Issue date: October 2010
NICE clinical guideline 111
Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
NICE clinical guideline 111
Nocturnal enuresis: the management of bedwetting in children and
young people
Ordering information
You can download the following documents from
www.nice.org.uk/guidance/CG111
• The NICE guideline (this document) – all the recommendations.
• A quick reference guide – a summary of the recommendations for
healthcare professionals.
• ‘Understanding NICE guidance’ – a summary for patients and carers.
• The full guideline – all the recommendations, details of how they were
developed, and reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE
guidance’, phone NICE publications on 0845 003 7783 or email
publications@nice.org.uk and quote:
• N2318 (quick reference guide)
• N2319 (‘Understanding NICE guidance’).
NICE clinical guidelines are recommendations about the treatment and care of
people with specific diseases and conditions in the NHS in England and
Wales.
This guidance represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Healthcare professionals are
expected to take it fully into account when exercising their clinical judgement.
However, the guidance does not override the individual responsibility of
healthcare professionals to make decisions appropriate to the circumstances
of the individual patient, in consultation with the patient and/or guardian or
carer, and informed by the summary of product characteristics of any drugs
they are considering.
Implementation of this guidance is the responsibility of local commissioners
and/or providers. Commissioners and providers are reminded that it is their
responsibility to implement the guidance, in their local context, in light of their
duties to avoid unlawful discrimination and to have regard to promoting
equality of opportunity. Nothing in this guidance should be interpreted in a way
that would be inconsistent with compliance with those duties.
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Contents
Introduction ...................................................................................................... 5
Patient-centred care ......................................................................................... 7
Key priorities for implementation ...................................................................... 9
1 Guidance ................................................................................................. 11
1.1 Principles of care .............................................................................. 12
1.2 Information for the child or young person and family ........................ 12
1.3 Assessment and investigation .......................................................... 12
1.4 Planning management ...................................................................... 18
1.5 Advice on fluid intake, diet and toileting patterns .............................. 18
1.6 Lifting and waking ............................................................................. 20
1.7 Reward systems ............................................................................... 20
1.8 Initial treatment – alarms ................................................................... 21
1.9 Lack of response to alarm treatment................................................. 24
1.10 Initial treatment – desmopressin .................................................... 25
1.11 Children and young people experiencing recurrence of bedwetting
27
1.12 Lack of response to initial treatment options.................................. 27
1.13 Anticholinergics ............................................................................. 28
1.14 Tricyclics ....................................................................................... 29
1.15 Training programmes for the management of bedwetting ............. 30
1.16 Children under 5 years with bedwetting ......................................... 31
2 Notes on the scope of the guidance ........................................................ 33
3 Implementation ........................................................................................ 33
4 Research recommendations .................................................................... 33
4.1 Multicomponent treatments ............................................................... 34
4.2 Standard interventions ...................................................................... 35
4.3 Psychological functioning and quality of life ...................................... 35
4.4 Complementary therapies ................................................................. 36
4.5 Bedwetting in adolescents ................................................................ 37
5 Other versions of this guideline ............................................................... 38
6 Related NICE guidance ........................................................................... 39
7 Updating the guideline ............................................................................. 39
Appendix A: Guideline Development Group, National Clinical Guideline Centre
and NICE project team ................................................................................... 40
Appendix B: The Guideline Review Panel ..................................................... 42
Appendix C: The algorithms ........................................................................... 43
NHS Evidence has accredited the process used by the Centre for Clinical Practice at
NICE to produce guidelines. Accreditation is valid for 3 years from April 2010 and is
applicable to guidance produced using the processes described in NICE’s ‘The
guidelines manual’ (2009). More information on accreditation can be viewed at
www.evidence.nhs.uk
NICE clinical guideline 111 – Nocturnal enuresis 5
Introduction
Bedwetting is a widespread and distressing condition that can have a deep
impact on a child or young person’s behaviour, emotional wellbeing and social
life. It is also very stressful for the parents or carers. The prevalence of
bedwetting decreases with age. Bedwetting less than 2 nights a week has a
prevalence of 21% at about 4 and a half years and 8% at 9 and a half years.
