Nocturnal Enuresis

Title of Guideline Nocturnal Enuresis Guideline

Dr Jyoti Balain
Dr Jonathan Evans
Contact Name and Job Title (author)
Dr Dilip Nathan

Community Paediatrics
Directorate & Speciality
Child Health
February 2014
Date of submission

Date on which guideline must be reviewed (this should be February 2019

one to three years)
All children and young people up to 19
Explicit definition of patient group to which it applies (e.g.
inclusion and exclusion criteria, diagnosis) years of age

This guideline is to assist all health

care professionals in their endeavour
Abstract to provide and excellent enuresis
service.

Nocturnal Enuresis, Bedwetting,

Key Words

Statement of the evidence base of the guideline – has the

guideline been peer reviewed by colleagues?

Evidence base: (1-5)

1a meta analysis of randomised controlled trials
1b at least one randomised controlled trial
2a at least one well-designed controlled study without These guidelines are based on NICE
randomisation
2b at least one other type of well-designed quasi- recommendations (2010).
experimental study
3 well –designed non-experimental descriptive studies
(ie comparative / correlation and case studies)
4 expert committee reports or opinions and / or clinical
experiences of respected authorities
5 recommended best practise based on the clinical
experience of the guideline developer

Consultation Process Peer review

All health care professionals involved

in care of children with nocturnal
Target audience enuresis

This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or
expert. Caution is advised when using guidelines after the review date.

Dr Dilip Nathan Page 1 of 17 February 2014

Scope of the Guideline

These guidelines are to assist health care professionals in their endeavour to provide an
excellent enuresis service. The guidance is applicable to children and young people up to 19
years with the symptom of bedwetting. These guidelines are based on NICE
recommendations (2010).

Introduction/Background

The impact of bedwetting upon the lives of children and families is often underestimated
despite the common nature of the condition. Up to 50% of parents do not seek help. Active
intervention is recommended instead of waiting until the child “grows out of it”.

Impact of Nocturnal Enuresis and Bedwetting

Bedwetting is a widespread and distressing condition that can have a deep impact on the
emotional, behavioural and social wellbeing of children and can be highly stressful for parents
and carers.
.
 Bedwetting affects normal daily routines and limits the child’s social life and
experiences (sleepovers and school trips).
 Bedwetting may generate negative emotions and behaviours for the child. This may
include a sense of helplessness, a lack of hope and optimism, an awareness of being
different from peers, guilt and shame, humiliation, victimization, and loss of self-
esteem.
 Bedwetting brings additional pressures to parenting and family life. Parents may feel
frustrated and helpless and although the majority of parents do not get angry with
their child as a result of bedwetting, there is increased risk of emotional and physical
abuse.
 There is evidence that children with bedwetting have higher than average levels of
oppositional behaviour and conduct problems.

Epidemiology of Nocturnal Enuresis

It is estimated that over half a million children between the ages of 5 and 6 years in the UK
regularly wet the bed. The prevalence of bedwetting decreases with age.

% Prevalence
% Prevalence Wetting at least once
Sex Wetting at least 3 times a week in 3 months

5 years 7 years 9 years 16 years

Male 13-19 15-22 9-13 1-6

Female 9-16 7-15 5-10 0.8

Dr Dilip Nathan Page 2 of 17 February 2014

Young people with Disability

At age 20 years:
% Prevalence rates
Disability Wetting at least once in every 3 months
Mild 0
Moderate 20
Profound 80

Wetting at least once in 3 months is used in children with severe disability because some of
these children have overactive bladder contractions and do not empty their bladder fully.
Therefore as such these children do not have an involuntary voiding.

Definitions
Bedwetting: Involuntary wetting during sleep without any inherent suggestion of frequency of
bedwetting or pathophysiology.

Daytime symptoms: 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.

Primary Nocturnal Enuresis: Child has never been dry for a period of more than 6 months.

Secondary Nocturnal Enuresis: Child has been dry for at least 6 months before wetting
restarted.

Mono-symptommatic enuresis: Children have problems only when asleep.

