Nocturnal enuresis

The word enuresis is derived from a Greek word (enourein) that means to void urine. It can occur either during the day or at night (though some restrict the term to bedwetting that occurs at night). Enuresis can be divided into primary and secondary forms. If a medical condition capable of causing the symptoms (eg, neurogenic bladder, diabetes, or urinary tract infection) is present, the diagnosis of enuresis generally is not made. However, if urinary incontinence was present on a regular basis before these other medical conditions developed or persisted after they were adequately treated, the diagnosis of enuresis is compatible with their presence. In addition, side effects of medications such as antipsychotics and diuretics should be considered as possible causes. The best time to investigate and discuss enuresis is when the parent or patient first raises the issue in the physicians office. However, the best time to treat the behavior might depend more on the motivation of the child. The most important aspect of the investigation is a meticulous history, which can establish the diagnosis, lead to more precise treatment recommendations, and minimize the need for invasive and costly investigations. The history should include the following:

Fluid intake Daytime voiding pattern Number and timing of episodes of bedwetting Sleep history Diet history Emotional status

If the history is not clear, request that the family record fluid intake, daytime voiding, and episodes of bedwetting for at least a 2-week period. A sleep history should include the times the child goes to bed, falls asleep, and awakens in the morning. Parents should be asked to make a subjective assessment of the childs depth of sleep. The presence of restless sleep, snoring, and the type and frequency of nocturnal arousals (eg, nightmares, sleep terrors, or sleepwalking) should be determined. Whether the child has experienced periods of dryness and the circumstances of these episodes should also be determined. A diet history should include the timing, quantity, and type of fluid and solid food intake during the entire day, not merely after supper. Many children with enuresis do not drink appreciable amounts of 1

liquids during the school day, arrive home from school thirsty, and drink most of their daily fluids in the 4 or 5 hours before bedtime, a pattern that favors nocturnal production of urine. An assessment of the emotional impact on the child is important. Information should be solicited from both the parents and the child. Basic and revealing information includes whether the child has experienced teasing by family or friends or has self-restricted participation in school, sleepovers, or trips. Alertness to symptoms reflecting common underlying problems is important. Patients with overactive bladder or dysfunctional voiding usually present with frequency, urgency, squatting behavior, and daytime and nighttime wetting. Cystitis and constipation are common associated problems in patients with overactive bladder or dysfunctional voiding. Symptoms of cystitis include dysuria; cloudy, foul-smelling urine; visible blood in the urine; frequency; urgency; and day and nighttime wetting. Symptoms of cystitis can be very subtle in some children. Constipation manifests as infrequent and painful passage of hard wide stool,encopresis, and colicky periumbilical pain. Some children with enuresis have bowel patterns that influence bladder control and capacity, but they are not constipated by conventional definitions. Thus, the history should include a careful assessment of the frequency and timing of bowel movements, whether the stool is easy to pass, and whether the child needs to push. Children who defecate later in the day, who miss days, and who need to push should be identified. Bowel-related problems and gait abnormalities are often present in patients withneurogenic bladder. Symptoms of sleep-disordered breathing (SDB) include snoring, mouth breathing, lack of restful sleep, and tiredness the following morning. The hallmark symptoms of urethral obstruction are the need to wait or push to initiate voiding and a weak or interrupted stream. When bedwetting is a feature of a major motor seizure, parents may hear nocturnal sounds associated with abnormal muscle movements. Girls with ectopic ureter are always wet. Symptoms of diabetes mellitus include polyuria, polydipsia, and weight loss despite a voracious appetite. Patients with diabetes insipidus present with polyuria, polydipsia, and symptoms related to the underlying hypothalamic or renal causes. A comprehensive physical examination is important and should include the following:

Measurement of blood pressure Inspection of external genitalia Palpation in the renal and suprapubic areas to look for enlarged kidneys or bladder 2

Palpation of the abdomen to look for hard, wide stool in the left lower quadrant and up to the left upper quadrant or a hard stool mass in the suprapubic area Thorough neurologic examination of the lower extremities, including gait, muscle power, tone, sensation, reflexes, and plantar responses Assessment of the anal wink Inspection and palpation of the lumbosacral spine