More frequent bedwetting is less common and has a prevalence of 8% at 4
and a half years and 1.5% at 9 and a half years1
The causes of bedwetting are not fully understood. Bedwetting can be
considered to be a symptom that may result from a combination of different
predisposing factors. There are a number of different disturbances of
physiology that may be associated with bedwetting. These disturbances may
be categorised as sleep arousal difficulties, polyuria and bladder dysfunction.
Bedwetting also often runs in families.
.
Experts and expert bodies differ in their definitions of ‘nocturnal enuresis’ (see
the full guideline for a discussion). The term ‘bedwetting’ is used in this
guideline to describe the symptom of involuntary wetting during sleep without
any inherent suggestion of frequency of bedwetting or pathophysiology.
This guideline makes recommendations on the assessment and management
of bedwetting in children and young people. The guidance applies to children
and young people up to 19 years with the symptom of bedwetting. Children
are generally expected to be dry by a developmental age of 5 years, and
historically it has been common practice to consider children for treatment
only when they reach 7 years. The guideline scope did not specify a minimum
age limit to allow consideration of whether there are interventions of benefit to
younger children previously excluded from advice and services due to their
age. We have included specific advice for children under 5 years, and
indicated treatment options for children between 5 and 7 years.
1
Butler RJ, Heron J (2008) The prevalence of infrequent bedwetting and nocturnal enuresis
in childhood: A large British cohort. Scandinavian Journal of Urology and Nephrology 42:
257–64
NICE clinical guideline 111 – Nocturnal enuresis 6
Children and young people with bedwetting may also have symptoms related
to the urinary tract during the day. A history of daytime urinary symptoms may
be important in determining the approach to management of bedwetting and
so the assessment sections include questions about daytime urinary
symptoms and how the answers to these may influence the approach to
managing bedwetting. However, the management of daytime urinary
symptoms is outside the scope of this guideline.
The treatment of bedwetting has a positive effect on the self-esteem of
children and young people. Healthcare professionals should persist in offering
different treatments and treatment combinations if the first-choice treatment is
not successful. Children and young people with bedwetting are cared for by a
number of different healthcare professionals in a variety of settings. All
healthcare professionals should be aware of and work within legal and
professional codes and competency frameworks.
The guideline will assume that prescribers will use a drug’s summary of
product characteristics to inform decisions made with individual patients.
NICE clinical guideline 111 – Nocturnal enuresis 7
Patient-centred care
This guideline offers best practice advice on the care of children and young
people with bedwetting.
Treatment and care should take into account patients’ needs and preferences.
Children and young people with bedwetting and their parents and/or carers
should have the opportunity to make informed decisions about their care and
treatment, in partnership with their healthcare professionals. If a child or
young person is not old enough or does not have the capacity to make
decisions, healthcare professionals should follow the Department of Health's
advice on consent (available from www.dh.gov.uk/consent) and the code of
practice that accompanies the Mental Capacity Act (summary available from
www.publicguardian.gov.uk). In Wales, healthcare professionals should follow
advice on consent from the Welsh Assembly Government (available from
www.wales.nhs.uk/consent).
If the patient is under 16, healthcare professionals should follow the guidelines
in ‘Seeking consent: working with children’ (available from
www.dh.gov.uk/consent).
Good communication between healthcare professionals and patients is
essential. It should be supported by evidence-based written information
tailored to the patient’s needs. Treatment and care, and the information
patients are given about it, should be culturally appropriate. It should also be
accessible to people with additional needs such as physical, sensory or
learning disabilities, and to people who do not speak or read English.
Families and carers should have the opportunity to be involved in decisions
about treatment and care. Where appropriate, for example for older children,
this should be with the child’s agreement.
Families and carers should also be given the information and support they
need.
NICE clinical guideline 111 – Nocturnal enuresis 8
Care of young people in transition between paediatric and adult services
should be planned and managed according to the best practice guidance
described in ‘Transition: getting it right for young people’ (available from
www.dh.gov.uk).
Adult and paediatric healthcare teams should work jointly to provide
assessment and services to young people with bedwetting. Diagnosis and
management should be reviewed throughout the transition process, and there
should be clarity about who is the lead clinician to ensure continuity of care.