Non-mono-symptommatic enuresis: Describes the symptoms of children who have urinary

incontinence at night and also have daytime symptoms

Pathophysiology (Figure 1)
The causes of Primary Nocturnal Enuresis (PNE) are unclear. Genetic, physiological and
psychological factors, as well as delay in maturation of the mechanism for bladder control
have been suggested.
Other factors, which may contribute to bedwetting, include: constipation, sleep apnoea and
upper airway obstructive symptoms, and diet or mild caffeinated drinks with diuretic effects.
Enuresis is more common in cases of neglect and abuse. Social and cultural factors account
for the greatest proportion of cases. .

Dr Dilip Nathan Page 3 of 17 February 2014

 Picture 1 Factors associated with bedwetting

Developmental
delay
Deranged
circadian rhythm
Psychosomatic
of ADH
manifestation
secretion

Primary
Nocturnal
Genetic Sleep-arousal
Enuresis
predisposition disturbances

Deranged
bladder reservoir Bladder
function detrusor/sphincter
dysfunction

Management

Key Principles

 Bedwetting is not the child’s fault and punitive measures should not be used.
 Offer support, assessment and treatment tailored to the circumstances and
needs of the child and family.
 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.
 Information and advice on fluid management should be tailored to the needs
of the individual child. Ensure the parents and carers agree and participate
in the proposed management plan.

History

Aim of history taking is to:

 Make a diagnosis
 Identify or rule out pathology
 Detect factors that influence the suitability and success of treatment
 Understand what wetting means for the child and family

Key Points of history taking:

Dr Dilip Nathan Page 4 of 17 February 2014

  Bedwetting started in the last few days or weeks? If so, consider whether this
is a presentation of a systemic illness.

 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.

 Pattern of bedwetting?
o How many nights a week does bedwetting occur?
o How many times a night does bedwetting occur?
o Does there seem to be a large amount of urine?
o At what times of night does the bedwetting occur?
o Does the child or young person wake up after bedwetting?

 Daytime symptoms?
o Daytime frequency (i.e. passing urine more than seven times a day)
o Daytime urgency
o Daytime wetting
o Passing urine infrequently (fewer than four times a day)
o Abdominal straining or poor urinary stream
o Pain or discomfort while passing urine.

 Toileting patterns?
o Daytime symptoms occur only in some situations
o Avoidance of toilets at school or other settings
o Does the child or young person go to the toilet more or less
frequently than his or her peers?

 History of fluid intake throughout the day. Any restrictions on fluids?

o How much does the child or young person drink during the day?
o Are they drinking less because of the bedwetting?
o Are the parents or carers restricting drinks because of the
bedwetting?

 Will recording information on fluid intake, daytime symptoms, bedwetting and

toileting patterns 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.

 Any co-morbidities/other relevant factors?

o Constipation and/or soiling
o Developmental delay, attention or learning difficulties
o Diabetes mellitus
o Behavioural or emotional problems
o Family problems or a vulnerable child or young person or family.

 Factors that might affect treatment and support needs, such as:
o Sleeping arrangements (for example, does the child or young person
have his or her own bed or bedroom)
o The impact of bedwetting on the child or young person and family
o 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.

Dr Dilip Nathan Page 5 of 17 February 2014

  Discuss with 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 maltreatment if:

o A child or young person is reported to be deliberately bedwetting
o Parents or carers are seen or reported to punish a child or young
person for bedwetting despite professional advice that the symptom
is involuntary.
o 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).

Table 2 Interpretation of History

Findings from history Possible interpretation

Large volume of urine in the first few

Typical pattern for bedwetting
hours of night
Variable volume of Typical pattern for children and young people
urine, often more than who have bedwetting and daytime symptoms
once a night with possible underlying overactive bladder
Severe bedwetting, which is less likely to
Bedwetting every night resolve spontaneously
than infrequent bedwetting
Previously dry for more
Bedwetting is defined as secondary
than 6 months
Any of these may indicate the presence of a
Daytime wetting or symptoms
bladder disorder such as an overactive bladder
Abdominal straining
or more rarely an underlying urological disease
Poor urinary stream
(when symptoms are very severe and
Pain /discomfort passing urine
persistent).
Common co-morbidity that can cause
Constipation
bedwetting and requires treatment
Frequent soiling is usually secondary to
Soiling underlying faecal impaction and constipation,
which may have been unrecognised.
May mask an underlying bladder problem,
such as overactive bladder disorder, and may
Inadequate fluid intake
impede the development of an adequate
bladder capacity.
These may be a cause or a consequence.
Behavioural and
Treatment may need to be tailored to the
emotional problems
specific requirements of each child or young
person and family.
A difficult or 'stressful' environment may be a
Family problem
trigger. These factors should be addressed
alongside the management.
Easy access to a toilet at night, sharing a
bedroom or bed and proximity of parents to
Practical issues
provide support are important issues to
consider and address when considering
treatment, especially with an alarm.