Abnormal physical findings are usually absent in children when enuresis is the sole symptom and are not necessarily present in children with overactive bladder or dysfunctional voiding. Abnormal findings may be present in patients with cystitis, constipation, neurogenic bladder, urethral obstruction, ectopic ureter, orobstructive sleep apnea (OSA). A spinal defect, such as a dimple, hair tuft, or skin discoloration, might be visible in approximately 50% of patients with an intraspinal lesion. Dimples above the cleft are especially suspicious. Assessment of the anal wink or the ability of a patient to stand on the toes is a satisfactory test of the integrity of the S2-4 spinal reflex arc. In some situations, observing the child void is helpful for assessing the urinary stream. If the child grunts audibly or uses the abdominal muscles to push or if the stream is weak or interrupted, a urethral obstruction may be present. In girls with ectopic ureter, a constant moistness is observed in the introitus, and regular drying with tissue reveals the persistent leak of urine. Tonsillar size in a child examined in the awake and sitting position may not correlate with OSA symptoms. Examination of the child in the prone position and during sleep may be necessary to visibly document obstruction. f a medical condition capable of causing the symptoms (eg, neurogenic bladder, diabetes, or urinary tract infection) is present, the diagnosis of enuresis generally is not made. However, if urinary incontinence was present on a regular basis before these other medical conditions developed or persisted after they were adequately treated, the diagnosis of enuresis is compatible with their presence. In addition, side effects of medications such as antipsychotics and diuretics should be considered as possible causes. Urinalysis is the most important screening test in a child with enuresis. Children with cystitis usually have white blood cells (WBCs) or bacteria evident in the microscopic urinalysis. Children with overactive bladder or dysfunctional voiding, urethral obstruction, neurogenic bladder, ectopic ureter, or diabetes mellitus are predisposed to cystitis. If the urinalysis findings suggest cystitis, urine should be sent for culture and sensitivity.

Urethral obstruction may be associated with red blood cells (RBCs) in the urine. The presence of glucose suggests diabetes mellitus. A random or first-morning specific gravity greater than 1.020 excludes diabetes insipidus. Blood tests usually are not needed. No imaging is needed if primary enuresis (PE) is suspected; however, radiologic evaluation might be warranted if other conditions are being considered. Failure to empty the bladder is a significant risk factor for cystitis and is common in patients with overactive bladder, dysfunctional voiding, neurogenic bladder, or urethral obstruction. Portable bladder ultrasonography is available to assess residual urine when the patient is in the office. The residual volume of urine is normally less than 5 mL. Diagnostic imaging studies are not routinely indicated; however, patients with coincidental daytime voiding symptoms should undergo ultrasonography of the bladder and kidneys. In patients with significant daytime symptoms whose ultrasonograms are normal, more invasive investigations should be deferred for 3 months, during which period the voiding routine and emptying are improved, cystitis is treated or prevented, and bowel health is improved. f the bladder wall is thickened or trabeculated or a significant postvoid residual volume of urine is noted, voiding cystourethrography (VCUG) should be considered. VCUG is warranted for patients in whom a neurogenic bladder is suspected. The lumbosacral spine should be visualized during the procedure to look for sacral agenesis or spinal dysraphism. The classic radiologic feature of a neurogenic bladder is a trabeculated bladder with a Christmas tree or pine cone configuration. VCUG is also warranted when urethral obstruction is suspected on the basis of an abnormal urinary stream or abnormal ultrasonography findings. If obstructive sleep apnea (OSA) is suspected, consider lateral radiography of the neck or referral to a pediatric otolaryngologist for direct visualization of the nasopharynx should be considered. Referral to a pediatric sleep specialist should also be considered. Magnetic resonance imaging (MRI) of the spine is indicated in any patient with any of the following:

An abnormal neurologic examination finding of the lower extremities A visible defect in the lumbosacral spine The triad of encopresis, gait abnormality, and daytime symptoms

MRI should be considered in patients with significant daytime voiding dysfunction that does not improve with treatment, even if neurologic and orthopedic examination findings are normal. Urodynamic studies help clarify the diagnosis of neurogenic bladder. A video urodynamic study measures both filling-phase parameters (eg, bladder capacity, presence or absence of unstable detrusor contractions, bladder compliance, and the state of the bladder neck) and voiding-phase parameters (eg, voiding pressures, bladder emptying, and the state of the external urethral sphincter). 4