NICE clinical guideline 111 – Nocturnal enuresis 9
Key priorities for implementation
• Inform children and young people with bedwetting and their parents or
carers that bedwetting is not the child or young person's fault and that
punitive measures should not be used in the management of bedwetting.
• Offer support, assessment and treatment tailored to the circumstances and
needs of the child or young person and parents or carers.
• Do not exclude younger children (for example, those under 7 years) from
the management of bedwetting on the basis of age alone.
• Discuss with the parents or carers whether they need support, particularly if
they are having difficulty coping with the burden of bedwetting, or if they are
expressing anger, negativity or blame towards the child or young person.
• Consider whether or not it is appropriate to offer alarm or drug treatment,
depending on the age of the child or young person, the frequency of
bedwetting and the motivation and needs of the child or young person and
their family.
• Address excessive or insufficient fluid intake or abnormal toileting patterns
before starting other treatment for bedwetting in children and young people.
• Explain that reward systems with positive rewards for agreed behaviour
rather than dry nights should be used either alone or in conjunction with
other treatments for bedwetting. For example, rewards may be given for:
− drinking recommended levels of fluid during the day
− using the toilet to pass urine before sleep
− engaging in management (for example, taking medication or helping to
change sheets).
NICE clinical guideline 111 – Nocturnal enuresis 10
• Offer an alarm as the first-line treatment to children and young people
whose bedwetting has not responded to advice on fluids, toileting or an
appropriate reward system, unless:
− an alarm is considered undesirable to the child or young person or their
parents and carers or
− an alarm is considered inappropriate, particularly if:
◊ bedwetting is very infrequent (that is, less than 1–2 wet beds per
week)
◊ the parents or carers are having emotional difficulty coping with the
burden of bedwetting
◊ the parents or carers are expressing anger, negativity or blame
towards the child or young person.
• Offer desmopressin to children and young people over 7 years, if:
− rapid-onset and/or short-term improvement in bedwetting is the priority of
treatment or
− an alarm is inappropriate or undesirable (see recommendation 1.8.1).
• Refer children and young people with bedwetting that has not responded to
courses of treatment with an alarm and/or desmopressin for further review
and assessment of factors that may be associated with a poor response,
such as an overactive bladder, an underlying disease or social and
emotional factors.
NICE clinical guideline 111 – Nocturnal enuresis 11
1 Guidance
The following guidance is based on the best available evidence. The full
guideline (www.nice.org.uk/guidance/CG111) gives details of the methods
and the evidence used to develop the guidance.
These recommendations apply to all healthcare professionals who are
involved in the management of bedwetting in children and young people.
Healthcare professionals are reminded of their duty under the Disability
Discrimination Act (2005) to make reasonable adjustments to ensure that all
people have the same opportunity for health.
For the purposes of this guideline we have used the terms 'bedwetting' and
'daytime symptoms' to describe those symptoms that may be experienced by
the population who present for treatment of 'bedwetting'.
The following definitions were used for this guideline:
• Bedwetting: involuntary wetting during sleep without any inherent
suggestion of frequency of bedwetting or pathophysiology.
• Daytime symptoms: daytime urinary symptoms such as wetting, urinary
frequency or urgency.
• Response to an intervention: the child has achieved 14 consecutive dry
nights or a 90% improvement in the number of wet nights per week.
• Partial response: the child’s bedwetting has improved but 14 consecutive
dry nights or a 90% improvement in the number of wet nights per week has
not been achieved.
NICE clinical guideline 111 – Nocturnal enuresis 12
1.1 Principles of care
1.1.1 Inform children and young people with bedwetting and their parents
or carers that bedwetting is not the child or young person's fault
and that punitive measures should not be used in the management
of bedwetting.
1.1.2 Offer support, assessment and treatment tailored to the
circumstances and needs of the child or young person and parents
or carers.
1.1.3 Do not exclude younger children (for example, those under 7 years)
from the management of bedwetting on the basis of age alone.
1.1.4 Perform regular medication reviews for children and young people
on repeated courses of drug treatment for bedwetting.
1.2 Information for the child or young person and family
1.2.1 Offer information tailored to the needs of children and young people
being treated for bedwetting and their parents and carers.
1.2.2 Offer information and details of support groups to children and
young people being treated for bedwetting and their parents or
carers.