Dr Dilip Nathan Page 6 of 17 February 2014

Examination
- Is this a healthy child?
- Disorders affecting urinary tract?

In all children:

 Height and weight

 Abdominal palpitation
 Spine
 Signs of neglect/abuse

In Children with suspected neurological cause:

 Rectal examination
 Genitalia
 Perineal sensation
 Ano-cutaneous reflex
 Neurological exam

Investigation In Secondary Care

There is little evidence that investigations are helpful for primary monosymptomatic NE. Most
children therefore do not require investigations.

The following investigations should be considered:

Urinalysis

Do not perform urinalysis routinely.

Indications for urinalysis :

 New onset bedwetting (in the last few days or weeks)
 Daytime symptoms
 Any signs of ill health
 History, symptoms or signs suggestive of urinary tract infection
 History, symptoms or signs suggestive of diabetes mellitus
 Unresponsive to first line treatment

Blood Pressure

There is no evidence to suggest that uncomplicated NE has an increased incidence

of hypertension.

Fluid Charting

If no clear pattern of bedwetting is established in the history, fluid charting may be

helpful.

Indications for post-void residual urine volume ultrasound

 Day time symptoms not typical of overactive bladder

 Refractory NE
 Daytime symptoms unresponsive to overactive bladder treatment

Indications for Renal Ultrasound Scan

 Suspected urinary tract abnormality

 Persistent post-void residual urine

Dr Dilip Nathan Page 7 of 17 February 2014

  Day time symptoms not responding to overactive bladder treatment
 Atypical abdominal straining, poor stream or palpable bladder
 Refractory NE, unresponsive to alarm & Desmopressin (+/- anticholinergics)
 Recurrent urinary tract infections.
 Severe day time symptoms

Micturating cysto-urethrogram (MCG), Urodynamics Studies

These investigations are done after referral to nephro-urology.

Diagnosis

Exclude or address systemic causes, triggers and co morbidities (Table 3).

Follow appropriate management as per the diagnosis, triggers and co-morbidities.

Table 3 : Diagnosis, triggers and co-morbidities

Urinary tract infection

Constipation and/or soiling
Diabetes mellitus
Medical, emotional or physical triggers
Known or suspected physical or neurological problems
Developmental delay, attention or learning difficulties
Family problems or vulnerable child, young person or family
Behavioural or emotional problems

Treatment

The management plan should be tailored to the individual child and family after
discussing and exploring the relevant issues affecting management (Table 4).

Use all the information obtained and your understanding of the diagnosis to explain
the problem and the management to the child and family in a meaningful way.

Table 4. Important management considerations for Child and Family

What do the family hope the treatment will achieve?

Is short-term dryness a priority for the family? – Holidays, sleepovers etc
Family’s views on cause of bedwetting
What interventions have been tried so far?
Factors that might affect treatment eg sleeping arrangements
Impact of bedwetting on the child and family
Family’s commitment level
Whether the parents or carers need support?

Dr Dilip Nathan Page 8 of 17 February 2014

 A 5 year-old child, who is bothered by his or her bedwetting, and motivated to receive
treatment, should indeed receive adequate interventions to help them overcome their
bedwetting (table 5).

Table 5: Nice recommendations for managing children

less than 5 years of age with bedwetting (2010)

Reassure that many children under 5 years wet the bed.

Take history of toilet training. Offer advice and support. Advise parents or carers to
toilet train their child unless there are reasons why it should not be attempted.
Advise parents or carers to take their child to the toilet if the child wakes during the
night.
Suggest a trial of 2 nights in a row without nappies or pull-ups for a child who has
been toilet trained during the day for at least 6 months.
Offer advice on alternative bed protection. Consider a longer trial if the family
circumstances allow it, for older under 5s or if a reduction in wetness is achieved.
Exclude a specific medical problem.
Assess constipation.

