Intended for healthcare professionals

Rapid response to:

Practice Guidelines

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

Rapid Response:

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

14 October 2014
Marta Elian
Neurologist
London, NW8 6HJ