Urodynamic studies and cystoscopy should be reserved for patients with urethral obstruction and neurogenic bladder and for patients with dysfunctional voiding who do not improve after 3 months of therapy. Uroflowmetry is a simple, noninvasive measurement of urine flow that is helpful in screening patients for neurogenic bladder and urethral obstruction. It is performed by having the child void into a special toilet with a pressure-sensitive device at the base. A normal uroflow study shows a single bell-shaped curve with a normal peak and average flow rate for age and size. Children must be instructed to void when the bladder is full but not overfull; the uroflow curve in an overfull bladder can be tower-shaped or broad, and this can confuse the interpretation. Patients with dysfunctional voiding, urethral obstruction, or neurogenic bladder have prolonged curves or an interrupted series of curves and low peak and average urine flow rates. The most important reason for treating enuresis is to minimize the embarrassment and anxiety of the child and the frustration experienced by the parents. Most children with enuresis feel very much alone with their problem. Family members with a history of enuresis should be encouraged to share their experiences and offer moral support to the child. The knowledge that another family member had and outgrew the problem can be therapeutic. Preliminary management focusing on behavioral modification and positive reinforcement is often helpful. The only therapies that have been shown to be effective in randomized trials are alarm therapy and treatment with desmopressin acetate or imipramine. Nonmonosymptomatic enuresis may be more difficult and time-consuming to treat.[16] Bladder training exercises are not recommended. With this therapy, the child is asked to ingest large quantities of fluid and to hold the urine in the bladder without voiding until uncomfortable. A therapeutic approach that involves (a) teaching a child not to respond normally to the sensation of a full bladder and (b) prescribing a therapy that is inherently painful seems fundamentally without merit. The results of studies that report on this therapy are either methodologically flawed or show no improvement. Enuresis is not a surgically treated condition. However, ectopic ureter and obstructive sleep apnea (OSA) respond to specific surgical interventions. Referral to a pediatric otolaryngologist or a pediatric sleep specialist may be appropriate if OSA is suspected. atients with PE are asked to keep a diary and should return for evaluation on a monthly basis to assess their progress. A positive attitude and motivation to be dry are important components of treatment. Children with enuresis benefit from a caring and patient parental attitude; punishment has no role to play in care. A positive approach by the physician is also important for instilling confidence and enhancing compliance. Many children have given up on achieving dryness, and an optimistic attitude must be encouraged. 5

Behavioral modification with positive reinforcement may enhance treatment results. Consistent followup is important for gauging therapeutic results. An explanation of the probable cause of the enuresis is important for every family. If a child has no daytime symptoms or has experienced significant dry spells in the past, it is unlikely that a structural abnormality is causing the enuresis. This should be explained to the parents to allay any fears about other causes and to reassure them that invasive investigations are not necessary. Parents should be asked to provide specific examples of potential causes that have them worried, so that the physician can address and help relieve these often irrational fears. Keen attention to a normal daytime voiding pattern is important. The child should be encouraged to void upon awakening, at common transition times and approximately every 1.5-2 hours, before leaving home or school for any reason, and always before bed. With voiding, the child should relax, use optimal posture, and take time to empty the bladder completely. At school, children should be encouraged to void regularly, at least 2 or 3 times daily. A note for the teacher should be written to ensure that the child is allowed regular access to the bathroom. Children should not be expected to wait for scheduled breaks to void. Holding the urine to the last minute should be discouraged. Children should be instructed to drink liberal amounts during the day and to maintain optimal hydration throughout the entire day. A well-hydrated child is not thirsty when he or she returns home from school and is not thirsty at bedtime. Thirst should be prevented so that a child does not drink excessive amounts in the evening hours before bed. Children who play sports or who are otherwise physically active in the evening after mealtime should be well hydrated for the activity. Parents should be asked to take the child to the bathroom to void before bedtime. Because this therapeutic measure is designed only to minimize the quantity of fluid in the bladder, full wakefulness is neither necessary nor desirable. Careful monitoring by a parent is necessary for the trip from bed to bathroom and back. Children should go to bed at an hour calculated to offer the optimal number of sleep hours for their age. If attention to the above preliminary management program for up to 3 months does not result in dryness, then either alarm therapy or pharmacologic therapy should be considered. Because neither therapy has been shown to be consistently superior to the other, the preliminary choice should be dictated by the clinical setting, the family preference, and the experience of the practitioner. Alarm Therapy Alarm therapy offers the possibility of sustained improvement of enuresis and should be considered for every patient. It is reported to improve bedwetting by increasing nocturnal bladder capacity or by enhanced arousal; it does not reduce nocturnal urine output. Numerous alarms are available. The alarm should be attached at bedtime to the underwear or pajamas in a position chosen to permit prompt sensing of wetness. Although most children with enuresis do not 6