Meaningful advice on:

 Fluids, diet and toileting patterns:

o Amount of fluid needed varies according to the ambient temperature,
dietary intake and physical activity.
o Caffeine-based drinks should be avoided.
o Eat a healthy diet and do not restrict diet to treat bedwetting.
o Importance of using the toilet to pass urine regularly during the day
and before sleep (4-7 times a day).
o Encourage regular toilet use alongside treatment.

Table 2: Advise on fluid intake from drinks for children and young people

Age (Years) Sex Total drink intake per day (ml)

4-8 Female 1000-1400
Male 1000-1400
9-13 Female 1200-2100
Male 1400-2300
14-18 Female 1400-2500
Male 2100-3200

 Rewards
o May be used, either alone or with other treatments.
o Rewards should be given for agreed behaviour rather than dry nights,
e.g.
 Drinking recommended levels of fluid during the day
 Using the toilet to pass urine before sleep
 Engaging in management (for example, taking medication or
changing sheets).

Dr Dilip Nathan Page 9 of 17 February 2014

 o Inform parents or carers that they should not use systems that
penalise or remove previously gained rewards.

 Lifting and Waking

o Lifting is carrying or walking a child to the 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 go to the toilet.
 Neither lifting nor waking will promote long-term dryness.
 Waking 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.

 Training programme

Do not use strategies that interrupt normal passing of urine or encourage infrequent
urination during the day. There is no evidence that dry-bed training (see appendix 3
for definition) with or without an alarm is helpful.

Address psychological/social difficulties

Consider involving a professional with psychological expertise for children and young people
with bedwetting and emotional or behavioural problems.

Flowchart 1 : Initial Treatment

Dr Dilip Nathan Page 10 of 17 February 2014

 Child with Bedwetting
 Advise on fluid intake, diet and toileting behaviour
 Address excessive or insufficient fluid intake and abnormal toileting patterns before
starting other treatments
 Advise on using reward system
 Suggest a trial without nappies or pull ups worn at night. Offer advice on alternative bed
protection
 Consider whether alarm or drug treatment is appropriate, depending on the age, maturity
and abilities, frequency of bed wetting and the motivation and needs of the family
 Assess the ability of the family to cope with an alarm

Advice Drug Treatment

Bedwetting has not responded Rapid onset and /or

Young child who has some
dry nights
to advice on fluids, toileting short term dryness is a
and an appropriate reward priority or
system and Alarm treatment is
Alarm treatment is desirable undesirable or
and appropriate Alarm treatment is
inappropriate

Alarm Treatment

Advise parents or  Offer an alarm as first  Offer desmopresssin for

carers to try a reward line treatment children over 7 years
system alone. ( As  Consider an alarm for  Consider desmopresin for
above) children under 7 years children aged 5-7 years if
treatment is required

Dr Dilip Nathan Page 11 of 17 February 2014

 Flow chart 2 : Alarm Treatment

Start alarm treatment and assess response

by 4 weeks – early signs of response?

Yes No

Continue with alarm Assess response at 3 months

Yes
2 weeks uninterrupted Is bedwetting improving and
dry nights achieved? the child and parents/carers
motivated to continue?

Yes No
No

Stop alarm treatment Continue alarm treatment

Repeated
Recurrence Recurrence

Consider restarting alarm Stop treatment with alarm alone

treatment if the child starts Is alarm treatment still acceptable?
regularly bedwetting again
Yes No

Partial
Response
Offer desmopressin Offer
combined with an desmopresssin
alarm alone

Dr Dilip Nathan Page 12 of 17 February 2014

Alarm Treatment

Alarm is most effective way of facilitating arousal from sleep to a full bladder sensation. It
works by waking the child when they start to wet the bed, sensitising the child to respond
quickly and appropriately to a full bladder during sleep.

Do not exclude alarm treatment as an option for children with:

 Daytime symptoms as well as bedwetting
 Secondary bedwetting

Consider alarm treatment tailored to the needs and/or abilities of child with:
 Hearing impairments (for example, consider a vibrating alarm)
 Learning difficulties and/or physical disabilities

Alarms could be combined with reward system

 Inform about the benefits of combining alarm treatment with a reward system. e.g.
waking up when the alarm goes off, going to the toilet, returning to bed and resetting
the alarm).
 Encourage the family to discuss and agree their roles and responsibilities for using
alarms and rewards

Alarm Treatment: Advise and Support

Ensure that advice and support for using an alarm are available. Agree with the family on how
this should be obtained.

