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Primary nocturnal enuresis

Scenario

Technician Vicky finds Sarah Bishop by the incontinence fixture. “Everything OK, Sarah?” asks Vicky.

“I don’t know really,” replies Sarah. “It’s Leo, he’s still not dry at night, and I’m not really sure what to do.”

“How old is he now?” enquires Vicky. “And have you tried anything already?”

“Leo’s six now, and he’s always been great during the day, it’s just nights that are hit and miss. I’ve tried waking him up to go to the toilet when I go up to bed and giving him less to drink, but nothing seems to work reliably.”

“What does he make of it?”

“Well, I don’t want to make a big thing of it, so we have just quietly continued with the pull-ups at night, and those mattress protector things, but they don’t always hold it all and the constant laundry is starting to get me down,” Sarah answers. “From Leo’s point of view, birthday parties are starting to become sleepovers and while he doesn’t want to miss out, he’s also worried that he’ll wet himself and his friends will see. Any idea what I can do?”

Answer

Leo may have primary nocturnal enuresis without any daytime symptoms – if the latter was not the case, or if he was experiencing bedwetting after several months of being dry at night, he would need referring to the GP – so there are a few things Sarah can try. The first is to ensure her son is not constipated, as this can cause of urinary incontinence in younger children, and to make sure he is drinking plenty of fluids, as inadequate intake can mask issues such as overactive bladder disorder, and hinder the development of the bladder’s capacity.

Assuming all is well with Leo’s bowels and hydration levels, a sensible next step is to keep a diary of fluid intake, bedwetting and toileting patterns for a couple of weeks. If the issue is twice a week or less, Vicky can reassure Sarah that a wait and see approach is best. If it is more often than this, Sarah may want to consider using an enuresis alarm in combination with a reward system such as a star chart for helping with changing sheets, drinking enough fluid during the day and using the toilet before going to bed. Desmopressin is an option if there is a need for quick or short-term control, for example, because of a school trip, or if an alarm isn’t suitable, for example because Leo shares a bedroom. Waking the child at night isn’t considered a useful strategy long term.

The bigger picture

Bedwetting is generally considered normal in children under the age of five years. In children older than this who are dry during the day, it is thought to be due to an inability to wake up in response to a full bladder; a larger than normal production of urine at night which exceeds the capacity of the bladder; a smaller than usual bladder capacity; or an overactive bladder. The prevalence is unknown, but it is thought to affect up to a fifth of children aged five years, around five per cent of 10 year olds, and around half as many teenagers.

There is a strong genetic link; the child of a parent who became dry later than their peers is likely to follow the same pattern. Other risk factors include obesity, developmental delay, incontinence (faecal or urinary), constipation, toilet training later than usual, gender (boys are more likely than girls to be bedwetters), sleep apnoea, and psychological or behavioural disorders such as autism and ADHD.

The impact can run deep, with the child feeling guilty, ashamed, helpless and humiliated, and avoiding social activities. Parents may struggle not only with the additional work involved in looking after a child who wets the bed, but sometimes with the financial strain incurred from buying night-time continence and mattress pads, extra bed linen and laundry products.

Extend your learning

  • Bedwetting alarms aren’t available on the NHS, but some GP surgeries and clinics loan them out. Find out if this is the case near your pharmacy
  • A resource parents may find useful is Eric, the children’s bowel and bladder charity
  • Bedwetting can be a sign of child abuse. Find out more here.

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