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Bedwetting or Primary Nocturnal Enuresis
What’s it all about?
Bed wetting or Primary Nocturnal Enuresis (PNE) is a common problem,affecting up to 20% of children at five years of age and up to 10% ofchildren at ten years of age.
Bedwetting is a really distressing experience for both for your child and for the family:
- The child is at increased risk of suffering low self-esteem, of becoming withdrawn; having strong feelings of shame and failure; be embarrassed; can affect performance at school.
- Bedwetting can have a significant negative impact on the child’s emotional and social development.
- There is an increased financial burden to family – purchasing nappies; mattress covers; bedclothes.
- There is increased distress to family members – disrupted sleep; continuous washing of clothes and bedclothes.
The problem is often not thought of by either parents or doctors assomething requiring timely, active management. The general feeling isthat it “will eventually go away” so they put off action.
Sorting out the problem includes assessing the nature of the bed wetting:
- If the child is awake is he or she constantly on the loo? This may mean there is a tendency to make a lot of urine at night and it has to go somewhere.
- Does the child have very deep sleep and is hard to wake? This means they could actually sleep through the physical cues that the bladder is full.
Things Worth trying!
- Passing urine before bed,
- Not drinking for two hours before sleep and
- Getting up to pass urine if waking overnight may help,
Often the condition requires further treatment. If so, the initial active management consists of an enuresis alarm and they do work for many. If this fails, or simply if your child refuses to wear one, a medication called Desmopressin is used.
Desmopressin is a synthetic medication a bit like the natural hormone called Vasopressin which increases at night so not as much urine is produced.
Desmopressin is available as a sublingual wafer, or melt, whichdissolves rapidly under the tongue. Desmopressin melt may be prescribedon PBS Authority by General Practitioners for primary nocturnalenuresis, if an enuresis alarm fails or is contraindicated.
Bit of a Background!
- Bed wetting or Primary nocturnal enuresis is a common problem affecting 20% of children at age of five years and up to 10% in those age ten years.
- Bedwetting is a distressing experience for both the child and family. Unfortunately, parents may feel that this problem is something they have to put up with and that the child will ‘grow out of it’.
- The longer primary nocturnal enuresis is left unmanaged, the harder it can become to treat.
- General Practitioners are well placed to help families deal with the problem of PNE.
I asked a paediatrician skilled in the management of bedwetting to clear up some concepts about it.
Question:
How common is bedwetting?
Answer:
- Primary nocturnal enuresis is a common problem, affecting up to 20% of children at five years of age and up to 10% at ten years of age.
- Nocturnal enuresis or bed wetting is more common in boys than in girls.
Question:
What is primary nocturnal enuresis?
Answer:
- It’s called Primary because it's not something which came on after the little one was dry. The child has never been dry at night and for more than 6 months.
- The theory goes that enuresis is caused by a mismatch between a small bladder capacity and/or nocturnal polyuria (making loads of urine at night) coupled with an inability to arouse to a full bladder sensation.
- Many children with nocturnal enuresis have a smaller night-time bladder capacity compared with the majority of kids.
- The wetting may be confined to night time or may occur during the day as well.
- Nocturnal polyuria (making more than 130% of urine output of non bed wetters) occurs in two-thirds of children with enuresis, resulting from inadequate secretion of arginine vasopressin (AVP) during sleep. This is the natural hormone that slows the making of night time urine.
Question:
What are the consequences of this treatable condition?
Answer:
Bedwetting is a distressing experience for both the child and family:
- The child is at increased risk of suffering low self-esteem, of becoming withdrawn; having strong feelings of shame and failure; be embarrassed; can affect performance at school.
- Bedwetting can have a significant negative impact on the child’s emotional and social development
- There is an increased financial burden to family – purchasing nappies; mattress covers; bedclothes
- There is increased distress to family members – disrupted sleep; continuous washing of clothes and bedclothes.
Question:
What if I do nothing?
Answer:
Families assume that the child will grow out of bedwetting, which ofcourse, many do, at a rate of approximately 14% per year. The extrawashing, disturbed sleep in order to change the bedding and clothingand nocturnal disruption to others in the family may be assumed to be anormal part of parenting.
For those children that don’t grow out of bedwetting, it is important to families know treatment is available.
