Practical consensus guidelines for the management of enuresis.

Abstract

Despite the high prevalence of enuresis, the professional training of doctors in the evaluation and management of this condition is often minimal and/or inconsistent. Therefore, patient care is neither optimal nor efficient, which can have a profound impact on affected children and their families. Once comprehensive history taking and evaluation has eliminated daytime symptoms or comorbidities, monosymptomatic enuresis can be managed efficaciously in the majority of patients. Non-monosymptomatic enuresis is often a more complex condition; these patients may benefit from referral to specialty care centers. We outline two alternative strategies to determine the most appropriate course of care. The first is a basic assessment covering only the essential components of diagnostic investigation which can be carried out in one office visit. The second strategy includes several additional evaluations including completion of a voiding diary, which requires extra time during the initial consultation and two office visits before treatment or specialty referral is provided. This should yield greater success than first-line treatment. Conclusion: This guideline, endorsed by major international pediatric urology and nephrology societies, aims to equip a general pediatric practice in both primary and secondary care with simple yet comprehensive guidelines and practical tools (i.e., checklists, diary templates, and quick-reference flowcharts) for complete evaluation and successful treatment of enuresis.

Full text

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ORIGINAL ARTICLE
Practical consensus guidelines for the management
of enuresis
Johan Vande Walle & Soren Rittig & Stuart Bauer &
Paul Eggert & Daniela Marschall-Kehrel & Serdar Tekgul
Received: 25 November 2011 /Accepted: 25 January 2012 /Published online: 24 February 2012
#The Author(s) 2012. This article is published with open access at Springerlink.com
Abstract Despite the high prevalence of enuresis, the pro-
fessional training of doctors in the evaluation and manage-
ment of this condition is often minimal and/or inconsistent.
Therefore, patient care is neither optimal nor efficient,
which can have a profound impact on affected children
and their families. Once comprehensive history taking and
evaluation has eliminated daytime symptoms or comorbid-
ities, monosymptomatic enuresis can be managed effica-
ciously in the majority of patients. Non-monosymptomatic
enuresis is often a more complex condition; these patients
may benefit from referral to specialty care centers. We
outline two alternative strategies to determine the most
appropriate course of care. The first is a basic assessment
covering only the essential components of diagnostic inves-
tigation which can be carried out in one office visit. The
second strategy includes several additional evaluations in-
cluding completion of a voiding diary, which requires extra
time during the initial consultation and two office visits
before treatment or specialty referral is provided. This
should yield greater success than first-line treatment. Con-
clusion: This guideline, endorsed by major international
pediatric urology and nephrology societies, aims to equip a
general pediatric practice in both primary and secondary
care with simple yet comprehensive guidelines and practical
tools (i.e., checklists, diary templates, and quick-reference
flowcharts) for complete evaluation and successful treat-
ment of enuresis.
Keywords Enuresis.Monosymptomatic.Consensus
guidelines.Primarycare.Management
Introduction
Evaluation and management of enuresis, a common condi-
tion, is not a priority in training programs for medical
J. Vande Walle
Pediatric Nephrology Unit, Ghent University Hospital,
Ghent, Belgium
S. Rittig
Department of Pediatrics, Aarhus University Hospital,
Skejby, Denmark
e-mail: soren.rittig@skejby.rm.dk
S. Bauer
Department of Urology, Children’s Hospital,
Harvard Medical School,
Boston, MA, USA
e-mail: stuart.bauer@childrens.harvard.edu
P. Eggert
University Children’s Hospital,
Kiel, Germany
e-mail: p.eggert@pediatrics.uni-kiel.de
D. Marschall-Kehrel
Urology Consultancy,
Frankfurt/Main, Germany
e-mail: kehrel.daniela@t-online.de
S. Tekgul
Department of Urology, Hacettepe University School of Medicine,
Ankara, Turkey
e-mail: tekgul-k@tr.net
J. Vande Walle (*)
Pediatric Nephrology UZ Ghent,
De Pintelaan 185,
9000 Ghent, Belgium
e-mail: johan.vandewalle@uzgent.be
Eur J Pediatr (2012) 171:971–983
DOI 10.1007/s00431-012-1687-7

