Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting.

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Issue date: October 2010

NICE clinical guideline 111Developed by the National Clinical Guideline Centre

Nocturnal enuresis

The management of bedwetting in

children and young people

Presentation based upon

Start

CONTINENCE STUDY AFTERNOON

Paul Watson

Lets Talk About Enuresis

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Nocturnal enuresis




Referral pageLetters page Advice leaflets Charts

The child has severe learning or physical disabilities.

The child has an underlying bladder or bowel condition.

The child is going through or is still suffering from a traumatic or emotional situation.

The child is younger than seven years of age.

The child is seven years of age or older with none of the above.

Guidelines for children with Enuresisbeing referred to the School Nurse Enuresis service

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Letter to referrerNew Patient Apt Health screening Apt

Please make new Apt

Please contact us/ or discharge

Your appointment is overdue

DNA’d 1st Apt.Contact or close

Alarm Loan Agreement

Please rebook or return alarm 1

Please rebook or return alarm 2

GP request for Desmo

Discharge letter to GP

http://www.paediatricpearls.co.uk/enu/1_Thank_u_4_your_referral_-_1.doc

http://www.paediatricpearls.co.uk/enu/2_New_Patient_Appointment.doc

http://www.paediatricpearls.co.uk/enu/2.1_Reception_health_interview_enuresis.doc

http://www.paediatricpearls.co.uk/enu/3_Advising_Parent_to_mk_new_apt.doc

http://www.paediatricpearls.co.uk/enu/6_Non_attendance_of_first_appointment_contact_or_close_-_5.doc

http://www.paediatricpearls.co.uk/enu/5_letter_to_parent_overdue_review..doc

http://www.paediatricpearls.co.uk/enu/4_Letter_to_parent_Contact_or_close.doc

http://www.paediatricpearls.co.uk/enu/enu/6.1_Loan_of_alarm.doc

http://www.paediatricpearls.co.uk/enu/7_Please_make_a_new_apt_or_return_the_alarm.doc

http://www.paediatricpearls.co.uk/enu/8_please__return__alarm.doc

http://www.paediatricpearls.co.uk/enu/9_GP_Request_for_Desmomelts.doc

http://www.paediatricpearls.co.uk/enu/9.1_Discharged_letter_to_GP.doc

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Nocturnal enuresis





Bed wetting Guide Childhood soiling

Enuresis Booklet

Daytime wettingAdvice tick list

Talk about bedwetting Nights away

http://www.paediatricpearls.co.uk/enu/Bedwetting.pdf

http://www.paediatricpearls.co.uk/enu/ChildhoodSoiling.pdf

http://www.paediatricpearls.co.uk/enu/crackingpuzzlebook08.pdf

http://www.paediatricpearls.co.uk/enu/Daytime.pdf

http://www.paediatricpearls.co.uk/enu/enuresis_tick_list.doc

http://www.paediatricpearls.co.uk/enu/TalkaboutBedwetting08.pdf

http://www.paediatricpearls.co.uk/enu/ERICNights.pdf

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Nocturnal enuresis





Tick List Progress Chart Fluid Chart


http://www.paediatricpearls.co.uk/enu/recording_progress.08.pdf

http://www.paediatricpearls.co.uk/enu/FluidChart.pdf

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Nocturnal enuresis





Decline referral. Referrer to refer to Specialist

Enuretic Service or other specialist service ie. CAMHS.

Specialist Enuresis service CAMHS

http://www.northantsproviderservices.nhs.uk/Resources/Contacts/Services/Continence.jsp

http://www.northantsproviderservices.nhs.uk/Resources/Contacts/Services/Continence.jsp

http://www.paediatricpearls.co.uk/enu/CAMHS.doc

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Nocturnal enuresis





Decline referral.Referrer advised to

refer to GP/ paediatrician

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Self Help Measures

6-7 drinks/ day6-7 voids/ daySmall drink before bedEasy access to toiletPositive thinkingContact ERIC

Bed wetting Guide

Enuresis Booklet

Advice tick list

Nights away

ERIC





http://www.paediatricpearls.co.uk/enu/eric.png



Nocturnal enuresis





AssessmentHistory•No. of voids per day (frequency/ urgency)•Fluid intake (type/ quantity)•Bowels•Daytime wetting•Age at onset/ symptom duration•Arousal from sleep•Size/ Number of wet patches/ night•Family history•History of UTI’s

Suspicion of abuse

Behaviour problems

History of UTI’s

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Nocturnal enuresis





Child or young person with bedwetting

• Advise on fluid intake, diet and toileting behavior•Address excessive or insufficient fluid intake and abnormal toileting patterns before starting other treatments •Advise on using a reward system •Suggest a trial without nappies or pull-ups for children and young people wearing them at night. Offer advice on alternative bed protection•Consider whether alarm or drug treatment is appropriate, depending on age, maturity and abilities of the child or young person, the frequency of bedwetting and the motivation and needs of the family•Assess the ability of the family to cope with an alarm

Advice

Advice

Advice Alarm Drug

http://www.paediatricpearls.co.uk/enu/page10.jpeg


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Advice

Does the child have some dry nights?