awaken to the alarm, they stop emptying the bladder. When the alarm sounds, a parent must help the child wake to full consciousness and attend to the bathroom to finish voiding. After the sheets and underwear or pajamas are changed, the child should be returned to bed and the alarm reset. Some successfully treated children replace enuresis with nocturia, and others sleep dry without the need to void at night. Some improve within the first 2 weeks of treatment, and others improve only after several months. A Cochrane review of 56 randomized trials involving 3257 children concluded that alarm therapy is beneficial.[13] About two thirds of children on alarm therapy were dry, but about half relapsed, so that only about a third remained dry at 6-month follow-up. Optimal results occur when the child is well motivated. Older children usually have better developed motivation. Parental motivation and involvement are also important. The parent should believe that the approach is worthwhile and should be prepared to participate every night for at least 3 consecutive months. Close biweekly or monthly follow-up care is important to sustain motivation, troubleshoot technical problems, and otherwise monitor the therapy. In successfully treated children, alarm therapy should be continued for at least 3 months and for 1 month after sustained dryness. Relapses are common, developing in 29-66% of children, and sometimes respond to further alarm therapy. If the child is still wet after a minimum of 3 months of consecutive use, alarm therapy can be discontinued and considered unsuccessful. Failure does not preclude future succeDesmopressin acetate Desmopressin acetate is the preferred medication for treating children with enuresis. A Cochrane review of 47 randomized trials concluded that desmopressin therapy reduces bedwetting; children treated with desmopressin had an average of 1.3 fewer wet nights per week.[14] The tablet and the orally disintegrating tablet (not available in the United States) have similar efficacy. The intranasal formulation carries a black box warning from the US Food and Drug Administration (FDA) and is no longer recommended for enuresis, because of the risk for severe hyponatremia that can cause seizures and death. Desmopressin acetate tablets or orally disintegrating tablets should be administered 1 hour before bedtime. The recommended starting dose for the tablet is 0.2 mg, and the drug can be titrated as necessary to a maximum dose of 0.6 mg. The equivalent starting dose for the orally disintegrating tablet is 120 g, and the maximum dose is 360 g. Desmopressins immediate onset of action allows the flexibility of choosing either intermittent administration for special occasions or long-term use to maintain dryness. For long-term use, desmopressin can be prescribed in 3-month quantities and discontinued between prescriptions to determine whether the wetting persists and thus whether continued use is justified. The safety profile of desmopressin acetate is favorable, and many studies have documented low rates of adverse effects. For the tablet, the incidence of minor adverse events is not significantly different from that for a placebo. 7