Inform the family and child in a meaningful way:

 Aims of treatment
 High long-term success rate
 Needs sustained commitment, involvement and effort
 It disrupts sleep, and parents or carers may need to help the child or young person to
wake to the alarm
 Not suitable for all families
 Record the progress
 How to trouble shoot common problems
 May take a few weeks before an effect is seen
 Alarm use can be restarted immediately without consulting a healthcare professional,
if bedwetting starts again after stopping treatment
 How to return the alarm when they no longer need it

Desmopressin Treatment (See Flowchart 3)

Desmopressin is a synthetic analogue of vasopressin with an anti-diuretic action, which

results in decreased urine production and increased urine concentration. It can be given to
children >5 yrs of age. It inhibits uninhibited bladder contractions and enhances arousability.

Dr Dilip Nathan Page 13 of 17 February 2014

 Flowchart 3 : Desmopressin Treatment

Start Desmopressin Treatment

Is complete dryness achieved after 1-2 weeks

Yes No

Assess Response at 4 Consider increasing

weeks dose (to 400mcg for
Sign of response? Desmotabs or 240 mcg
for Desmomelts)
Response Partial or no response

Advise that Desmopressin is Consider stopping

Yes No
Continue treatment taken 1-2 hours before
Desmopressin treatment
for 3 months bedtime, instead of at
bedtime if the child can
comply with fluid restriction
Response
Partial response

Stop Desmopresssin Consider continuing

Treatment Desmopressin for longer

Bedwetting recurs Partial or no response

Restart Desmopressin and consider  Refer for to nephrology team. Reassess

repeated courses for repeated recurrence
 Withdraw every 3 months to assess
response
 Withdraw gradually if using repeated
courses
factors associated with poor response
(e.g. overactive bladder, underlying
disease of social or emotional factors).
 Consider combination treatment

Advice and Information on Desmopressin

 Fluid intake must be a limited to a minimum from one hour before until eight
hours after administration (beware of binge drinking teenagers).
 In case of fever and/or diarrhoea, Desmopressin treatment should be stopped
until the patient has fully recovered.
 Helpful for short-term support, e.g. parent stress, trips away etc.
 See BNF –C for dosage.
 Two forms available – Desmotab and Desmomelt.
 Do not routinely measure weight, serum electrolytes, blood pressure, urine
osmolality.

Dr Dilip Nathan Page 14 of 17 February 2014

Do not exclude Desmopressin

 Daytime symptoms as well as bedwetting

 Sickle cell disease, if they can comply with night-time fluid restriction. Provide advice
about withdrawal of Desmopressin at times of sickle cell crisis.
 Emotional or behavioural problems, developmental delay or attention or learning
difficulties, if they can comply with night-time fluid restriction.

Anticholinergics

 Involuntary detrusor contractions cause urgency and urge incontinence, usually with
frequency and nocturia. Anticholinergics reduce these contractions and increase
bladder capacity.
 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.
 Anticholinergics are used in addition to and not instead of bladder routines that
promote regular relaxed voiding.
 Constipation should be treated prior to starting anticholinergics.
 A bladder scan is not required prior to initiating treatment if the symptoms are typical
of overactive bladder.
 Oxybutynin (as per BNF-C) should be considered first for children under 12 years of
age. Side-effects can be minimised by starting on a low dose and gradually
increasing the dose.
 Tolterodine can be considered for children over 12 years of age or children under 12
years who have not responded to oxybutynin.
 If child are able to swallow tablets then long acting medication offers overnight cover
with fewer adverse effects.
 Use treatment to cover 24 hours if the child has daytime symptoms. Use a single
night-time dose if there are no symptoms of overactive bladder. It should be clear
within 28 days whether anticholinergics are effective - only continue if evidence of
response/partial response.