Question:
Are Family Doctors the one to sort all this out and how should they do it?
Answer:
- Most importantly, the General Practitioner needs to examine and talk with the child as well as the parents.
- Being dry in the daytime should be discussed. Secondary causes of night-time incontinence may then be ruled out, such as easily treatable behavioral causes, malformations of the bladder and external urethra and chronic urinary tract infections.
- The vital think for your doctor is to take the time and ask you all the right questions.
- Next the doctor needs to assess whether the child is sleeping so deeply they do not wake with the stimulus of a full bladder, work out if the little one is making loads of urine at night and make sure they are not running to the loo all the time because their bladder has the shakes (detrusor instability). These are the three basic causes of primary nocturnal enuresis.
Question:
So how do we go about fixing the problem?
Answer:
- It is important not to make the child feel guilty or stupid because of the problem. Usually parents have already tried getting the child to pass urine before bed, not drinking for two hours before sleep and getting up to pass urine if waking overnight. Often nappies or pull-ups are being used overnight to decrease the mess however these do not provide a treatment addressing the cause of the condition.
- The next management choice consists of an enuresis alarm, either a pad and bell or a body worn alarm.
- Body worn alarms consist of a small sensor clipped to the underwear and an alarm unit attached to the pyjamas, at the child’s shoulder. Pad and bell alarms consist of large rubber sensor mat on the bed which is connected to an alarm unit next to the bed. Enuresis alarms are available from pharmacies, direct from suppliers, continence clinics and some continence foundations.
- It’s really is important that the child wants to be dry when using an alarm, and since alarms may take time and effort from the family and child, it is essential that everyone is understanding.
- It may take up to three months for a bedwetting alarm to work and best results are achieved with the support of your family doctor. Bed wetting alarms are not suitable for all patients and not all patients will respond to an alarm. The key to success with a bed wetting alarm is correct use. Parents and the child must be motivated and educated if an enuresis alarm is be successful.
Question:
What if the alarm fails?
Answer:
- If enuresis alarm treatment fails, desmopressin may be prescribed. If a child has a hearing impairment or shares a room with another child who will be disturbed, desmopressin may be used as a first line treatment.
Question:
What instructions are to be given when using desmopressin?
Answer:
- Desmopressin is indicated for the treatment of PNE in children from the age of 6 years old, who are refractory to an enuresis alarm or in whom an enuresis alarm is contraindicated or inappropriate. Dosage is given at bedtime.
- Fluid intake must be limited to a minimum from 1 hour before until 8 hours after desmopressin administration. It is important for the child to maintain good hydration throughout the day.
Question:
There is now a new formulation of desmopressin for primary nocturnal enuresis. What is this and what are the benefits?
Answer:
There is now available a new option for the administration of desmopressin.
- From 1st April this year PBS Authority status has been granted to desmopressin melt. Desmopressin melt is a sublingual wafer which dissolves rapidly under the tongue.
- Desmopressin melt offers improved administration convenience with no need for additional water intake just before bedtime.
- Desmopressin melt is available as a 120μg sublingual wafer, which is equivalent to the desmopressin tablet 200μg. The starting dose is one wafer or one tablet given at bedtime. The maximum dose for the treatment of PNE is 240μg (2x120μg) of desmopressin melt, equivalent to 400μg (2x200μg) of desmopressin tablets.
- Desmopressin melt is available in cartons of 30 x 120μg sublingual wafers
Question:
When should your doctor decide to stop treatment?
Answer:
- It may take up to several months for bedwetting to be successfully treated. However, fewer wet nights or smaller wet patches indicate an improvement in the child’s PNE. Successful treatment of PNE is defined as between two to three weeks’ continuous dry nights.
- Usually the enuresis alarm is unlikely to work if no improvement has been achieved by three months.
- Desmopressin should be administered for 12 weeks, followed by 1 week off treatment to gauge if there has been a positive effect.
- Desmopressin treatment may be continued for longer if the response to treatment is good and if relapse occurs when treatment is stopped.
It’s really important to talk with your doctor about bed wetting because so much can be done to affect a change.
For More Information
If you want to get more information about desmopressin, the NPS or National Prescribing Service has an up-to-date web site where you can read a CMI (Consumer Medicines Information) sheet with more facts on the quality use of this medication.
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