The only serious adverse effect reported in patients with enuresis treated with desmopressin is the development of seizure or other central nervous system (CNS) symptoms due to water intoxication. A review of case reports of water intoxication associated with desmopressin confirmed that excess fluid intake was a feature in at least 6 of 11 individuals. This serious adverse effect can be prevented by educating the patient not to consume an excess of fluids on any evening in which desmopressin is administered. A maximum of 1 cup of fluid should be offered at the evening meal, no more than 1 cup between mealtime and bedtime, and no fluid at all within the 2 hours preceding bedtime. Early symptoms of water intoxication include headache, nausea, and vomiting. If these symptoms develop, the medication should be discontinued and the child promptly assessed by a physician. As of December 2007, the FDA had reviewed 61 postmarketing cases of hyponatremic-related seizures associated with the use of desmopressin. In 55 cases, sodium levels of 104-130 mEq/L during the seizure event were reported. In 2 cases, the patients died (both patients experienced hyponatremia and seizures). There were 36 cases associated with intranasal formulations, 25 of which occurred in pediatric patients younger than 17 years. The most commonly reported indication for use in these 25 pediatric cases was enuresis. In 39 of the 61 cases, there was at least 1 concomitant drug or disease that was also associated with hyponatremia, seizures, or both. Combination of alarm therapy with desmopressin therapy has been reported to result in dryness not achievable with either therapy alone. Anticholinergic agents An anticholinergic medication may be helpful in some patients, especially those with overactive bladder, dysfunctional voiding, or neurogenic bladder. These medications reduce uninhibited detrusor contractions, increase the threshold volume at which an uninhibited detrusor contraction occurs, and enlarge the functional bladder capacity. Oxybutynin chloride and tolterodine are commonly prescribed in this setting. Oxybutynin chloride also has antispasmodic and analgesic properties. Anticholinergic adverse effects include dry mouth, blurred vision, facial flushing, constipation, poor bladder emptying, and mood changes. Constipation as an adverse event is especially problematic in that it might increase the risk for wetting. Anticholinergic medications should not be administered during a fever, because one anticholinergic effect is a decrease in sweating. Similarly, they should be used with caution in children who exercise or play strenuously, especially on hot days. Oxybutynin is given in a dose of 2.5-5 mg administered at bedtime. A long-acting preparation is available but has not been approved for use in children. Tolterodine is not approved for use in children younger than 12 years. Flavoxate, a urinary spasmolytic, may be helpful in some patients with overactive bladder and dysfunctional voiding but is approved only for children older than 12 years. 8

The combination of desmopressin acetate and oxybutynin chloride may be efficacious in children with overactive bladder or dysfunctional voiding who respond to anticholinergic therapy with improved daytime symptoms but who continue to wet at night. Imipramine A Cochrane review of 58 randomized trials concluded that imipramine is effective in reducing bedwetting; children treated with imipramine had 1 fewer wet night per week.[15] The relapse rate is high when the medication is discontinued. The usual dose, taken 1-2 hours before bedtime, is 25 mg for patients aged 6-8 years and 50-75 mg for older children and adolescents. Adverse effects include constipation, difficulty initiating voiding, irritability, drowsiness, reduced appetite, and personality changes. Imipramine overdose can be fatal, and a cautionary warning is necessary with every prescription. Because of the unfavorable adverse effect profile and the significant risk of death with overdose, the World Health Organization (WHO) does not recommend imipramine for the treatment of enuresis. Children should be instructed to drink a liberal amount during the day, to maintain good hydration throughout the day, and to drink enough to prevent thirst when they arrive home from school and at bedtime. Children who play sports in the evening should be optimally hydrated for the activity. Pharmacologic management plays an important role in the treatment of bedwetting. Three pharmacologic approaches are currently considered: desmopressin acetate, anticholinergic medications, and imipramine. Class Summary Secretion of vasopressin at night reduces urine output. Water is conserved and concentrated by increasing the flow in the kidney through the collecting tubules to the medullary interstitium. Desmopressin acetate is a synthetic analogue of antidiuretic hormone (ADH). The mechanism of action was initially presumed to be a reduction in overnight production of urine. It was later found that some children with bedwetting had lower nocturnal levels of ADH than children who were dry at night. This finding provided a scientific rationale for desmopressin use; however, not all children with bedwetting have lower levels of ADH at night, overproduce urine at night, or respond to desmopressin. In addition, not all children who respond to desmopressin have lower levels of ADH or overproduce urine at night before being treated with the medication. Desmopressin increases the cellular permeability of collecting ducts, resulting in reabsorption of water by kidneys. It is formulated as a tablet and as a nasal spray. Because of the risk for severe hyponatremia, the intranasal formulation is no longer indicated for primary enuresis. Some children with bedwetting have a small functional bladder capacity at night. Other children with bedwetting also have daytime symptoms of frequency and urgency. These children may benefit from 9