1.2.3 Offer information about practical ways to reduce the impact of
bedwetting before and during treatment (for example, using bed
protection and washable and disposable products).
1.3 Assessment and investigation
1.3.1 Ask whether the bedwetting started in the last few days or weeks. If
so, consider whether this is a presentation of a systemic illness.
1.3.2 Ask if the child or young person had previously been dry at night
without assistance for 6 months. If so, enquire about any possible
NICE clinical guideline 111 – Nocturnal enuresis 13
medical, emotional or physical triggers, and consider whether
assessment and treatment is needed for any identified triggers.
1.3.3 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 or young person wake up after bedwetting?
1.3.4 Ask about the presence of 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.
1.3.5 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 or young person goes to the toilet more or less
frequently than his or her peers.
1.3.6 Ask about the child or young person's fluid intake throughout the
day. In particular, ask whether the child or young person, or the
parents or carers are restricting fluids.
1.3.7 Consider whether a record of the child or young person’s fluid
intake, daytime symptoms, bedwetting and toileting patterns would
NICE clinical guideline 111 – Nocturnal enuresis 14
be useful in the assessment and management of bedwetting. If so,
consider asking the child or young person and parents or carers to
record this information.
1.3.8 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
infection
• there is a history, symptoms or signs suggestive of diabetes
mellitus.
1.3.9 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 a vulnerable child or young person or family.
1.3.10 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 (for example, those listed in
recommendation 1.3.9).
1.3.11 Investigate and treat children and young people with suspected
urinary tract infection in line with ‘Urinary tract infection’ (NICE
clinical guideline 54).
NICE clinical guideline 111 – Nocturnal enuresis 15
1.3.12 Investigate and treat children and young people with soiling or
constipation in line with ‘Constipation in children and young people’
(NICE clinical guideline 99).
1.3.13 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).]
1.3.14 Consider investigating and treating daytime symptoms before
bedwetting if daytime symptoms predominate.
1.3.15 Consider involving a professional with psychological expertise for
children and young people with bedwetting and emotional or
behavioural problems.
1.3.16 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 parents or carers have
the necessary level of commitment, including time available, to
engage in a treatment programme.
1.3.17 Discuss with the parents or carers whether they need support,
particularly if they are having difficulty coping with the burden of
bedwetting, or if they are expressing anger, negativity or blame
towards the child or young person.
NICE clinical guideline 111 – Nocturnal enuresis 16
1.3.18 Consider maltreatment
2
• a child or young person is reported to be deliberately bedwetting
if:
• parents or carers are seen or reported to punish a child or young
person for bedwetting despite professional advice that the
symptom is involuntary
• a child or young person has secondary daytime wetting or
secondary bedwetting that persists despite adequate
assessment and management unless there is a medical
explanation (for example, urinary tract infection) or clearly
identified stressful situation that is not part of maltreatment (for
example, bereavement, parental separation).
[This recommendation is adapted from ‘When to suspect child maltreatment’
(NICE clinical guideline 89).]
1.3.19 Use the findings of the history to inform the diagnosis (according to
table 1) and management of bedwetting.
2
For the purposes of the child mistreatment guideline, to consider maltreatment means that
maltreatment is one possible explanation for the alerting feature or is included in the
differential diagnosis.
NICE clinical guideline 111 – Nocturnal enuresis 17
Table 1 Findings from the history and their possible interpretation
Findings from
history
Possible interpretation
Large volume of urine
in the first few hours
of night
Typical pattern for bedwetting only.
Variable volume of
urine, often more than
once a night
Typical pattern for children and young people who have
bedwetting and daytime symptoms with possible underlying
overactive bladder.
Bedwetting every
night
Severe bedwetting, which is less likely to resolve
spontaneously than infrequent bedwetting.
Previously dry for
more than 6 months
Bedwetting is defined as secondary.
•Daytime frequency
•Daytime urgency
•Daytime wetting
•Abdominal straining
or poor urinary stream
•Pain passing urine
Any of these may indicate the presence of a bladder
disorder such as overactive bladder or more rarely (when
symptoms are very severe and persistent) an underlying
urological disease.
