Management of bedwetting in children and young people: summary of NICE guidance
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5399 (Published 27 October 2010) Cite this as: BMJ 2010;341:c5399
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The NICE team are to be congratulated on completing their report and
providing guidelines for the management of enuresis in the current era.
The management of enuresis has been a topic of debate for more than 100
years but there is still a wide range of opinion and limited consensus.
A review in the British Medical Journal of 1958 from general
practitioners in Derby UK reported on their first 100 courses of treatment
using an alarm (1). They reviewed the published observational studies on
alarm use back to Mowrer and Mowrer in 1938, including an Australian study
published by another general practitioner Neil Crosby in 1950 (2). They
commented that alarm management " although obtaining a high rate of cure
has not been widely adopted". They observed ten "failures" from 100
patients but three became dry on all but one or two nights each week, not
now considered a "failed" treatment using definitions used in many trials
of medication induced decrease in nocturnal enuresis. They did comment
that the pads and alarms of different makers differ considerably. This
was even before the addition in 1982 of body-worn alarms (3) to the
possible options after an observational study in a "treatment resistant"
cohort. Subsequent modifications have increased the options. A recent
community paediatric clinic audit from Australia confirmed that utilising
a bodyworn alarm as a standard initial strategy provided satisfactory
results for most patients(4). It is of interest that the NICE guidelines
reinforce the proposals made 50 years ago that alarms should be the first
active intervention, despite the availability now of a wider range of
pharmaceuticals.
The NICE guidelines do make it clear that management strategies need
to be modified for individuals The adolescents and adults, who present to
tertiary and adult care facilities most often "failed" or relapsed after
using one or many strategies. This sub group have been common among those
who have been treated in clinics by myself and nursing colleagues and
among those who have contacted the telephone enuresis advisory service we
set up for Australia in 1985(5). In recent years I have found the use of
combination therapy of an alarm and either desmopressin or/and an anti-
cholinergic, as supported by the NICE guideline, to be effective in this
group, but attention to detail is critical and may not have been stressed
enough in the BMJ "guideline" summary or even within the 473 pages of
the full NICE report.
An analysis of reasons for previous "failures" is important before
embarking on alternative strategies such as adding medication even after
apparent "failure" of alarm management. An alarm system that does not
result in waking (with the help of parent or carer if needed) will not be
effective; and an unreliable alarm that gives false signals when there is
no wetness will not be continued by the user. Consideration may need to be
given to the type of alarm used, and an alternative considered, eg the
combination of noise with vibration or vibration only. A change of alarm
should be considered before a move to the combination of alarm with
medication as suggested by NICE and the choice of an alarm should not only
be on the basis of unit cost. The style of alarm if effective initially
should remain available for early reintroduction if there is relapse after
"response".
An alarm with desmopressin in doses suggested by NICE, may be
effective but may provide control but not "cure". Desmopressin can
sometimes be too effective and reduces nocturnal urine flow to a level
when there is no wetting. No wetting so no alarm to generate
"conditioning" and combination therapy is controlling but probably not
"curing". My strategy is now to titrate desmopressin downwards in this
situation, to a dose that does not stop wetting but delays wetting to once
most nights and also to later in the night. Later in the night there is a
less "drowsy" response to the alarm and multiple alarms are avoided
(which are very tiring and can result in use of the alarm being
discontinued). This titration is now easier with the availability of
"DesmoMelts' which can more easily be reduced in size to reduce the dose
and so obtain the required result.
Doses of anticholinergic, or of combined desmopressin and
anticholinergic, can also be titrated to this target of a single wetting
to activate the alarm. This suggestion is made on the basis of
physiological logic and my own clinical experience and has not yet been
subjected to controlled trials. It is at variance to the NICE suggestion
to titrate upwards only, unless the objective is control not "cure". The
strategy merits consideration in those with troublesome bed-wetting who
are non-responsive to alarm management alone or to non-titrated
combination alarm and pharmaceuticals. It should be on the list of topics
for future research.
The NICE guidelines are a valuable step in progress to reverse the
philosophy of "they will grow out of it" still held by some - even if this
is a better viewpoint than "bedwetting should be beaten out of them" as
was common in the era when alarm management was first reported. The NICE
guidelines should also encourage more practitioners, not only those in the
UK, to consider alarms as first line management and move only later to the
prescription pad unless there is a short term urgent need for night-time
dryness.