treatment with an anticholinergic medication that allows the bladder to hold more urine. Outside of these situations, treatment with an anticholinergic medication is not likely to decrease the incidence of bedwetting. Oxybutynin should be considered in children who are likely to have small functional bladder capacity either only at night or throughout the day. Daytime symptoms that may indicate potential for therapeutic benefit include frequency, urgency, and incontinence. Nighttime symptoms include wetting more frequently than once per night. It is not approved for children younger than 12 years. Tolterodine is a competitive muscarinic receptor antagonist for overactive bladder; it differs from other anticholinergic drugs in that it has selectivity for the urinary bladder over salivary glands. Tolterodine is used in patients likely to have small functional bladder capacity either only at night or throughout the day. Daytime symptoms that may indicate potential for therapeutic benefit include frequency, urgency, and incontinence. Nighttime symptoms include wetting more frequently than once per night. Flavoxate is used for symptomatic relief of incontinence. It has anticholinergic effects and exerts a direct effect on muscle. It counteracts smooth muscle spasm of the urinary tract. mipramine was first prescribed for bedwetting in an era when psychological causes were considered common. The modern understanding is that psychological causes are not a common cause of enuresis. The mechanism whereby imipramine improves bedwetting is not clear. Current theories include central nervous system (CNS)-related or local bladder-related effects. Imipramine facilitates urine storage by decreasing bladder contractility and increasing outlet resistance. It inhibits reuptake of norepinephrine or serotonin at the presynaptic neuron.

References 1. Robson WL, Leung AK, Van Howe R. Primary and secondary nocturnal enuresis: similarities in presentation. Pediatrics. Apr 2005;115(4):9569. [Medline]. 2. Moffatt ME. Nocturnal enuresis: psychologic implications of treatment and nontreatment. J Pediatr. Apr 1989;114(4 Pt 2):697-704. [Medline]. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013:355-7. 4. von Gontard A, Eiberg H, Hollmann E, Rittig S, Lehmkuhl G. Molecular genetics of nocturnal enuresis: linkage to a locus on chromosome 22. Scand J Urol Nephrol Suppl. 1999;202:76-80. [Medline].
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5. Arnell H, Hjalmas K, Jagervall M, et al. The genetics of primary nocturnal enuresis: inheritance and suggestion of a second major gene on chromosome 12q. J Med Genet. May 1997;34(5):360-5. [Medline].[Full Text]. 6. Norgaard JP, Pedersen EB, Djurhuus JC. Diurnal anti-diuretic-hormone levels in enuretics. J Urol. Nov 1985;134(5):1029-31. [Medline]. 7. Rittig S, Knudsen UB, Norgaard JP, Gregersen H, Pedersen EB, Djurhuus JC. Diurnal variation of plasma atrial natriuretic peptide in normals and patients with enuresis nocturna. Scand J Clin Lab Invest. Apr 1991;51(2):209-17. [Medline]. 8. Mattsson S, Lindstrom S. Diuresis and voiding pattern in healthy schoolchildren. Br J Urol. Dec 1995;76(6):783-9. [Medline].

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Ask whether the bedwetting started in the last few days or weeks. If so, consider whether this is a presentation of a systemic illness.[1.3.1]

Ask if the child or young person had previously been dry at night without assistance for 6 months. If so, enquire about any possible medical, emotional or physical triggers, and consider whether assessment and treatment is needed for any identified triggers. [1.3.2]

Ask about the pattern of bedwetting, including questions such as:

How many nights a week does bedwetting occur? How many times a night does bedwetting occur? Does there seem to be a large amount of urine? At what times of night does the bedwetting occur? Does the child wake up after bedwetting? [1.3.3]

6.2.3.4. Ask about the presence of any daytime symptoms in a child or young person with bedwetting, including:

daytime frequency (that is, passing urine more than seven times a day) daytime urgency daytime wetting passing urine infrequently (fewer than four times a day) abdominal straining or poor urinary stream pain passing urine. [1.3.4]

6.2.3.5. Ask about daytime toileting patterns in a child or young person with bedwetting, including:

whether daytime symptoms occur only in some situations avoidance of toilets at school or other settings whether the child goes to the toilet more or less frequently than his or her peers.[1.3.5]

6.2.3.6. 12

Ask about the child or young persons fluid intake throughout the day. In particular, ask whether the child or young person, or the parents or carers are restricting fluids.[1.3.6] 6.2.3.7. Do not perform urinalysis routinely in children and young people with bedwetting, unless any of the following apply:

bedwetting started in the last few days or weeks there are daytime symptoms there are any signs of ill health there is a history, symptoms or signs suggestive of urinary tract infections there is a history, symptoms or signs suggestive of diabetes mellitus.[1.3.8]