Constipation A common comorbidity that can cause bedwetting and
requires treatment (see 'Constipation in children and young
people' [NICE clinical guideline 99]).
Soiling Frequent soiling is usually secondary to underlying faecal
impaction and constipation which may have been
unrecognised.
Inadequate fluid
intake
May mask an underlying bladder problem, such as
overactive bladder disorder, and may impede the
development of an adequate bladder capacity.
Behavioural and
emotional problems
These may be a cause or a consequence of bedwetting.
Treatment may need to be tailored to the specific
requirements of each child or young person and family.
Family problems A difficult or 'stressful' environment may be a trigger for
bedwetting. These factors should be addressed alongside
the management of bedwetting.
Practical issues Easy access to a toilet at night, sharing a bedroom or bed
and proximity of parents to provide support are all important
issues to consider and address when considering treatment,
especially with an alarm.
NICE clinical guideline 111 – Nocturnal enuresis 18
1.4 Planning management
1.4.1 Explain the condition, the effect and aims of treatment, and the
advantages and disadvantages of the possible treatments to the
child or young person and parents or carers (see recommendations
1.8.13 and 1.10.9).
1.4.2 Clarify what the child or young person and parents or carers hope
the treatment will achieve. Ask whether short-term dryness is a
priority for family or recreational reasons (for example, for a sleep-
over).
1.4.3 Explore the child or young person’s views about their bedwetting,
including:
• what they think the main problem is
• whether they think the problem needs treatment.
1.4.4 Explore and assess the ability of the family to cope with using an
alarm for the treatment of bedwetting.
1.4.5 Consider whether or not it is appropriate to offer alarm or drug
treatment, depending on the age of the child or young person, the
frequency of bedwetting and the motivation and needs of the child
or young person and their family.
1.5 Advice on fluid intake, diet and toileting patterns
1.5.1 Advise children and young people with bedwetting and their
parents or carers that:
• adequate daily fluid intake is important in the management of
bedwetting
• daily fluid intake varies according to ambient temperature,
dietary intake and physical activity. A suggested intake of drinks
is given in table 2:
NICE clinical guideline 111 – Nocturnal enuresis 19
Table 2 Suggested daily intake of drinks for children and young people
Age Sex Total drinks per day
4–8 years Female
Male
1000–1400 ml
1000–1400 ml
9–13 years Female
Male
1200–2100 ml
1400–2300 ml
14–18 years
Female
Male
1400–2500 ml
2100–3200 ml
1.5.2 Advise the child or young person and parents or carers that the
consumption of caffeine-based drinks should be avoided in children
and young people with bedwetting.
1.5.3 Advise the child or young person and parents or carers to eat a
healthy diet and not to restrict diet as a form of treatment for
bedwetting.
1.5.4 Advise the child or young person of the importance of using the
toilet at regular intervals throughout the day.
1.5.5 Advise parents or carers to encourage the child or young person to
use the toilet to pass urine at regular intervals during the day and
before sleep (typically between four and seven times in total). This
should be continued alongside the chosen treatment for
bedwetting.
1.5.6 Address excessive or insufficient fluid intake or abnormal toileting
patterns before starting other treatment for bedwetting in children
and young people.
1.5.7 Suggest a trial without nappies or pull-ups for a child or young
person with bedwetting who is toilet trained by day and is wearing
nappies or pull-ups at night. Offer advice on alternative bed
protection to parents and carers.
NICE clinical guideline 111 – Nocturnal enuresis 20
1.6 Lifting and waking3
1.6.1 Offer advice on waking and lifting during the night as follows:
• Neither waking nor lifting children and young people with
bedwetting, at regular times or randomly, will promote long-term
dryness.
• Waking of children and young people by parents or carers, either
at regular times or randomly, should be used only as a practical
measure in the short-term management of bedwetting.
• Young people with bedwetting that has not responded to
treatment may find self-instigated waking (for example, using a
mobile phone alarm or alarm clock) a useful management
strategy.
1.7 Reward systems
1.7.1 Explain that reward systems with positive rewards for agreed
behaviour rather than dry nights should be used either alone or in
conjunction with other treatments for bedwetting. For example,
rewards may be given for:
• drinking recommended levels of fluid during the day
• using the toilet to pass urine before sleep
• engaging in management (for example, taking medication or
helping to change sheets).
