Practical consensus guidelines for the management of enuresis

Johan Vande Walle, Soren Rittig, Stuart Bauer, Paul Eggert, Daniela Marschall-Kehrel, Serdar Tekgul, American Academy of Pediatrics, European Society for Paediatric Urology, European Society for Paediatric Nephrology, International Children’s Continence Society, Johan Vande Walle, Soren Rittig, Stuart Bauer, Paul Eggert, Daniela Marschall-Kehrel, Serdar Tekgul, American Academy of Pediatrics, European Society for Paediatric Urology, European Society for Paediatric Nephrology, International Children’s Continence Society

Abstract

Despite the high prevalence of enuresis, the professional training of doctors in the evaluation and management of this condition is often minimal and/or inconsistent. Therefore, patient care is neither optimal nor efficient, which can have a profound impact on affected children and their families. Once comprehensive history taking and evaluation has eliminated daytime symptoms or comorbidities, monosymptomatic enuresis can be managed efficaciously in the majority of patients. Non-monosymptomatic enuresis is often a more complex condition; these patients may benefit from referral to specialty care centers. We outline two alternative strategies to determine the most appropriate course of care. The first is a basic assessment covering only the essential components of diagnostic investigation which can be carried out in one office visit. The second strategy includes several additional evaluations including completion of a voiding diary, which requires extra time during the initial consultation and two office visits before treatment or specialty referral is provided. This should yield greater success than first-line treatment.

Conclusion: This guideline, endorsed by major international pediatric urology and nephrology societies, aims to equip a general pediatric practice in both primary and secondary care with simple yet comprehensive guidelines and practical tools (i.e., checklists, diary templates, and quick-reference flowcharts) for complete evaluation and successful treatment of enuresis.

Figures

Fig. 1
Fig. 1
Flowcharts summarizing recommended evaluation of children with enuresis. a Strategy 1 = minimal; b Strategy 2 = optimal. CMT clinical management tool, MNE monosymptomatic enuresis, MVV maximum voided volume, NP nocturnal polyuria
Fig. 2
Fig. 2
First-line treatment options for monosymptomatic enuresis (a alarm and b desmopressin)