6.2.3.8. Assess whether the child or young person has any comorbidities or there are other factors to consider, in particular:

constipation and/or soiling developmental, attention or learning difficulties diabetes mellitus behavioural or emotional problems family problems or vulnerable child or family.[1.3.9]

6.2.3.9. Consider assessment, investigation and/or referral when bedwetting is associated with:

severe daytime symptoms a history of recurrent urinary infections known or suspected physical or neurological problems comorbidities or other factors (as for example, those listed in recommendation 1.3.9).[1.3.10]

6.2.3.10. Investigate and treat children and young people with suspected urinary tract infection in line with Urinary tract infection (NICE clinical guideline 54).*1.3.11+ 13

6.2.3.11. Investigate and treat children and young people with soiling or constipation in line with Constipation in children and young people (NICE clinical guideline 99).*1.3.12+ 6.2.3.12. Children and young people with suspected type 1 diabetes should be offered immediate (same day) referral to a multidisciplinary paediatric diabetes care team that has the competencies needed to confirm diagnosis and to provide immediate care [This recommendation is from Type 1 diabetes (NICE clinical guideline 15). *1.3.13+ 6.2.3.13. Consider investigating and treating daytime symptoms before bedwetting if daytime symptoms predominate.[1.3.14] 6.2.3.14. Consider involving a professional with psychological expertise for children and young people with bedwetting and emotional or behavioural problems. [1.3.15] 6.2.3.15. Discuss factors that might affect treatment and support needs, such as:

sleeping arrangements (for example, does the child or young person have his or her own bed or bedroom) the impact of bedwetting on the child or young person and family whether the child or young person and their parents or carers have the necessary level of commitment, including time available, to engage in a treatment programme.[1.3.16]

6.4.3.16. Use the findings of the history to inform the diagnosis (according to table 1) and management of bedwetting. [1.3.19] Go to: 6.3 What is the incremental benefit and cost effectiveness of radiological examination, in the evaluation of children and young people under 19 years old who have bedwetting? 6.3.1 Evidence review 14

See tables at 6.2.1.1 for outline of studies included. 6.3.2 Evidence statements Van Der Vis-melsen (1992) 44

ntroduction: Constipation is one of the multiple factors that cause enuresis. The correlation between enuresis and constipation is well established. But there is limited research on the correlation of time of voiding and constipation. Aim: To find a correlation between time of enuresis and constipation. Material and methods: This cross sectional study was carried out in Mofid Childrens Hospital, from January 2010 to June 2011. All patients with constipation or enuresis were included in this study and evaluated for both conditions. We classified cases according to time of enuresis in 3 categories. Data were analyzed by SPSS and Epi-info with 2 and t-test. Value of p below 0.05 was considered significant. Results: In this study, 560 patients who visited a physician with constipation (n = 400) or enuresis (n = 160) were included. We investigated children with constipation for enuresis, and children with enuresis for constipation. Finally, constipation was present in 480 cases and enuresis in 289 cases. Duration of constipation was 9.60 7.1 (1-42) weeks and duration of enuresis was 6.17 4.74 (1-25) weeks. Of 160 patients with enuresis, 80 (50%) had constipation. Of 400 patients with constipation, 129 had enuresis (32.25%). There was a significant correlation between duration of constipation and duration of enuresis (p < 0.001, Pearson test). Of 318 constipated boys, 148 (61.46) had enuresis. Of 162 girls with constipation, 61 (37.65%) had enuresis. The rate of enuresis among constipated boys was significantly higher than girls (p = 0.0001, 2). Of 560 patients, constipation and enuresis; only constipation; and only enuresis were found in 209 (37.32%), 271 (48.40%), and 80 (14.28%) cases respectively. Conclusions: Duration of constipation was correlated with duration of enuresis. The rate of enuresis in constipated boys was significantly higher than in constipated females. We strongly recommend careful inspection of both conditions in each patient who presents with one of them.

No one knows for sure what causes nighttime wetting, also called nocturnal enuresis, but bedwetting is usually a natural part of development, and most children grow out of it. However, enuresis not being able to control peeing in the daytime or nighttime can be a sign of another medical condition, especially if it begins abruptly or is accompanied by other symptoms. Then it may be time for your child to be seen by Nemours pediatric urologists who specialize in treating urologic problems in children.

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