How is it treated and managed?
Treatment of children aged 7 and over
Children aged 6 and under
The majority of children aged 6 and under would be expected to become continent at night in the near future. Consequently, in these children it is better not to aggressively treat this problem but use a benign strategy of star charts and praise or small rewards for dry nights. Lifting at night may also be tried to reduce the frequency of wet nights. Often this is all that is necessary for the child to become reliably dry. Children who reach seven and are still not dry at night despite this strategy will usually be offered treatment.
Treatment of children aged 7 and over
Children may be treated with one or a combination of the following therapies. A common combination is the ‘three system approach’. This is detailed after the individual therapies have been described.
Behavioural Therapy
This means building good routines and behaviours around going to the toilet to empty bladder and bowels. It involves encouraging and supporting a child to do the following -:
- Begin the day by voiding in the toilet,
- Encourage the child not to hold on to urine unless they are doing bladder training,
- Encourage voiding at least once every 2 hours - enough to avoid urgency and incontinence,
- Ensure access to the toilet is easy at school (parents may have contacted the school),
- Encouraging the child to drink liberal amounts of water during the morning and early afternoon,
- Minimising intake of fluids after dinner,
- Encourage daily bowel movement, preferably before school.
Lifting at night
This involves making sure the child empties their bladder in the toilet at a point in the night just before they would normally wet the bed. There are two ways of doing it:
- Waking the child so they go the toilet – the child will often stay awake after this.
- Lifting the sleeping child and putting them on the toilet without waking them – this is more popular because the child can be returned back to bed without waking up.
Either of these approaches reduces the number of wet nights and may be all that is required in young children. Lifting is usually done once at around the time wetting normally occurs and before the parents go to bed. It is not expected that parents would be doing this more than once or getting up especially to do lifting. Not waking the child takes much less time, as a woken child may require settling again.
Alarm Therapy
This may be in the form of a pad placed under the sheets or attached to the underclothes, which sounds an alarm as soon is it becomes slightly wet. It is designed to sound just as the child begins to pass urine. The alarm wakes the child up so that they can finish emptying their bladder in the toilet. Parents are involved in this treatment, as they must ensure the child wakes and goes to the toilet each time the alarm sounds. The treatment is ineffective if the child switches off the alarm and goes back to sleep.
Usually the alarm will sound before the parents go to bed but they may also need to get up during the night if it goes off later or a second time. Substantial improvement is seen quickly with this treatment and it would not be expected to continue for more than 6 months, with the child remaining dry every night for the final few months of treatment.
This treatment involves time and effort in terms of making sure the alarm and pad are set and in the right place every night, listening for the alarm and attending to the child when it sounds. Attention during the night is only required for the first few months of treatment, the child is expected to be dry for the final few months if the treatment is working. The system will need to be checked before the child goes to bed – this takes a few minutes as part of the bed time routine.
The treatment is highly effective with a positive effect being noticed within the first month in those cases where it will be successful. Around 2/3 of children using this method will become dry at night. A reduction in wet nights will be seen in the first month and the alarm continues to be used until a pattern of consecutive dry nights has been maintained for some months. On average alarm therapy needs to be used for 3-6 months. This treatment is likely to be most effective in those children with delayed bladder maturation. If there has been no improvement after 1 month with the alarm treatment it can be stopped as it is unlikely to be effective.
Drug treatment
Desmopressin
Treatment with drugs is used on an occasional basis to help children stay dry when it is particularly important to do so. Desmopressin is the drug most commonly used, it mimics the action of a natural hormone in the body called Anti Diuretic hormone (ADH). It effectively stops the kidneys from excreting water so if combined with a large fluid intake can cause a serious side effect called ‘water intoxication’. Symptoms of this include headache, nausea and vomiting.
It is sometimes used on an ongoing basis and is effective in around half of children for the duration of therapy – enuresis reoccurs when it is stopped. The drug can be taken as a tablet or melt in the mouth preparation (note spray no longer used in children). This treatment is most effective in the group of children with relative lack of ADH at night. Medication is taken only once a day at bed time and takes a few minutes.
Note the different way this drug is used when part of the three system approach.
Oxybutynin and tolterodine
These drugs are anti-cholinergic drugs. They increase bladder capacity by reducing over activity of the detrusor (bladder) muscle. They theoretically increase bladder volume. Side effects are the ‘anti-cholinergic’ side effects and these include constipation, dry mouth, blurred vision and flushing.
They are only used when children have not responded to non-drug therapies and may be used in conjunction with desmopressin. This treatment tends to be used on an ongoing basis. Enuresis tends to recur when treatment is stopped.
Medication is taken only once a day at bed time and takes a few minutes.
Note the different way this drug is used when part of the three system approach.
Imipramine and other tricyclic drugs
These drugs are used only when all other therapies including other drugs have failed. They stop bedwetting in around 20% of treated children. Symptoms recur when treatment is stopped.
Tablets are taken once a day at bed time. Side effects may be severe and include mood changes, nausea, sleep problems and heart problems. It is easy to overdose on small amounts of these tablets so they must be stored securely in the home and the parent must supervise the child taking the tablets. Supervising the child taking the tablet and securing the drugs again takes a few minutes each evening.
Three System Approach
This approach combines alarm therapy with drug treatment, the three components are -:
- Desmopressin a drug to reduce urine production correcting deficient anti-diuretic hormone release.
- Bladder relaxing drugs such as oxybutynin to prevent detrusor (bladder) muscle overactivity.
- Alarm therapy
These treatments may be used in a step-wise fashion or together and may be combined with behavioural therapies detailed above or bladder training. Bladder training involves holding on to a full bladder for as long as possible, at least once a day, to increase bladder volume. This can promote an increase in bladder capacity in children with enuresis who often have a small bladder capacity for their age.
Parents will need to supervise their children to make sure that they take medication as prescribed and carry out any behaviour modifications recommended. They will also need to attend to their child’s alarm therapy as detailed under alarm therapy. Around 70% of children would be expected be dry at night after a few months of this treatment, therefore additional care needs related to enuresis and its treatment would not be expected to last more than 6 months in the typical case.
In rare cases night time attention related to treatment on an ongoing basis will be needed and corroborating evidence from the enuresis clinic should be obtained to confirm this.
Note: Treatment / therapy outcomes are generally very successful within the first few weeks or months of treatment. It is important therefore that the likely duration of care needs is fully considered in deciding whether entitlement is appropriate.