References

    1. Baeyens D, Lierman A, Roeyers H, Hoebeke P, Walle JV. Adherence in children with nocturnal enuresis. J Pediatr Urol. 2009;5(2):105–109. doi: 10.1016/j.jpurol.2008.10.002.
    1. Berry AK. Helping children with nocturnal enuresis: the wait-and-see approach may not be in anyone's best interests. Am J Nurs. 2006;106(8):56–63. doi: 10.1097/00000446-200608000-00024.
    1. Butler R, McKenna S. Overcoming parental intolerance in childhood nocturnal enuresis: a survey of professional opinion. BJU Int. 2002;89(3):295–297. doi: 10.1046/j.1464-4096.2001.01774.x.
    1. Butler RJ, Holland P, Robinson J. Examination of the structured withdrawal program to prevent relapse of nocturnal enuresis. J Urol. 2001;166(6):2463–2466. doi: 10.1016/S0022-5347(05)65617-0.
    1. Carskadon MA. Sleep deprivation: health consequences and societal impact. Med Clin North Am. 2004;88(3):767–776. doi: 10.1016/j.mcna.2004.03.001.
    1. Committee for Medicinal Products For Human Use (2006) Reflection paper: formulations of choice for the paediatric population. London. Available at: . Accessed 19 Jan 2012
    1. Culpepper L. Secondary insomnia in the primary care setting: review of diagnosis, treatment, and management. Curr Med Res Opin. 2006;22(7):1257–1268. doi: 10.1185/030079906X112589.
    1. De Guchtenaere A, Raes A, Vande Walle C, et al. Evidence of partial anti-enuretic response related to poor pharmacodynamic effects of desmopressin nasal spray. J Urol. 2009;181(1):302–309. doi: 10.1016/j.juro.2008.09.040.
    1. De Jonge DA. Epidemiology of enuresis: a survey of the literature. In: Kolvin I, MacKeith RC, Meadow SR, editors. Bladder control and enuresis. London: Heinemann Medical Books; 1973.
    1. Dehoorne JL, Raes AM, Van LE, Hoebeke P, Vande Walle JG. Desmopressin resistant nocturnal polyuria secondary to increased nocturnal osmotic excretion. J Urol. 2006;176(2):749–753. doi: 10.1016/S0022-5347(06)00297-7.
    1. Dogan HS, Akpinar B, Gurocak S, Akata D, Bakkaloglu M, Tekgul S. Non-invasive evaluation of voiding function in asymptomatic primary school children. Pediatr Nephrol. 2008;23(7):1115–1122. doi: 10.1007/s00467-008-0776-3.
    1. Ertan P, Yilmaz O, Caglayan M, Sogut A, Aslan S, Yuksel H. Relationship of sleep quality and quality of life in children with monosymptomatic enuresis. Child Care Health Dev. 2009;35(4):469–474. doi: 10.1111/j.1365-2214.2009.00940.x.
    1. Evans JH. Evidence based management of nocturnal enuresis. BMJ. 2001;323(7322):1167–1169. doi: 10.1136/bmj.323.7322.1167.
    1. Evans J, Malmsten B, Maddocks A, Popli HS, Lottmann H. Randomized comparison of long-term desmopressin and alarm treatment for bedwetting. J Pediatr Urol. 2011;7(1):21–29. doi: 10.1016/j.jpurol.2010.04.018.
    1. Farhat W, McLorie GA, O’Reilly S, Khoury A, Bägli DJ. Reliability of the pediatric dysfunctional voiding symptom score in monitoring response to behavioral modification. Can J Urol. 2001;8(6):1401–1405.
    1. Fergusson DM, Horwood LJ, Shannon FT. Factors related to the age of attainment of nocturnal bladder control: an 8-year longitudinal study. Pediatrics. 1986;78(5):884–990.
    1. Foxman B, Valdez RB, Brook RH. Childhood enuresis: prevalence, perceived impact, and prescribed treatments. Pediatrics. 1986;77(4):482–487.
    1. Garber KM. Enuresis: an update on diagnosis and management. J Pediatr Health Care. 1996;10(5):202–208. doi: 10.1016/S0891-5245(96)90002-4.
    1. Glazener CM, Evans JH, Peto RE (2005) Alarm interventions for nocturnal enuresis in children. Cochrane Database Syst Rev (2):CD002911
    1. Hagglof B, Andren O, Bergstrom E, Marklund L, Wendelius M. Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scand J Urol Nephrol Suppl. 1997;183:79–82.
    1. Hansen MN, Rittig S, Siggaard C, et al. Intra-individual variability in nighttime urine production and functional bladder capacity estimated by home recordings in patients with nocturnal enuresis. J Urol. 2001;166(6):2452–2455. doi: 10.1016/S0022-5347(05)65614-5.
    1. Hellström AL, Hanson E, Hansson S, Hjälmås K, Jodal U. Micturition habits and incontinence in 7-year-old Swedish school entrants. Eur J Pediatr. 1990;149(6):434–437. doi: 10.1007/BF02009667.