Indications:
 Not responded to an alarm and/or desmopressin
 Partial response to desmopressin alone
 Daytime symptoms
 Repeat course may be used for recurrence following successful treatment

Do not use

 Anticholinergic alone without daytime symptoms

 Combination of anticholinergic with imipramine

Information and advice on drug treatment

 Success rates are difficult to predict

 Combined drug treatments are more effective
 Combination drugs can be taken together at bedtime
 Treatment should be continued for 3 months
 Repeated courses can be used

Tricyclics

Dr Dilip Nathan Page 15 of 17 February 2014

If offering a tricyclic, imipramine should be used for the treatment of bedwetting in children
and young people (see BNF- C for doses).

Imipramine
 Not a first-line treatment
 Should be prescribed by a specialist in bedwetting
 Medical review every 3 months
 Withdraw imipramine gradually when stopping treatment
 Should not be used in combination with anticholinergics as they have anticholinergic
action.

Information and advice

 Reduction in wetness, but the majority will relapse after stopping
 Mechanism of action – anticholinergic effects.
 Taken at bedtime
 Dose should be increased gradually
 Treatment should be continued for 3 months
 Repeated courses may be considered
 Dangers of overdose, the importance of safe storage and taking only the prescribed
amount.

Combination Treatment

Alarm and Desmopressin

Insufficient evidence. One RCT showed reduced wet nights in short term but no significant
difference in long term at 6 months.

Oxybutymin with Desmopressin

May be beneficial in children with daytime symptoms.

Alarm and Dry bed training

Not recommended
Therapy Resistant Enuresis
 Post void residual
 Do not give up support – multidisciplinary approach
 Review of history and examination.
 Consider and address any existing co-morbidities, triggers and diagnosis (Table 3).
 Refer to nephrology team for assessment and further investigations.
 Exclude social and environmental issues – e.g. abuse, phobia of toilets, housing,
overcrowding etc.

Indications for referral to Nephro-Urology are:

 Post void residual
 Day time symptoms not responding to overactive bladder treatment
 Atypical abdominal straining, poor stream and palpable bladder
 NE unresponsive to Alarm and Desmopressin +/ - anticholinergics
 Recurrent UTI
 Abnormal Renal Ultrasound
 Severe daytime symptoms

Alternative Interventions
 Electro acupuncture has been studied with some success but no RCT.
 Lifting is not recommended because it encourages the child to empty the bladder
while asleep.
 Waking the child does not encourage development of self-control bladder function

Dr Dilip Nathan Page 16 of 17 February 2014

  Stop-Start training – No real reviews and not recommended as it promotes
dysfunctional voiding in some children.

Appendices
Appendix 1: Dry bed training

Dry-bed training is a training programme that may include combinations of a number

of different behavioural interventions, and that may include rewards, punishment,
training routines and waking routines, and may be undertaken with or without an
alarm.

References

1) NICE Guideline, 2010Bosson S, Lyth N, Nocturnal Enuresis, Clinical Evidence, 9,2003,

407-413.

2) Delvin J.B., Prevalence and Risk Factors for Childhood Nocturnal Enuresis,
Irish Medical Ournal, 1991, 84; 118-120.

3) Butler McGrigan, Rogers Bedwetting, treating the underlying problem, 2004.

4) PNE Workshop – Helping children through PNE, Jonathan Evans, 2004.

5) ERIC, 34 Old School House, Brittannia Road, Kingswood, Bristol, BS15 8DB.

6) Glazener C.M., Evans J.H., Desmopressin for Nocturnal Enuresis in children

a) (Cochrane Review) Issue 21, 2004.

7) Glazener C.M.A., Evans J.C.E., (Cochrane Review), The Cochrane Library, Issue 3,
Ocford 2003.

Further Reading

1) Nocturnal Enuresis, The Child’s Experience, Richard J Butler, Buttermouth & Heinemann
1994.

2) Management of bedwetting, Dwg and Therapeutics Bulletin, Vol 42, No5, May 2004.

3) World Health Organisation, Non organic Enuresis, The ICD-10 Classification, Geneva
WHO 1992.

4) Effective Health Care, Treating Nocturnal Enuresis in Children, Vol 8, Number 2, 2003.

5) ERIC. Nocturnal and Daytime wetting – a handbook for professionals. Available in

Children’s centre library City hospital

Dr Dilip Nathan Page 17 of 17 February 2014