1.7.2 Inform parents or carers that they should not use systems that
penalise or remove previously gained rewards.
1.7.3 Advise parents or carers to try a reward system alone (as
described in recommendation 1.7.1) for the initial treatment of
bedwetting in young children who have some dry nights.
3
Lifting is carrying or walking a child to toilet. Lifting without waking means that effort is not
made to ensure the child is fully woken. Waking means waking a child from sleep to take
them to the toilet.
NICE clinical guideline 111 – Nocturnal enuresis 21
1.8 Initial treatment – alarms
1.8.1 Offer an alarm as the first-line treatment to children and young
people whose bedwetting has not responded to advice on fluids,
toileting or an appropriate reward system, unless:
• an alarm is considered undesirable to the child or young person
or their parents or carers or
• an alarm is considered inappropriate, particularly if:
− bedwetting is very infrequent (that is, less than 1–2 wet beds
per week)
− the parents or carers are having emotional difficulty coping
with the burden of bedwetting
− the parents or carers are expressing anger, negativity or
blame towards the child or young person.
1.8.2 Assess the response to an alarm by 4 weeks and continue with
treatment if the child or young person is showing early signs of
response4
1.8.3 Continue alarm treatment in children and young people with
bedwetting who are showing signs of response until a minimum of
2 weeks’ uninterrupted dry nights has been achieved.
. Stop treatment only if there are no early signs of
response.
1.8.4 Assess whether it is appropriate to continue with alarm treatment if
complete dryness is not achieved after 3 months. Only continue
with alarm treatment if the bedwetting is still improving and the child
or young person and parents or carers are motivated to continue.
1.8.5 Do not exclude alarm treatment as an option for bedwetting in
children and young people with:
4
Early signs of a response may include smaller wet patches, waking to the alarm, the alarm
going off later and fewer times per night and fewer wet nights.
NICE clinical guideline 111 – Nocturnal enuresis 22
• daytime symptoms as well as bedwetting
• secondary bedwetting.
1.8.6 Consider an alternative type of alarm (for example, a vibrating
alarm) for the treatment of bedwetting in children and young people
who have a hearing impairment.
1.8.7 Consider an alarm for the treatment of bedwetting in children and
young people with learning difficulties and/or physical disabilities.
Tailor the type of alarm to each individual's needs and abilities.
1.8.8 Consider an alarm for the treatment of bedwetting in children under
7 years, depending on their ability, maturity, motivation and
understanding of the alarm.
Using an alarm
1.8.9 Inform children and young people and parents or carers about the
benefits of alarms combined with reward systems. Advise on the
use of positive rewards for desired behaviour, such as waking up
when the alarm goes off, going to the toilet after the alarm has
gone off, returning to bed and resetting the alarm.
1.8.10 Encourage children and young people with bedwetting and their
parents or carers to discuss and agree on their roles and
responsibilities for using the alarm and the use of rewards.
1.8.11 Ensure that advice and support are available to children and young
people and their parents or carers who are given an alarm, and
agree how these should be obtained. Be aware that they may need
a considerable amount of help in learning how to use an alarm.
NICE clinical guideline 111 – Nocturnal enuresis 23
1.8.12 Inform the child or young person and their parents or carers that
the aims of alarm treatment for bedwetting are to train the child or
young person to:
• recognise the need to pass urine
• wake to go to the toilet or hold on
• learn over time to hold on or to wake spontaneously and stop
wetting the bed.
1.8.13 Inform the child or young person and their parents or carers that:
• alarms have a high long-term success rate
• using an alarm can disrupt sleep
• that parents or carers may need to help the child or young
person to wake to the alarm
• using an alarm requires sustained commitment, involvement and
effort from the child or young person and their parents or carers
• they will need to record their progress (for example, if and when
the child or young person wakes and how wet they and the
bed are)
• alarms are not suitable for all children and young people and
their families.
1.8.14 If offering an alarm for bedwetting, inform the child and young
person and their parents or carers how to:
• set and use the alarm
• respond to the alarm when it goes off
• maintain the alarm
• deal with problems with the alarm, including who to contact
when there is a problem
• return the alarm when they no longer need it.