    1. Hislop J, Arber S. Sleepers wake! The gendered nature of sleep disruption among mid-life women. Sociology. 2003;37:695–711. doi: 10.1177/00380385030374004.
    1. Hjalmas K, Arnold T, Bower W, et al. Nocturnal enuresis: an international evidence based management strategy. J Urol. 2004;171(6 Pt 2):2545–2561. doi: 10.1097/01.ju.0000111504.85822.b2.
    1. Hunsballe JM, Rittig S, Djurhuus JC. Sleep and arousal in adolescents and adults with nocturnal enuresis. Scand J Urol Nephrol Suppl. 1995;173:59–60.
    1. Kamperis K, Hagstroem S, Rittig S, Djurhuus JC. Combination of the enuresis alarm and desmopressin: second line treatment for nocturnal enuresis. J Urol. 2008;179(3):1128–1131. doi: 10.1016/j.juro.2007.10.088.
    1. Longstaffe S, Moffatt ME, Whalen JC. Behavioral and self-concept changes after six months of enuresis treatment: a randomized, controlled trial. Pediatrics. 2000;105(4 Pt 2):935–940.
    1. Lottmann H, Froeling F, Alloussi S, et al. A randomised comparison of oral desmopressin lyophilisate (MELT) and tablet formulations in children and adolescents with primary nocturnal enuresis. Int J Clin Pract. 2007;61(9):1454–1460. doi: 10.1111/j.1742-1241.2007.01493.x.
    1. Marschall-Kehrel D, Harms TW. Structured desmopressin withdrawal improves response and treatment outcome for monosymptomatic enuretic children. J Urol. 2009;182(4 Suppl):2022–2026. doi: 10.1016/j.juro.2009.03.068.
    1. National Institute for Health and Clinical Excellence . Nocturnal enuresis: the management of bedwetting in children and young people. London: NICE; 2010.
    1. Neveus T, Eggert P, Evans J, et al. Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the International Children’s Continence Society. J Urol. 2010;183(2):441–447. doi: 10.1016/j.juro.2009.10.043.
    1. Neveus T, Hetta J, Cnattingius S, et al. Depth of sleep and sleep habits among enuretic and incontinent children. Acta Paediatr. 1999;88(7):748–752. doi: 10.1111/j.1651-2227.1999.tb00036.x.
    1. Nevéus T, von Gontard A, Hoebeke P, et al. The standardisation of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children’s Continence Society (ICCS) J Urol. 2006;176(1):314–324. doi: 10.1016/S0022-5347(06)00305-3.
    1. Pugner K, Holmes J. Nocturnal enuresis: economic impacts and self-esteem preliminary research results. Scand J Urol Nephrol Suppl. 1997;183:65–69.
    1. Raes A, Dehoorne J, Van LE, Hoebeke P, Vande WC, Vansintjan P, et al. Partial response to intranasal desmopressin in children with monosymptomatic nocturnal enuresis is related to persistent nocturnal polyuria on wet nights. J Urol. 2007;178(3 Pt 1):1048–1051. doi: 10.1016/j.juro.2007.05.060.
    1. Rembratt A, Graugaard-Jensen C, Senderovitz T, Nørgaard JP, Djurhuus JC. Pharmacokinetics and pharmacodynamics of desmopressin administered orally versus intravenously at daytime versus night-time in healthy men aged 55–70 years. Eur J Clin Pharmacol. 2004;60(6):397–402. doi: 10.1007/s00228-004-0781-9.
    1. Riley KE. Evaluation and management of primary nocturnal enuresis. J Am Acad Nurse Pract. 1997;9(1):33–39. doi: 10.1111/j.1745-7599.1997.tb01272.x.
    1. Rittig S, Jensen AR, Jensen KT, Pedersen EB. Effect of food intake on the pharmacokinetics and antidiuretic activity of oral desmopressin (DDAVP) in hydrated normal subjects. Clin Endocrinol (Oxf) 1998;48(2):235–241. doi: 10.1046/j.1365-2265.1998.00340.x.
    1. Rittig S, Schaumburg HL, Siggaard C, Schmidt F, Djurhuus JC. The circadian defect in plasma vasopressin and urine output is related to desmopressin response and enuresis status in children with nocturnal enuresis. J Urol. 2008;179(6):2389–2395. doi: 10.1016/j.juro.2008.01.171.
    1. Robson L. Bedwetting. Parkhurst Exch. 2007;15(12):66–67.
    1. Robson WL. Clinical practice. Evaluation and management of enuresis. N Engl J Med. 2009;360(14):1429–1436. doi: 10.1056/NEJMcp0808009.
    1. Rush EC, Chhichhia P, Kilding AE, Plank LD. Water turnover in children and young adults. Eur J Appl Physiol. 2010;110:1209–1214. doi: 10.1007/s00421-010-1621-5.
    1. Sapi MC, Vasconcelos JS, Silva FG, Damião R, da Silva EA. Assessment of domestic violence against children and adolescents with enuresis. J Pediatr (Rio J) 2009;85(5):433–437.