Yes No

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Advise parents or carers to try reward

system alone

The child is Appropriate for

clinic


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Alarm Treatment

•Bedwetting has not responded to advice on fluids, toileting and an appropriate reward system and

•Alarm treatment is desirable and appropriate

Yes No

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Offer an alarm as first-line treatment

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Drug Treatment

•Rapid-onset and/or short-term dryness is a priority OR•Alarm treatment is undesirable OR•Alarm treatment is inappropriate (particularly if parents or carers are having emotional difficulty coping or are expressing anger, negativity or blame)

Yes No

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Offer desmopressin for children and young people

over 7 years

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Nocturnal enuresis





Start alarm treatment.

Assess response by 4 weeks

Early signs of response?

Yes No

Recurrence following success

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Continue with alarm.

Have there been 2 weeks uninterrupted dry nights achieved?

Yes No

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Stop alarm treatment.

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Continue with alarm

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Assess progress at 3 months

Is bedwetting improving and are

the child and parents/carers motivated to

continue?

Yes No

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Consider restarting alarmTreatment if the child

Starts regularly Bedwetting again

Recurrence Repeated recurrence

Stop treatment with alarm alone

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Repeated recurrence

Is alarm treatment still acceptable?

Yes No

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Nocturnal enuresis





Offer desmopressin combined with

an alarm

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Nocturnal enuresis





Offer desmopressin

alone

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Start desmopressin

treatment

Is complete dryness

achieved after 1-2 weeks?

Yes No

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Assess response at 4 weeks

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Consider increasing dose

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Response Partial or noresponse

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2


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3


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Continue treatment for3 months

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Consider advising that desmopressin is taken 1-2 hours

before bedtime, instead of at bedtime, if the child can comply

with fluid restriction

Yes No

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Consider stopping desmopressin treatment

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Refer for further review and assessment of factors

associated with poor response (e.g. overactive bladder,

underlying disease or social and emotional factors)

Furthertreatments


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Blank page

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Stop desmopressin Treatment

unlessBedwetting recurs

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Consider continuing desmopressin treatment

(up to 6 months)

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Nocturnal enuresis





Restart desmopressin and consider repeated courses of desmopressin for repeated

recurrences

•Withdraw every 3 months to assess response•Withdraw gradually if using repeated courses

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Follow child protection protocol & procedures

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Diagnosis – Three Systems Model

Lack of arousal from sleep.Inability to wake to bladder

sensations.Sleeping through wetting.

Bladder instability/ low functional bladder capacity

•Sense of urgency

•Frequent daytime voiding

•Low voided volume

•Multiple wetting

•Variable sized wet patch

•Wakes after wetting

Nocturnal polyuria (Low Nocturnal vasopressin levels)

•Wets soon after sleep

•Large wet patches

•Dry nights only if child wakes

•Weak urine

YES

YES

Both

YES

Letters page Referral page Advice leaflets Charts

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Nocturnal enuresis





Self Help Measures

6-7 drinks/ day6-7 voids/ daySmall drink before bedEasy access to toiletPositive thinkingContact ERIC

Bed wetting Guide

Enuresis Booklet

Advice tick list

Nights away

ERICContinue





http://www.paediatricpearls.co.uk/enu/eric.png

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Treatment Anticholinergernic medication and

bladder retraining.

Review by GP or specialist if medication required.

Review


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Signs of improvement• Delays point of voiding to early

morning• Less wetting during episode• More dry nights• Parent/ child satisfied with

progress

Initial Review 2-4 weeks after treatment

Responding to treatment

Not responding to treatment


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Continue Treatment 3-6 months

Signs of success• Dry nights

NOYES


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Continue treatment max 6 weeks

Treatment a success?

YES NO

Letters page Advice leafletsReferral page Charts

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Success = 14 consecutive dry nights

NOYES


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Continue treatment 3-9 months

Can be used as long as symptom control is required – reassess every three months

Treatment a success?

YES NO

Letters page Advice leafletsReferral page Charts

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Cease Treatment


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Give break and retry as appropriate after 3-6 months


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Nocturnal enuresis




Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting.

Documents

nice clinical guideline

management of bedwetting

young people presentation

issue date

bedwetting nights

school nurse enuresis

specialist service

specialist enuretic