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doctors (MDs), despite being a common condition. Frequent
bedwetting (defined as >3 wet nights per week) has an
estimated prevalence of nearly 10% in children aged 7 years
[9, 16, 17, 22, 57] and is associated with embarrassment and
significant emotional and practical difficulties for affected
children and their families. Information available to families
on the internet is often inaccurate, while guidelines for
doctors are often center- or subdiscipline-dependent and
are published in highly specific specialty journals not avail-
able to the majority of MDs in primary or secondary pedi-
atric care [13, 18, 24, 33, 37, 41, 46, 47]. No unifying set of
recommendations for a diagnostic and management algo-
rithm of enuresis currently exists.
Aims of this paper
This manuscript aims to present an international consensus
on a practical, rational approach to the diagnosis and man-
agement of bedwetting in the primary care setting. Recom-
mendations are based on the International Children’s
Continence Society (ICCS) standardization document on
monosymptomatic enuresis (MNE) [31], empirical evi-
dence, and discussions of leading experts in pediatric urol-
ogy and nephrology during a consensus meeting in 2009.
The recommendations have been reviewed and endorsed by
committees representing the American Academy of Pediat-
rics, European Society for Paediatric Urology (ESPU), Eu-
ropean Society for Paediatric Nephrology, and the ICCS.
This guideline is intended as a practical supplement to the
recentICCSstandardizationreport[31]andprovidesdirection
and tools (e.g., checklists, flowcharts, and diaries) for MDs to
use in children with enuresis and their parents, by outlining
minimum evaluation criteria, initial treatment options, and
indications for referral to a specialist center/doctor.
Background
Box 1: Terminology
Definitions
Comorbidity factors: Factors proven to be associated with increased
incidence of enuresis and/or increased therapy resistance
Expected bladder capacity (EBC): Calculated as [30+(age in years ×
30)] in milliliters
Maximum voided volume (MVV): The largest volume of urine voided
in a 24-h period, as documented in a bladder diary kept over
3–4 days, excluding first morning voids
Conditions
Enuresis: Intermittentincontinencewhileasleepinachild>5 yearsofage
Monosymptomatic enuresis: Enuresis with no other lower urinary tract
symptoms
Nocturnal polyuria (NP): Overproduction of urine at night, defined as
nocturnal urine output exceeding 130% of EBC for age
Non-monosymptomatic enuresis: Enuresis with other, mainly daytime,
lower urinary tract symptoms
Overactive bladder (OAB): all children with complaints of urgency
and frequency with or without incontinence
A full glossary of all relevant terminology and definitions can be found
in the 2006 ICCS standardization paper [33]
The pathophysiology of enuresis is complex, involving
the central nervous system (several neurotransmitters and
receptors), circadian rhythm (sleep and diuresis), and blad-
der function derangements. A simplified screening process
enables identification of two archetypes of enuresis:
&
Underlying NP associated with low overnight vasopres-
sin levels [38], decreased urinary osmolality, and poor
likelihood of a desmopressin response
“Small for age” bladder volume associated with OAB
(overlaps with subtype of non-monosymptomatic enure-
sis (NMNE)—patients with lower urinary tract symp-
toms), reduced desmopressin response, and higher rates
of response to the enuresis alarm
&
A combination of both forms is possible, and such
patients generally respond well to combined therapy with
desmopressin and an alarm. In addition to these urinary/
bladder storage characteristics, all children with enuresis
experience impaired arousal from sleep which prevents
waking to void in the toilet [25, 32].
In children aged ≥5 years, enuresis is considered abnor-
mal. Reasons for proactive management include the distress
caused to child and family, difficulty of “sleeping over” on
holiday or at friends’ houses, social withdrawal, reduced
self-esteem [12], and potential disturbance of the child’s
and the parents’ sleep architecture that may have an impact
on daytime functioning and health [5, 7, 23, 60]. Moreover,
untreated enuresis (especially if severe) can persist indefi-
nitely, with prevalence rates in adulthood of 2–3% [61, 63].
As such, prompt therapy may avoid serious consequences
for the child’s well-being. Additional reasons include the
risk that some parents may be intolerant of their child’s
wetting [3, 43, 55] and the significant inconvenience and
costs associated with frequent laundering of bedsheets and
clothing [34, 44]. The lack of public awareness that this is a
treatable condition means that some families prefer to keep
it a secret, hoping for spontaneous resolution, rather than
seeking medical help [2].
Children who wet the bed, especially those with se-
vere enuresis, are likely to benefit from appropriately
timed treatment; the 2–3% who continues to wet into
early adulthood without treatment may be prevented
from enduring the prolonged impact of the incontinence
[20, 27, 30, 34, 45].
972Eur J Pediatr (2012) 171:971–983

