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Primary care management and referral guideline Primary care management and referral guideline

Enuresis in Children – Management and referral guideline

Red flags

  • Systemic illness
  • Polyuria or polydypsia
  • Poor urinary stream in male patient
  • New onset daytime urinary incontinence in a previously dry patient
  • Child abuse or neglect

Purpose

Primary care management and referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.

Introduction

Enuresis, or bedwetting, is the involuntary loss of urine during sleep in a child aged ≥ 5 years. It is multifactorial and may result from deranged central nervous system mechanisms, altered circadian rhythm, or bladder dysfunction.

Enuresis:

  • is common, affecting about 10% of children aged > 7 years.
  • can cause significant distress to the child and their parents. Early intervention is essential to improve the child’s quality of life and reduce the chance of enuresis persisting into adulthood.
  • may coexist with involuntary loss of urine while the child is awake – daytime incontinence or daytime wetting. This generally indicates a daytime lower urinary tract (LUT) condition, e.g. bladder and bowel dysfunction, over or underactive bladder, dysfunctional voiding.

The International Children’s Continence Society standardisation recommends classifying enuresis into:

  • Non-monosymptomatic enuresis or enuresis with other lower urinary tract symptoms (LUTS), e.g. frequency, daytime incontinence, urgency, genital or lower urinary tract pain.
  • Monosymptomatic enuresis or enuresis without other LUTS:
    • Primary enuresis (most common), or enuresis in a child who has never been consistently dry. Underlying organic causes are uncommon.
    • Secondary enuresis or enuresis in a child who has been consistently dry for > 6 months.

Patients with non-monosymptomatic enuresis or secondary monosymptomatic enuresis are more likely to have an underlying disorder than those with primary monosymptomatic enuresis.

Assessment

Take an age appropriate history – ask about:

  • enuresis features.

    Enuresis features

    • Amount and frequency of wetting.
    • Whether onset was:
      • primary (never sustained dryness), or
      • secondary (previously dry > 6 months).
    • If secondary, check for underlying causes e.g., medical (UTI, diabetes) or emotional (parents’ divorce, change of school, abuse).
  • symptoms of bladder dysfunction or other urological disorder.

    Symptoms of bladder dysfunction or other urological disorder

    • Daytime incontinence.
    • Leakage (drops of urine in underpants) – may be:
      • before or after voiding.
      • intermittent or continuous.
    • Voiding pattern:
      • Poor stream or interrupted flow.
      • Hesitation.
      • Urinary frequency – abnormal frequency if < 4 or > 7 times a day.
      • Urinary urgency (highly suggestive of overactive bladder).
      • Holding manoeuvres.
      • Straining to urinate.
  • history of UTIs, renal disorders, or spinal cord problems.
  • family history of enuresis (common) or renal problems.
  • other factors which may impact treatment.

    Other factors

    • Constipation, e.g. 3 or fewer bowel motions per week, soiling:
      • May sometimes be the underlying cause of enuresis.
      • Consider Rome IV criteria for functional constipation – 2 or more criteria must be present for at least 1 month:
        • ≤ 2 bowel motions per week.
        • Withholding or incomplete evacuation.
        • Painful or hard bowel movements.
        • Large-diameter stools.
        • Large faecal mass in the rectum.
    • Developmental delay.
    • Psychological or behavioural problems.
    • Sleeping arrangements.
    • Parental attitudes towards the child.
    • Emotional impact of enuresis in the child.
  • fluid intake.

    Fluid intake

    • Check daytime, evening, and night drinks.
    • Check for type and quantity of fluids, e.g. caffeinated drinks.
    • If polydipsia, consider diabetes or psychogenic causes.

Consider the use of a voiding diary (available in smartphone apps, e.g. Drydawn) to further assess bladder capacity and ascertain if nocturnal polyuria is present.

Perform an age appropriate examination:

  • Record height and weight and plot in an appropriate growth chart – available in most general practice software.
  • Perform a genital examination. Follow recommended protocol and consider a chaperone.

    Genital examination

    • Check for anomalies of external genitalia, e.g. phimosis, labial adhesions, hypo or epispadia.
    • Check underwear for urinary leakage, or soiling.
    • Rectal palpation for faecal rectal mass in primary care is not recommended.