    1. Schulpen TW. The burden of nocturnal enuresis. Acta Paediatr. 1997;86(9):981–984. doi: 10.1111/j.1651-2227.1997.tb15183.x.
    1. Sit FKY, Yeung CK, Sihoe JDY, Liu JWH (2003) Self-esteem before and after treatment in Chinese children with nocturnal enuresis and urinary incontinence: a qualitative approach. ICCS Abstracts 40
    1. Tekgul S, Nijman R, Hoebeke P, Canning D, Bower W, von Gontard A (2009) Diagnosis and management of urinary incontinence in childhood. Report from the 4th International Consultation on Incontinence. Health Publication Ltd
    1. Tekgul S, Riedmiller H, Gerharz E et al (2008) Guidelines on paediatric urology. European Society of Paediatric Urology [cited (2010) Nov 4]. Available at:
    1. Theunis M, Van Hoecke E, Paesbrugge S, Hoebeke P, Vande Walle J. Self-image and performance in children with nocturnal enuresis. Eur Urol. 2002;41(6):660–667. doi: 10.1016/S0302-2838(02)00127-6.
    1. van Dommelen P, Kamphuis M, Van Leerdam FJ, et al. The short- and long-term effects of simple behavioral interventions for nocturnal enuresis in young children: a randomized controlled trial. J Pediatr. 2009;154:662–666. doi: 10.1016/j.jpeds.2008.12.001.
    1. Van Herzeele C, Alova I, Evans J, et al. Poor compliance with primary nocturnal enuresis therapy may contribute to insufficient desmopressin response. J Urol. 2009;182(4 Suppl):2045–2049. doi: 10.1016/j.juro.2009.06.001.
    1. van Kerrebroeck PE, Nørgaard JP. Desmopressin for the treatment of primary nocturnal enuresis. Ped Health. 2009;3:311–327. doi: 10.2217/phe.09.20.
    1. van Londen A, van Londen-Barentsen MW, van Son MJ, Mulder GA. Arousal training for children suffering from nocturnal enuresis: a 2 1/2 year follow-up. Behav Res Ther. 1993;31(6):613–615. doi: 10.1016/0005-7967(93)90113-9.
    1. Vande Walle J, Vande Walle C, Van SP, et al. Nocturnal polyuria is related to 24-hour diuresis and osmotic excretion in an enuresis population referred to a tertiary center. J Urol. 2007;178(6):2630–2634. doi: 10.1016/j.juro.2007.08.029.
    1. Vande Walle JG, Bogaert GA, Mattsson S, et al. A new fast-melting oral formulation of desmopressin: a pharmacodynamic study in children with primary nocturnal enuresis. BJU Int. 2006;97(3):603–609. doi: 10.1111/j.1464-410X.2006.05999.x.
    1. von Gontard A (2009) Psychological aspects of urinary incontinence, enuresis and faecal incontinence. In: Abrams P, Cardozo L, Khoury S, Wein A (eds). Report from the 4th International Consultation on Incontinence. 4th edition. Health Publication Ltd, p. 760–792
    1. Wagner WG, Johnson JT. Childhood nocturnal enuresis: the prediction of premature withdrawal from behavioral conditioning. J Abnorm Child Psychol. 1988;16(6):687–692. doi: 10.1007/BF00913478.
    1. Watanabe H, Kawauchi A, Kitamori T, Azuma Y. Treatment system for nocturnal enuresis according to an original classification system. Eur Urol. 1994;25(1):43–50.
    1. Wolfish NM. Sleep/arousal and enuresis subtypes. J Urol. 2001;166(6):2444–2447. doi: 10.1016/S0022-5347(05)65612-1.
    1. Woo SH, Park KH. Enuresis alarm treatment as a second line to pharmacotherapy in children with monosymptomatic nocturnal enuresis. J Urol. 2004;171(6 Pt 2):2615–2617. doi: 10.1097/01.ju.0000113036.13536.29.
    1. Yeung CK, Diao M, Sreedhar B. Cortical arousal in children with severe enuresis. N Engl J Med. 2008;358(22):2414–2415. doi: 10.1056/NEJMc0706528.
    1. Yeung CK, Sihoe JD, Sit FK, Bower W, Sreedhar B, Lau J. Characteristics of primary nocturnal enuresis in adults: an epidemiological study. BJU Int. 2004;93(3):341–345. doi: 10.1111/j.1464-410X.2003.04612.x.
    1. Yeung CK, Sit FK, To LK, et al. Reduction in nocturnal functional bladder capacity is a common factor in the pathogenesis of refractory nocturnal enuresis. BJU Int. 2002;90(3):302–307. doi: 10.1046/j.1464-410X.2002.02884.x.
    1. Yeung CK, Sreedhar B, Sihoe JD, Sit FK, Lau J. Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int. 2006;97(5):1069–1073. doi: 10.1111/j.1464-410X.2006.06074.x.

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