NICE clinical guideline 111 – Nocturnal enuresis 24
1.8.15 Inform the child and young person and their parents or carers that it
may take a few weeks for the early signs of a response to the alarm
to occur and that these may include:
• smaller wet patches
• waking to the alarm
• the alarm going off later and fewer times per night
• fewer wet nights.
1.8.16 Inform the child or young person and their parents or carers that
dry nights may be a late sign of response to the alarm and may
take weeks to achieve.
1.8.17 Inform the parents or carers that they can restart using the alarm
immediately, without consulting a healthcare professional, if the
child or young person starts bedwetting again following a response
to alarm treatment.
1.9 Lack of response to alarm treatment
1.9.1 If bedwetting does not respond to initial alarm treatment, offer:
• combination treatment with an alarm and desmopressin or
• desmopressin alone if continued use of an alarm is no longer
acceptable to the child or young person or their parents
and carers.
1.9.2 Offer desmopressin alone to children and young people with
bedwetting if there has been a partial response to a combination
of an alarm and desmopressin following initial treatment with
an alarm.
NICE clinical guideline 111 – Nocturnal enuresis 25
1.10 Initial treatment – desmopressin
1.10.1 Offer desmopressin to children and young people over 7 years, if:
• rapid-onset and/or short-term improvement in bedwetting is the
priority of treatment or
• an alarm is inappropriate or undesirable (see recommendation
1.8.1).
1.10.2 Consider desmopressin for children aged 5–7 years if treatment is
required and:
• rapid-onset and/or short-term improvement in bedwetting is the
priority of treatment or
• an alarm is inappropriate or undesirable (see recommendation
1.8.1).
1.10.3 Do not exclude desmopressin as an option for the management of
bedwetting in children and young people who also have daytime
symptoms. However, do not use desmopressin in the treatment of
children and young people who only have daytime wetting.
1.10.4 In children and young people who are not completely dry after 1 to
2 weeks of the initial dose of desmopressin (200 micrograms for
Desmotabs or 120 micrograms for DesmoMelt), consider
increasing the dose (to 400 micrograms for Desmotabs or
240 micrograms for DesmoMelt).
1.10.5 Assess the response to desmopressin at 4 weeks and continue
treatment for 3 months if there are signs of a response. Consider
stopping if there are no signs of response. Signs of response
include:
• smaller wet patches
• fewer wetting episodes per night
• fewer wet nights.
NICE clinical guideline 111 – Nocturnal enuresis 26
1.10.6 Do not exclude desmopressin as an option for the treatment of
bedwetting in children and young people with sickle cell disease if
an alarm is inappropriate or undesirable and they can comply with
night-time fluid restriction. Provide advice about withdrawal of
desmopressin at times of sickle cell crisis.
1.10.7 Do not exclude desmopressin as an option for the treatment of
bedwetting in children and young people with emotional, attention
or behavioural problems or developmental and learning difficulties if
an alarm is inappropriate or undesirable and they can comply with
night-time fluid restriction.
1.10.8 Do not routinely measure weight, serum electrolytes, blood
pressure and urine osmolality in children and young people being
treated with desmopressin for bedwetting.
1.10.9 If offering desmopressin for bedwetting, inform the child or young
person and their parents or carers:
• that many children and young people, but not all, will experience
a reduction in wetness
• that many children and young people, but not all, will relapse
when treatment is withdrawn
• how desmopressin works
• of the importance of fluid restriction from 1 hour before until
8 hours after taking desmopressin
• that it should be taken at bedtime
• if appropriate, how to increase the dose if there is an inadequate
response to the starting dose
• to continue treatment with desmopressin for 3 months
• that repeated courses of desmopressin can be used.
1.10.10 Consider advising that desmopressin should be taken 1–2 hours
before bedtime in children and young people with bedwetting that
has either partially responded or not responded to desmopressin
NICE clinical guideline 111 – Nocturnal enuresis 27
taken at bedtime. Ensure that the child or young person can comply
with fluid restriction starting from 1 hour before the drug is taken.
1.10.11 Consider continuing treatment with desmopressin for children and
young people with bedwetting that has partially responded, as
bedwetting may improve for up to 6 months after starting treatment.
