to leave home or begin a sexual relationship.

There is some evidence of a link with bullying (Williams et al, 1996), and it is thought that depression and suicidal behaviour may be associated with victimisation and bullying (BMA, 2003). Teenagers with continence problems could therefore be at increased risk of emotional and mental health problems. Other considerations to bear in mind when helping this group include:

- Confidentiality issues;

- Alcohol and drug use that might have an effect on the wetting (possible binges at weekends);

- Other health factors, such as stress and anxiety (a particular link to secondary enuresis);

- Housing or financial problems if living independently away from family;

- Sexual health issues (there may be a history of abuse).

It is important that assessment and treatment are available to young people in a setting that is appropriate for their age, that it is given without embarrassment, and that they are not made to feel as if they are being treated like children. School nurse drop-in clinics, or appointments after school hours at the enuresis clinic, can provide ideal facilities. Research shows that up to 40% of adolescents receive no treatment, even though many have consulted specialists. (Nappo et al, 2002).

Conclusion

Despite bedwetting being a common and multifactorial problem, which causes distress to children, young people and their families, it still remains hidden. Recent research has identified a treatment approach that can lead children to the most effective treatment methods, but the challenge is to encourage more families to seek help.

Accessible and integrated paediatric continence services are the way forward, as early and effective intervention can have life-changing effects for a child and save the health service money.

A general medical examination is advised before treatment to rule out physical, congenital or neurological causes for the bedwetting. This usually includes

- Routine urinalysis, to detect whether or not the child has a urinary tract infection;

- Recording blood pressure to exclude kidney disease;

- Examining the abdomen and external genitalia to check for constipation and to exclude abnormalities of the urethra, including epispadias;

- Observing lower limb reflexes and the spine to exclude neurological problems. Referral to a specialist should be made if these routine tests suggest an abnormality. Any urinary tract infections, constipation or daytime wetting should be treated. A bladder scan (ultrasound), which is a non-invasive test that identifies abnormalities such as dilatation of the ureters and residual urine in the bladder, is recommended only when there are persistent urinary tract infections or wetting in the day.

Points for reflection

- Can you define enuresis?

- How would you assess a child with enuresis?

- On what is the three systems approach to enuresis based?

- How would you explain enuresis to a parent?

- How would you manage a teenager who has a bedwetting problem?

This article has been double-blind peer-reviewed.

For related articles on this subject and links to relavent websites see www.nursingtimes.net

Information

Eric (Education and Resources for Improving Childhood Continence) provides the following services for families:

- A telephone helpline (weekdays 10am-4pm); Tel: 0845 370 8008 (local rate);

- An interactive website: www.eric.org.uk and www.trusteric.org (for young people);

- National campaigns to improve access to water and toilet facilities in schools - Water is Cool in School: www.wateriscoolinschool.org.uk and Bog Standard: www.bog-standard.org;

- Telephone support group for families;

- A 12-page booklet, Bedwetting - A Guide for Parents;

- Leaflets, including Nights Away - No Worries and Growing Up and Coping With Bedwetting (free with SAE and 47p stamp), or download from www.eric.org.uk;

- Books and training days for health professionals;

- Additional resources and support for children with soiling difficulties and special needs.

  • Comment

Have your say

You must sign in to make a comment

Please remember that the submission of any material is governed by our Terms and Conditions and by submitting material you confirm your agreement to these Terms and Conditions. Links may be included in your comments but HTML is not permitted.

Related Jobs