    Recommended protocol

    • Only perform a genital examination if there is a specific and clear clinical indication.
    • Always seek voluntary consent from the parent or guardian, and the child or young person.
      • Explain the purpose of the examination and only proceed if the child or young person consents. Do not proceed if the child refuses to cooperate.
      • Consider capacity to consent of patients who are physically, mentally, or intellectually impaired, and those of culturally or linguistically diverse background (amongst others).
    • Always consider:
      • the presence of a chaperone in the room. Adolescents are entitled to decline this, and the doctor may decline conducting the examination if a chaperone is declined by the patient.
      • needs of infants and younger children – allow the parent or guardian to remain close to the child or hold the child on their lap during the examination.
      • needs of older children and adolescents – allow them to undress or dress in private and wear a gown for the examination.
      • the patient’s specific needs, e.g. if disabled or of culturally or linguistically diverse background.
    • If relevant, discuss and explain limits of confidentiality with adolescents.
  • Examine:
    • abdomen – check for palpable masses, organomegaly (e.g., renal, faecal loading, distended bladder), or tenderness.
    • spine – check for signs of dysraphism or other anomalies.
  • Check lower limb neurology including gait, posture, reflexes, and muscle tone, e.g. spinal cord dysfunction.

Consider differential diagnoses.

Differential diagnoses

  • Chronic constipation with reduced functional bladder volume or instability (very common).
  • Urinary tract infection (UTI) or acute illness affecting ability to maintain continence.
  • Inadequate fluid intake.
  • Infrequent voiding pattern – dysfunctional voiding.
  • Conditions causing polyuria (renal failure, diabetes insipidus or mellitus, renal tumours).
  • Bladder overactivity – highly suggested if urinary urgency.
  • Congenital abnormality of urinary tract (rare).
  • Neurological disorder e.g., spina bifida (rare).
  • Psychosocial stressors – consider in children with secondary enuresis.

Investigations:

  • Avoid routine investigations in primary monosymptomatic enuresis.
    Monosymptomatic enuresis
    Enuresis without other lower urinary tract symptoms (LUTS).

    • Primary enuresis (most common), or enuresis in a child who has never been consistently dry. Underlying organic causes are uncommon.
    • Secondary enuresis or enuresis in a child who has been consistently dry for > 6 months.
  • If non-monosymptomatic enuresis or new onset incontinence in a previously dry child, especially if daytime.
    Non-monosymptomatic enuresis
    Enuresis with other lower urinary tract symptoms including daytime incontinence.

    • check urine dipstick and arrange urine microscopy, culture, and sensitivities for UTI, and specific gravity, e.g. for diabetes insipidus.
    • check BGL (glucometer).
    • consider arranging renal tract ultrasound (pre and post void volumes) while waiting for specialist assessment.

Management

If suspected child neglect or abuse, ensure the child’s safety.

Ensure the child’s safety

  • Contact child safety services immediately and manage according to their advice.
  • If signs of physical abuse (inflicted injury), or child at imminent risk of harm, consider transfer by ambulance to your nearest ED.
  • Clearly document the event.

Discuss immediately with your local paediatric team and manage accordingly if any of:

  • Systemic illness.
  • Polyuria or polydypsia.
  • Poor urinary stream in male patient.
  • New‑onset daytime urinary incontinence in a previously dry patient.

If structural anomaly identified on renal tract ultrasound, refer for paediatric surgery (urology) assessment (mark referral as urgent).

Always treat UTI or constipation if present:

  • Actively seek and treat constipation in all patients with enuresis. Constipation may be the sole cause of enuresis, which will settle once constipation is treated.
  • If recurrent UTI, see Urinary Tract Infection (UTI) in Children.

Manage by type of enuresis:

  • Non-monosymptomatic enuresis and UTI and constipation ruled out or treated:
    Non-monosymptomatic enuresis
    Enuresis with other lower urinary tract symptoms including daytime incontinence.

    • Identify and address the cause of daytime symptoms – this will be needed before bedwetting can be addressed. Consider the possibility of bladder dysfunction, e.g. overactive bladder, dysfunctional voiding.
    • Offer education to parents, reassurance to the child, and trial general measures as with primary monosymptomatic enuresis.

      Parent education

      • Advise the parent:
        • that bedwetting is a relatively common problem that can be solved in most patients.
        • not to blame their child as bedwetting is not their fault.
        • to be supportive of their child and reward effort and not result.
        • that strategies like waking up or punishing the child do not help.
      • Give written information: Children’s Health Queensland Hospital and Health Service – Bedwetting (nocturnal enuresis) Fact sheet.
      Reassurance to the child

      • Reassure the child that:
        • bedwetting is not their fault.
        • bedwetting is common and some of their peers are likely to have similar problems.
        • the problem can usually be solved.
        • it is OK to talk to their parents or doctor about the problem.