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Management of enuresis
This clinical management tool (CMT) should help to:
&
&
&
Raise awareness
Provide current information to affected families and MDs
Override false advice and misinformation from unregu-
lated sources
Limit recommendations to evidence-based treatment
strategies
&
In primary care, “trial and error” treatment for enuresis is
often the rule rather than the exception; this approach is a
waste of time and money and increases frustration among
families and doctors. It may also have an adverse psycho-
logical effect on the child [48]. We believe the rational
therapeutic approach outlined in the ICCS standardization
document [31] would lead to higher success rates.
Specialists have more time to perform a full diagnostic
evaluation that may result in improved outcomes than pri-
mary care physicians, due to restrictions in time and budget
that limit protocol adherence in every affected child. We
also recognize that there may be country- and center-
specific variations in the level of investigation possible.
Therefore, we propose two levels of evaluation, allowing
MDs to choose an appropriate strategy.
Box 2: Strategies for evaluating patients with enuresis in primary care
Strategy 1: Minimal evaluation, covering only the essential components
of diagnostic investigation during a single office visit that includes
evaluation and treatment or referral to a consultant or specialty center
Strategy 2: All components of strategy 1 as well as a small number of
additional evaluations that may require extra time during the initial
consultationandtwoofficevisitsbeforetreatmentorreferralisprovided.
This probably carries a greater chance of successful first-line treatment
If the chosen strategy is not successful, the child should
be referred to a specialist who can provide a more in-depth
evaluation of the problem. Flowcharts summarizing the
recommended evaluation of patients with enuresis (strate-
gies 1 and 2) are shown in Fig. 1.
Basic evaluation process
History taking—for strategies 1 and 2
Thorough history taking is an essential component for strat-
egies 1 and 2. A checklist CMT, with footnotes explaining
the relevance of each area of questioning and consequences
for potential referral, is provided (Table 1) to assist with this
process. Essential areas of questioning are listed with more
detailed questions to elicit further information when neces-
sary. Although the CMT is designed to be completed by the
doctor, it could be adapted as a “self-assessment” test for
patients/parents and given to families beforehand to reduce
consultation time [11, 15].
Physical examination
A brief but thorough physical examination should be per-
formed primarily to identify rare underlying anatomical
(phimosis and labial agglutination) or neurogenic (spinal
malfunction) causes. Relevant observations are listed in
Table 2. Use of urodynamic studies, X-ray, and cystoscopy
are not appropriate in this setting; if indicated based on data
collected, the family should be referred to a specialist.
Patients with explicit NMNE
A consensus opinion advocates that daytime symptoms be
treated before the enuresis is addressed as coexisting bladder
dysfunction is associated with less favorable outcomes for
both desmopressin and alarm therapy. Specialist referral is
almost mandatory. Children with these findings are consid-
ered complex, and their management is controversial and
outside the framework of this paper since little evidence-
based medicine to guide treatment exists. Furthermore, ther-
apy resistance is likely, and many of the proposed therapies
require off-label use of medication.
Patients with constipation
Enuresis (especially NMNE) often occurs concomitantly
with constipation. Constipation should therefore be identi-
fied and treated before managing enuresis (see Box 3—the
Rome criteria).
Box 3: Rome III criteria for diagnosis of constipation [35]
At least two of the following criteria must be met for ≥2 months before
diagnosis:
(a) ≤2 defecations in the toilet per week
(b) ≥1 episode of fecal incontinence per week
(c) History of retentive posturing or excessive volitional stool retention
(d) History of painful or hard bowel movements
(e) Presence of a large fecal mass in the rectum
(f) History of large diameter stools that may obstruct the toilet
Patients should not have a diagnosis of irritable bowel syndrome
Other comorbidities
Eating and drinking habits should be reviewed. Helpful
advice based on opinion rather than empirical evidence
includes avoiding excessive fluids in the evening [24],
avoiding caffeinated beverages (expert opinion), ensuring
adequate fluid intake during the daytime, avoiding a high
Eur J Pediatr (2012) 171:971–983973