1.11 Children and young people experiencing recurrence
of bedwetting
1.11.1 Consider alarm treatment again if a child or young person who was
previously dry with an alarm has started regularly bedwetting again.
1.11.2 Offer combination treatment with an alarm and desmopressin to
children and young people who have more than one recurrence of
bedwetting following successful treatment with an alarm.
1.11.3 Consider using repeated courses of desmopressin for children and
young people with bedwetting that has responded to desmopressin
treatment but who experience repeated recurrences. Withdraw
desmopressin treatment at regular intervals (for 1 week every
3 months) to check if dryness has been achieved when using it for
the long-term treatment of bedwetting.
1.11.4 Gradually withdraw desmopressin rather than suddenly stopping it
if a child or young person has had a recurrence of bedwetting
following response to previous desmopressin treatment courses.
1.11.5 Consider alarm treatment as an alternative to continuing drug
treatment for children and young people who have recurrences of
bedwetting, if an alarm is now considered appropriate and
desirable.
1.12 Lack of response to initial treatment options
1.12.1 Refer children and young people with bedwetting that has not
responded to courses of treatment with an alarm and/or
desmopressin for further review and assessment of factors that
NICE clinical guideline 111 – Nocturnal enuresis 28
may be associated with a poor response, such as an overactive
bladder, an underlying disease or social and emotional factors.
1.13 Anticholinergics
The use of anticholinergics for bedwetting in children and young people is
discussed in the recommendations in this section. Not all anticholinergics
have a UK marketing authorisation for treating bedwetting in children and
young people. If a drug without a marketing authorisation for this indication is
prescribed, informed consent should be obtained and documented.
1.13.1 Do not use an anticholinergic alone for the management of
bedwetting in children and young people without daytime
symptoms.
1.13.2 Consider an anticholinergic combined with desmopressin for
bedwetting in children and young people who also have daytime
symptoms and have been assessed by a healthcare professional
with expertise in prescribing the combination of an anticholinergic
and desmopressin.
1.13.3 Consider an anticholinergic combined with desmopressin for
children and young people who have been assessed by a
healthcare professional with expertise in the management of
bedwetting that has not responded to an alarm and/or
desmopressin and have any of the following:
• bedwetting that has partially responded to desmopressin alone
• bedwetting that has not responded to desmopressin alone
• bedwetting that has not responded to a combination of alarm
and desmopressin.
1.13.4 Consider continuing treatment for children and young people with
bedwetting that has partially responded to desmopressin combined
with an anticholinergic, as bedwetting may continue to improve for
up to 6 months after starting treatment.
NICE clinical guideline 111 – Nocturnal enuresis 29
1.13.5 Consider using repeated courses of desmopressin combined with
an anticholinergic in children and young people who have
responded to this combination but experience repeated
recurrences of bedwetting following previous response to
treatment.
1.13.6 If offering an anticholinergic combined with desmopressin for
bedwetting, inform the child or young person and their parents or
carers:
• that success rates are difficult to predict, but more children and
young people are drier with this combination than with
desmopressin alone
• that desmopressin and an anticholinergic can be taken together
at bedtime
• to continue treatment for 3 months
• that repeated courses can be used.
1.13.7 Do not offer an anticholinergic combined with imipramine for the
treatment of bedwetting in children and young people.
1.14 Tricyclics
1.14.1 Do not use tricyclics as the first-line treatment for bedwetting in
children and young people.
1.14.2 If offering a tricyclic, imipramine should be used for the treatment of
bedwetting in children and young people.
1.14.3 Consider imipramine for children and young people with bedwetting
who:
• have not responded to all other treatments and
• have been assessed by a healthcare professional with expertise
in the management of bedwetting that has not responded to an
alarm and/or desmopressin.
NICE clinical guideline 111 – Nocturnal enuresis 30
1.14.4 If offering imipramine for bedwetting, inform the child or young
person and their parents or carers:
• that many children and young people, but not all, will experience
a reduction in wetness
• how imipramine works
• that it should be taken at bedtime
• that the dose should be increased gradually
• about relapse rates (for example, more than two out of three
children and young people will relapse after a 3-month course of
imipramine) &
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