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:

Combination management of enuresis with alarms and medication.

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.

12 November 2010
Martin S Knapp
Nephrologist
Mildura Nephrology