Martin S Knapp MD, FRCP, FRACP
Nephrologist and Director Malem Medstat, Australia.
knappm@optusnet.com.au
1.Crosby N, Essential Enuresis: successful treatment based on
physiological concepts. Medical Journal of Australia. 1950; Oct7:533-545
2. Gillison TH and Skinner JL. Treatment of nocturnal enuresis by the
electric alarm. BMJ:1958; Nov 29: 1268-1272
3. Malem, H, Knapp,MS, Hiller,EJ, Electronic bed-wetting alarm and toilet
trainer. 1982: BMJ: 285;22
4. Cutting D, Pallant JF, Cutting FM, Nocturnal Enuresis: application
of evidence based medicine in community practise. Journal of Paediatrics
and Child Health, 2007; 43;167-172
5. Knapp, MS., Hicks,S.,Gibson,K & Jenion,J. Enuresis Services for Non
-Metropolitan Australia. Proceedings, International Childhood Continence
Soc.: 1995; 43-45
Competing interests: In 1993 I set up a non-profit national telephone advisory service for Australians to provide advice on enuresis management and also a company that distributes Malem enuresis alarms and other products in Australia.I am also in private clinical nephrology practise and provide advice on enuresis management and clinical nephrology and declare competing interests to patients, professional colleagues and others.
As a mother of two young children I was surprised to read the NICE
guidance on management of bedwetting. NICE does not advise positive
rewards for dry nights. I therefore turned to the original full text. This
recommendation is based on studies of small numbers of children at
enuresis clinics. Clearly these children are the ones for whom simple
reward systems have not worked. In effect the children who do not respond
to positive rewards for dry nights and therefore attend enuresis clinics
are then found in RCTs not to respond to positive rewards for dry nights.
The vast majority of children do respond to positive rewards for dry
nights and so do not attend these clinics and therefore never make it into
a trial. NICE then guides all health professionals in the country against
using a simple rational technique on the basis of data from a small subset
of children. NICE's method of issuing guidelines divorced from their
reasoning is demeaning to thinking professionals and leads to misleading
and unhelpful instructions.
Judith Burchardt
Competing interests: No competing interests
Re: Management of bedwetting in children and young people: summary of NICE guidance
In response to recent publications emphasising psychological cause of nocturnal bedwetting (1,2), I would like to draw attention to a neglected (disregarded) concept first described in 1933 in Brain (3) followed by publications (4) 1944, (5) 1961, (6) 1963, and (7) 1981. Namely:
Enuresis nocturna is a genetically determined developmental delay.
The negative effect of bedwetting on the affected child and the family is often emphasised with varying degree of commiseration.
The concept of persisting bedwetting being a developmental delay – genetically determined – was first published eight decades ago by Denny-Brown and Robertson in Brain (3). Despite its importance it is never quoted. This work was followed seven to four decades later by several important publications including Gesell (4) Baldwin (5) Harbour et al (6) Klackenberg (7). All supporting Denny-Brown’s theory.
Their work is equally and completely disregarded.
In a study of 100 Israeli bedwetters positive family history - in 83% was revealed. There was a remarkable intra familial consistency regarding time: as over several generations various family members stopped bedwetting at the same age - Elian et al (8) reinforcing the maturational concept – not dissimilar to familial consistency in language development or onset of menarche.
When exploring family history considerable difficulty is caused by fathers: they rarely attend outpatient clinics with their child; mothers are usually reluctant to ask their husbands; fathers who were bedwetters often claim not to remember it; they need considerable pressure to activate their memory. On the other hand their mothers – and paternal grandmothers if available for interview – as a rule do remember.
Managing bedwetting by regulating fluid intake, by interfering with the child’s sleep, waking children with alarm clock or electrical devices are harsh measures bordering on cruel. Drug therapy and psychotherapy are ineffective, annoying for child and carers and usually resented.
It seems highly likely that the psychological symptoms are the effect of treatment attempts and not the cause of the problem.
Perhaps doctors should exchange their “treating hat” with “teaching hat”. After all Doctor means Teacher - Elian M (8). Explaining to the child and family the genetic/maturational concept is freeing them of guilt and worry and is more effective without cruel waking methods and without side effects as with drugs.
Enuresis Nocturna should be urgently removed from its current attachment to the psychiatric domain. It should have been replaced a long time ago by explaining the concept of genetics and of maturational delay, evidence available and neglected for eight decades. With the teaching and subsequent reassurance of child and family the psychological symptoms remain negligible.
References:
(1) Wright, Ann; Childhood Nocturnal Enuresis: Assessment and Management in Primary Care. British Journal of Family Medicine, 2014; p14-18.
(2) NICE Guidance BMJ 2010;341-99.
(3) Denny-Brown D, Robertson EG: On the Physiology of Micturition; Brain 1933;56 p149-90.
(4) Gesell AL; The Infant in the Culture of Today;New York Harper 1944; 322.
(5) Baldwin H; Enuresis in Children – J. Paediatric 1961;58 p8-6-19.
(6) Harbour RF et al; Enuresis as a disorder of development; BMJ 1963;1 p787-90.
(7) Klackenberg G; Nocturnal Enuresis in a longitudinal perspective; Acta Paediat Scand; 1981;70 p787-90.
(8) Elian M et al; Nocturnal Enuresis: A Familial Condition. J.R. Soc Med 1984; 77 p529-30.
(9) Elian M: Treating Bedwetting; BMJ 1991;302 p729.
Competing interests: No competing interests