Nocturnal enuresis Flashcards
What is enuresis?
Enuresis is defined as the involuntary discharge of urine, day or night, in a child aged 5 or older, without any congenital or acquired defects of the nervous system or urinary tract.
How is nocturnal enuresis classified?
Nocturnal enuresis is classified as primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months prior).
What are common underlying causes or triggers of nocturnal enuresis?
Common triggers include constipation, diabetes mellitus, and urinary tract infections (UTI) if the onset is recent.
What general advice is recommended for managing nocturnal enuresis?
General advice includes monitoring fluid intake, encouraging regular daytime and pre-sleep bladder emptying, and using lifting and waking techniques.
How should reward systems be used in managing nocturnal enuresis according to NICE?
Reward systems, like star charts, should be used for agreed behaviors such as using the toilet before sleep, rather than for dry nights.
What is the role of an enuresis alarm in managing nocturnal enuresis?
Enuresis alarms, which have sensor pads to detect wetness, are generally considered first-line treatment and have a high success rate.
When is desmopressin recommended in the management of nocturnal enuresis?
Desmopressin is recommended particularly when short-term control is needed, like for sleepovers, or if an enuresis alarm has been ineffective or is not acceptable.
summarise NOCTURNAL ENURESIS
Nocturnal enuresis
The majority of children achieve day and night time continence by 3 or 4 years of age. Enuresis may be defined as the ‘involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’
Nocturnal enuresis can be defined as either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before)
Management
look for possible underlying causes/triggers
constipation
diabetes mellitus
UTI if recent onset
general advice
fluid intake
toileting patterns: encourage to empty bladder regularly during the day and before sleep
lifting and waking
reward systems (e.g. Star charts)
NICE recommend these ‘should be given for agreed behaviour rather than dry nights’ e.g. Using the toilet to pass urine before sleep
enuresis alarm
generally first-line for children
have sensor pads that sense wetness
high success rate
desmopressin
particularly if short-term control is needed (e.g. for sleepovers) or an enuresis alarm has been ineffective/is not acceptable to the family
An 8-year-old boy presents to GP with his mother. His mother explains that he is still bed-wetting almost every night. He has been extensively investigated in the past year for this issue and has no physical defects to explain his enuresis. He is otherwise fit and well.
Mum has tried limiting his fluid intake before bedtime, encouraging regular, timely toileting, and lifting and waking, to no avail.
What is the most appropriate next step to manage his enuresis?
Enuresis alarm
No fluid intake for 2-hours before bedtime
Refer for sleep studies
Trial desmopressin
Urine dip for UTI
An enuresis alarm is generally used first-line for nocturnal enuresis if general advice has not helped
Important for meLess important
Enuresis alarm is the first-line therapy following general advice. This is an alarm that will make a loud sound or vibrate when a sensor detects moisture from even a small amount of urine. This can take months before having an effect but is generally considered an effective therapy, with up to 60% of patients having dry nights at follow-up.
No fluid intake for 2-hours before bedtime never forms part of enuresis management. Limiting fluids throughout the day and before bedtime (particularly caffeinated drinks) forms part of general advice, which has already been tried, but withholding all fluids is not recommended.
Refer for sleep studies is incorrect. While enuresis in a child this age should warrant consideration of other conditions that can cause/worsen the issue, such as sleep-disordered breathing, this is not the most appropriate management at this stage.
Trial desmopressin is not indicated at this stage. Desmopressin is an analogue of anti-diuretic hormone (ADH) and is used when general advice and enuresis alarm has failed.
Urine dip for UTI is incorrect. UTIs can cause incontinence/enuresis but this issue has been ongoing for a long time, at least a year. If this patient had a UTI one would have seen other signs/symptoms by this stage.
A 7-year-old boy is referred to the enuresis clinic by his GP. His mother initially contacted the GP concerned with ongoing bedwetting and it transpires that the boy has never had a ‘dry night’.
The GP has provided general advice on diet, fluid intake and toileting behaviour, though the mother says the bedwetting has not resolved. Despite the use of a reward system, the boy still wets the bed at night and the mother is getting concerned.
She speaks to the enuresis clinic and is sent home with an intervention.
What is this intervention likely to be?
A better prize for the reward system
Desmopressin
Enuresis alarm
Oxybutynin
Tolterodine
Enuresis alarm
An enuresis alarm is generally used first-line for nocturnal enuresis if general advice has not helped
In a child with nocturnal enuresis, an enuresis alarm is generally offered if advice alone is not enough. This is first-line as per NICE guidance.
A better prize for the reward system may be worth exploring; after all, the child may not be motivated if he does not feel the prize is worth the effort. However, it should be assumed that the mother can motivate their child appropriately and so it is more likely this will not be the route taken by the clinic. If it hasn’t worked, it is probable outcomes will not change by repeating this intervention.
Desmopressin, oxybutynin and tolterodine are all pharmacological interventions used in nocturnal enuresis (tolterodine is unlicensed). Desmopressin is usually offered if the enuresis alarm does not work.
A 6-year-old boy is reviewed in clinic due to nocturnal enuresis. His mother has tried using a star-chart but unfortunately this has not resulted in any significant improvement. Of the following options, what is the most appropriate initial management strategy?
Enuresis alarm
Trial of oral desmopressin
Trial of imipramine
Trial of intranasal desmopressin
Restrict fluids in the afternoon and evening
Enuresis alarm
An enuresis alarm is generally used first-line for nocturnal enuresis if general advice has not helped
Restricting fluids is not recommended advice - Clinical Knowledge Summaries suggest: ‘Do not restrict fluids. The child should have about eight drinks a day, spaced out throughout the day, the last one about 1 hour before bed.’
A 6-year-old girl presents to the GP with her mother with nocturnal enuresis. She is wetting the bed most nights. Her parents have tried toileting before bed time, reducing liquid consumption before bed time and have tried a reward chart for dry nights without success. What is the next step in treatment?
Prescribe desmopressin
Continue with reward system
Enuresis alarm
Reassure this is normal and will improve with age
Increase frequency of toileting before bed time
Enuresis alarm
An enuresis alarm is generally used first-line for nocturnal enuresis if general advice has not helped
This question focuses on the stepwise treatment of nocturnal enuresis. In this scenario, lifestyle measures such as decreasing fluid intake and toileting before bed have already been tried. A reward chart has also been implemented without success. Although this is a common problem in children, it is not considered normal over the age of 5 and so reassurance would not help in this situation.
The two options left to consider at this stage are to prescribe desmopressin or to try and enuresis alarm.
The current first-line treatment is an enuresis alarm. If the child is aged under 7, it must be tried before other measures are considered. As the child in the above scenario is 6 years-old, the best option would be to try an enuresis alarm.
Desmopressin may be used first-line if the child is over the age of 7 and does not wish to use the enuresis alarm or if a short term solution is required. This is not the case in this scenario and so would not be the correct answer.