      General measures

      • Fluids:
        • Drinking more fluids during the daytime – daytime fluid restriction is not indicated in patients with enuresis.
        • Limiting drinking during the last two hours before bedtime.
        • Not drinking at night.
        • Avoiding caffeinated drinks, e.g. coffee, chocolate, tea, fizzy drinks.
      • Toileting:
        • Having regular toilet breaks during the day and peeing before bedtime.
        • Ensuring easy access to toilet at night, e.g. night light, potty.
        • Ensuring regular bowel movements.
      • Protection:
        • Using diapers or pullups – these can give more comfort to the child and decrease worry of wetting the bed.
        • Using waterproof mattress covers, or absorbent sheets to minimise effect.
      • Reinforcement:
        • Using star charts and reward systems can be effective in some children.
        • Reinforcing dry nights and reducing negative emphasis on wet beds.
    • Consider early referral to your local General Paediatrics service for specialised care.
      Specialised care
      Patients with non-monosymptomatic enuresis are more likely to have underlying organic pathology. The assessment and management of patients with possible bladder dysfunction is complex. Selected patients may benefit from:

      • bladder retraining strategies (outside the scope of this guideline).
      • the use of anticholinergic medications e.g., oxybutynin (specialist use only).
  • Monosymptomatic enuresis – manage according to subtype:
    Monosymptomatic enuresis
    Enuresis without other lower urinary tract symptoms (LUTS).

    • Primary enuresis (most common), or enuresis in a child who has never been consistently dry. Underlying organic causes are uncommon.
    • Secondary enuresis or enuresis in a child who has been consistently dry for > 6 months.
    • Secondary enuresis.

      Secondary enuresis

      1. Rule out or manage underlying pathology, e.g. diabetes, UTI, constipation.
      2. Address any psychosocial stressors.
      3. Consider early referral if UTI and constipation have been ruled out or treated and enuresis persists.
      4. Offer general management as for primary enuresis.
    • Primary enuresis.

      Management for primary enuresis

      1. Offer education and reassurance:
        • Education to parent
          Parent education
          Advise the parent:

          1. that bedwetting is a relatively common problem that can be solved in most patients.
          2. not to blame their child as bedwetting is not their fault.
          3. to be supportive of their child and reward effort and not result.
          4. that strategies like waking up or punishing the child do not help.
        • Reassurance to the child
          Reassurance to the child
          Reassure the child that:

          1. bedwetting is not their fault.
          2. bedwetting is common and some of their peers are likely to have similar problems.
          3. the problem can usually be solved.
          4. it is OK to talk to their parents or doctor about the problem.
      2. Advise general measures to improve symptoms and reduce stress to the child.

        General measures

        • Fluids:
          1. Drinking more fluids during the daytime – daytime fluid restriction is not indicated in patients with enuresis.
          2. Limiting drinking during the last two hours before bedtime.
          3. Not drinking at night.
          4. Avoiding caffeinated drinks, e.g. coffee, chocolate, tea, fizzy drinks.
        • Toileting:
          1. Having regular toilet breaks during the day and peeing before bedtime.
          2. Ensuring easy access to toilet at night, e.g. night light, potty.
          3. Ensuring regular bowel movements.
        • Protection:
          1. Using diapers or pullups – these can give more comfort to the child and decrease worry of wetting the bed.
          2. Using waterproof mattress covers, or absorbent sheets to minimise effect.
        • Reinforcement:
          1. Using star charts and reward systems can be effective in some children.
          2. Reinforcing dry nights and reducing negative emphasis on wet beds.
      3. Discuss treatment options:
        • Expectant management
          Expectant management
          Offer general advice, review in 6 to 12 months and consider active treatment or referral if not improving.

          1. Most children with monosymptomatic enuresis will achieve dryness over time.
          2. A wait and see approach may be appropriate in younger children or when parents or child are not prepared to trial other measures.
        • Bedwetting alarms

          Enuresis alarm programs

          1. The treatment of choice for motivated children aged > 6 years.
          2. High success rate with low risk of relapse. The success rate is better if behavioural management strategies are in place, e.g. reward systems.
          3. May be used in children with mild to moderate intellectual impairment and in the hearing impaired (vibrating alarms).
          4. Parents will need to respond to the alarm, as well as the child. Consider parent’s emotional response to the child and whether able to cope with the added burden of sleep disruption.
          5. Duration of treatment – may take 6 to 8 weeks to work.
            1. If no response noted after 4 weeks, consider stopping, review diagnosis, and consider retrial at a later date.
            2. If child improving, continue until at least 2 consecutive dry weeks achieved.
            3. If only partial response at 3 weeks, review diagnosis and consider referring to your local General Paediatrics service.
          6. Relapse responds readily to repeat program.
          7. Alarms are available for hire or purchase online or from pharmacies.
            Bedwetting alarm stockists
            This is not an exhaustive list.

