WE ARE PLEASED TO BE ABLE TO BRING YOU THESE 2 VIDEOS, WHICH YOU CAN SHARE WITH YOUR PATIENTS AND THEIR PARENTS. WE KNOW THAT PARENTS AND CHILDREN ALIKE WILL FIND THEM VERY HELPFUL AND REASSURING.
The first film expresses the very personal view of 2 mums whose children have experienced bedwetting. They share their views and experiences of the aspects that have been challenging for both them and their children, and how they have approached them.
The second, very emotive, animated film is set to the voices of 2 children who talk about their first-hand experience of bedwetting - sharing both their concerns and their hopes.
Joshua, 5 years & 3 months
MEDICAL HISTORY: Joshua presented 6 months ago. Bedwetting has persisted every night since toilet training. He has been advised to limit evening drinks, wake to take to the toilet prior to his mother going to bed, and to keep a diary of wetting.
- They have returned as Joshua continues to wet every night despite following advice.
- No day-time incontinence
- Physical examination was normal, no UTI
- His mother is concerned about the ongoing wetting in view of his age
- Joshua sleeps soundly, is hard to wake in the morning after 11-12 hours sleep
- His mother is 28 weeks pregnant with her fourth child and is anxious for resolutions
- Explanations of causes of night time wetting, based on the three systems model. Ensure Joshua and his mum are aware the bedwetting is outside his control and therefore not his fault.1
- Exclude constipation.2-5
- Confirm there are no daytime symptoms of urgency, frequency or wetting using a two day frequency volume chart. Ensure voided volumes are as expected for age: (Age in years + 1) x 30 to give expected voided volume for age in mls.4-7
- Be aware that Joshua falls into the group for whom bedwetting is less likely to resolve spontaneously, due to the frequency of wet nights8 and that he should not be excluded from treatment on the basis of age alone.5
- Provide information about correct day-time drinking and bladder training if appropriate5. Monitor progress with this.
- Consider use of desmopressin, if acceptable to Joshua and his family, as he is unlikely to be mature enough to manage an alarm and this is unlikely to be an acceptable option for his mum – DesmoMelt® are likely to be the most appropriate due to Joshua’s age.5,6
- Ensure that the family are given appropriate advice about the use of desmopressin 5,6(refer to manufacturer information and to NICE guidance on Enuresis.5
- Monitor progress every 3 months by means of a period of at least 1 week without desmopressin.5,
- If treatment has produced a successful response (14 consecutive dry nights) consider withdrawing it – structured withdrawal may be helpful.5,6
- Continue to offer evaluation of treatment, reassess and adjust treatment until Joshua is dry, or for as long as he and his family wish to engage.5
Sophie, 8 years
MEDICAL HISTORY: Sophie first presented with bedwetting over a year ago and was advised to limit night time drinks and that she would grow out of it. No follow up consultation was arranged. She has presented to the GP practice 5 times over the last eighteen months with a variety of mild complaints including abdominal pain and constipation.
- Initial complaint of intermittent abdominal pain
- Sophie’s mother is concerned that Sophie still wets the bed – Sophie described this as ‘occasionally’ and they were vague about details (frequency and amount).
- Sophie’s mother has restricted drinks before bed and Sophie says she does not drink much during the day.
- Sophie seems withdrawn and unhappy. Her mother appears to be intolerant of daytime time wetting and the faecal stains on her underwear. Therefore, the alarm may be unsuitable.
- Explain the causes of night time wetting, based on the three systems model. Ensure Sophie and her mum are aware bedwetting is outside her control and therefore not her fault.1
- Assess for constipation, using two weeks of bowel records, and for bladder overactivity using a two day frequency volume chart.
- Explain that daytime wetting and soiling are also outside Sophie’s control.
- Treat constipation first, or refer to appropriate professional for treatment and monitor progress.2-5,9
- Assess for bladder overactivity with a two – three day frequency volume chart and treat with bladder training and possibly with anticholinergic medication – monitor response.4-7
- Start monitoring the frequency of night time wetting – use of diary or progress chart.
- When constipation is well controlled and bladder overactivity is being addressed, try an alarm or desmopressin for the night time wetting, dependent on Sophie and her family’s preference. N.B. alarms should not be used for infrequent wetting (less than one to two nights a week). Monitor regularly and reassess as required.3-6
- Offer desmopressin if Sophie’s mother would prefer this to an alarm.
- Ensure that Sophie is getting appropriate emotional support, and consider referral to an appropriate service, if there are ongoing concerns about mood or behaviour.
Leo, 9 years
MEDICAL HISTORY:Bedwetting has previously been mentioned by parents in previous consultations, but has never been the main presenting problem, and so has not been addressed. Leo has previously used pull ups to contain the wetting.
- Leo is very wet most nights.
- Leo is now too large for pull ups and is getting skin rashes. His parents are angry about the cost of the washing and new mattresses. They have applied for Disability Living Allowance.
- Leo has been told by parents that he cannot go on school residential trips or stay with his grandmother or aunt until he is dry at night. Possible parental intolerance is a concern.
- There are no daytime symptoms. Physical exam and urine normal.
- Offer explanations of causes of night time wetting, based on the three systems model. Ensure Leo and his parents are aware that bedwetting is outside his control and therefore not his fault.1
- Suggest practical measures to reduce the impact of wetting (bedding protection).5
- Exclude constipation.2-5
- Assess fluid intake during the day and bladder function, using a two day frequency volume chart.4-7
- Discuss treatment options and desmopressin as first line treatment. Offer regular reassessment and frequent monitoring and support. Do not offer an alarm as treatment if any concern about parental intolerance remains.3-6,10
- If the concerns of parental intolerance are unfounded or the home situation changes, then an alarm may be considered if acceptable to Leo and his family.3-6
- If there is no response to treatment consider offering anticholinergic medication in addition to desmopressin.3-5
- Consider Leo’s wellbeing and whether there are any safeguarding concerns. 5 If so act in accordance with local safeguarding policies and procedures.
Jenny, 14 years
MEDICAL HISTORY: Jenny has Down’s syndrome. She became reliably clean and dry during the day at 5 years old. Mum is requesting nappies or pull ups be provided to contain night time wetting, as she is now too large for products that mum can buy and they are expensive.
- Jenny is normally very wet 4-5 nights a week, with pull ups often leaking.
- Her mother is not keen on or expecting treatment, as she has been told Jenny will be dry when she is developmentally ready and is expecting you to provide pull ups for night times.
- Jenny does not drink much during the day, but usually has coke when she gets in from school and likes hot chocolate before bed.
- There are no daytime symptoms.
- Jenny is fit and well, but has poor fine motor skills. She tells you that she would like to give up wearing pull ups for bed.
- Ensure that Jenny and her mum understand that night time wetting is a treatable condition by offering explanations of the causes of night time wetting, based on the three systems model.1
- Exclude constipation..2-5
- Assess daytime fluid intake and bladder function using a two day frequency volume chart..4-7
- Offer fluid advice. Stress minimal consumption of carbonated or caffeinated drinks.5
- Offer an alarm or desmopressin as first line treatment.
- Avoid alarms if Jenny is concerned about sudden unexpected noises, as this is not a viable option for children who struggle to resettle after being awoken, or are frightened by sudden loud noises.5,11
- It may be suitable to trial with an alarm clock and assess her response. Set the alarm to wake Jenny at a set time, allow her to void and return to sleep. 5,11
- Reassess regularly and adjust treatment according to response.5