            1. WetAlert
            2. Bedwetting Institute
            3. Bedwetting Alarms
        • Pharmacological therapy

          Pharmacological therapy

          1. Desmopressin is the medication of choice. If planning long term use, consider referring to your local General Paediatrics service.

            Desmopressin

            1. Products – Minirin Melt wafer or Minirin tablet.
            2. Indicated if:
              1. An alarm program has been trialled and failed or considered inappropriate due to child or family circumstances, or
              2. Rapid onset or short-term improvement is a priority of treatment, e.g. sleep over at friend’s house, school camp.
            3. High response rate but not sustained on withdrawal.
            4. Action – reduces overnight urine production and also has some unspecified central effect, possibly on the arousal system.
            5. Available on the PBS as a streamlined authority for primary nocturnal enuresis in patients aged > 6 years for whom alarms are ineffective or contraindicated.
            6. Can be trialled for short-term use on nights away from home – a 1 to 2‑week trial period at home is suggested to determine if response is adequate.
            7. There are safety concerns regarding water intoxication which may lead to hyponatraemia, cerebral oedema, convulsions, and even death. Minimise risk by:
              1. using lowest effective dose and restricting fluid from 1 hour prior to 8 hours after dose.
              2. not using in children who cannot control fluid restriction.
              3. avoiding intra-nasal preparations.

            Discreet use of pull-ups may prove a safer and more effective alternative.

          2. Oxybutynin is sometimes used by specialists in the treatment of patients with overactive bladder.
          3. Tricyclics are no longer recommended for the treatment of monosymptomatic enuresis.

If child not responding to an adequate trial of the above measures (at least 3 months), consider referring to your local General Paediatrics service.

If any other concerns, discuss with your local paediatric team.

When to refer

  • If suspected child neglect or abuse:
    • contact child safety services immediately.
    • and signs of physical abuse (inflicted injury), or child at imminent risk of harm, consider transfer by ambulance to your nearest ED.
  • Discuss immediately with your local paediatric team if any of:
    • Systemic illness.
    • Polyuria or polydypsia.
    • Poor urinary stream in male patient.
    • New‑onset daytime urinary incontinence in a previously dry patient.
  • If structural anomaly identified on renal tract ultrasound, refer for paediatric surgery (urology) assessment (mark referral as urgent).
  • Refer to your local General Paediatrics service if:
    • non-monosymptomatic enuresis.
    • monosymptomatic enuresis not responding to medical management (e.g., alarm, desmopressin).
    • only partial response to alarm program at 3 weeks.
    • planning long-term use of desmopressin.
  • If any other concerns, discuss with your local paediatric team.

Referring to your local Paediatric services

Public

Check the patient’s catchment area before requesting assessment. When services are available in the patient’s local area, refer the patient to the local hospital.

Queensland Children’s Hospital

1. Referral can be made by either:

  • GP Smart Referral via BP or Medical Director.
  • Secure messaging.
    Secure messaging
    Send a written request to the Referral Centre via eReferral
    (Medical Objects ID: RQ402900084, HealthLink ID: qldrchld):

    • To download templates, see Referral Forms.
    • If unable to attach investigations or use secure messaging, fax to 1300 407 281.

    For more information, contact the Referral Centre:
    P.O. Box 3474, South Brisbane QLD 4101
    Phone 1300 762 831
    Fax 1300 407 281

2. Check the minimum referral criteria and insert the required information into referral.

Private

Search for a provider via the National Health Services Directory.

Guideline approval and disclaimer

Guideline approval history
Version no. 1.0 Approval date 1/06/2018 Review date 1/06/2021

Disclaimer

The information contained in this GP referral and management guideline is intended for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect.
This guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from this guideline, taking into account individual circumstances may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for the following:
  • ●  Providing care within the context of locally available resources, expertise, and scope of practice.
  • ●  Supporting consumer rights and informed decision making in partnership with healthcare practitioners including the right to decline intervention or ongoing management.
  • ●  Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary.
  • ●  Ensuring informed consent is obtained prior to delivering care.
  • ●  Meeting all legislative requirements and professional standards.
  • ●  Applying standard precautions, and additional precautions as necessary, when delivering care.
  • ●  Documenting all care in accordance with mandatory and local requirements.
Children’s Health Queensland disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable.

Resources

For health professionals

For families

Contact details

Hospital Switchboard
(Ask for the General Paediatric Registrar)
t: 07 3068 1111

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