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protein diet or salt in the evening (as these induce solute
diuresis) [53], and remembering to void before bedtime.
Discussion and reassurance
Paramount to the success of this process is an explanation at
the outset of why these measures can be helpful. Children
and families should be educated about the condition and
reassured that (a) it is a common problem that they should
not be embarrassed, (b) it likely affects other members of
their peer group, and (c) there are effective treatments to
resolve it. Frank discussion should be encouraged and edu-
cational materials provided for children and parents to help
engage the whole family in the treatment process. Empa-
thetic support should be provided if enuresis persists.
Additional evaluations for strategy 2
Patient recall does not always correspond with actual void-
ing patterns. Where possible, it is ideal to provide families
a
b
Child ≥5 years
who wets bed
Advice
(eg causes, fluid and food intake)
CMT questioning
Physical examination and dipstick
Symptoms suggestive of bladder
dysfunction/comorbidity?
YES:
Treat these first/refer if
necessary
NO: MNE
Advice on treatment options:
shared decision based on preferences,
motivation and diary if completed
Alarm Desmopressin
Voided volumes/NP
help guide treatment
choice in Strategy 2
EXTENSION
Child ≥5
years who
wets bed
Advice
(eg causes, fluid and food intake)
CMT questioning
Physical examination and dipstick
Night + daytime
Diary
Symptoms suggestive of bladder
dysfunction/comorbidity?
YES:
Treat these first/refer if
necessary
NO: MNE
Advice on treatment options:
shared decision based on preferences,
motivation and diary if completed
Alarm
(reduced MVV)
Desmopressin
(NP)
Fig. 1 Flowcharts
summarizing recommended
evaluation of children with
enuresis. a Strategy 1 0
minimal; b Strategy 2 0
optimal. CMT clinical
management tool, MNE
monosymptomatic enuresis,
MVV maximum voided volume,
NP nocturnal polyuria
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of child with no apparent symptoms of NMNE with bladder
diaries (see template) for completion before a second ap-
pointment (evidence level 3, grade B). This has the
advantage of helping to distinguish MNE from NMNE and
to give important information on bladder capacity and noc-
turnal urine production.
Table 1 Checklist clinical management tool (CMT)
Signs and symptoms Presence/
absence
Consider
referral if
positive (R)
Nocturnal enuresis
Does the child wet the bed?
Number of nights per week --------------------
Establishes severity, which is suggestive of prognosis
Age 5 years
Younger patients are likely to experience spontaneous resolution without intervention;
treatment only considered in children 5 years
Symptoms suggestive for underlying bladder dysfunction
Leakages of urine during the day
Drops of urine in the underpants
Before voiding
After voiding
Very wet underpants
Frequency of leakage (N = episodes per day)
Intermittent or continuous leakage every day?
History of daytime incontinence over 3½ years of age
Suggestive of overactive bladder/NMNE
Urinary frequency (# of voids) ( 8 x/day)?
Suggestive of overactive bladder
Voiding postponement (# of voids) ( 3 x/day)?
Suggestive of dysfunctional voiding
Sudden and urgent need to urinate?
Suggestive of overactive bladder
Holding maneuvers observed (e.g. Vincent’s curtsey – pressing heel
into perineum, leg crossing, standing on tiptoes)
Suggestive of dysfunctional voiding
Needs to push in order to urinate, i.e. need to use abdominal muscles
to strain to pass urine?
Suggestive of dysfunctional voiding
Interrupted urinary stream, or several voids, one after another?
Suggestive of dysfunctional voiding
History of urinary tract infection?
Often associated with underlying bladder dysfunction
Illness and/or malformation?
Of kidneys and/or urinary tract
Of spinal cord
Comorbidity – factors that might predict therapy resistance
Bowel movements – presence or history of the following?
Constipation ( 3 bowel movements/week)
Traces of feces in the underpants (fecal incontinence) – not due
to insufficient wiping of the bottom?
May predict treatment resistance; resolution of constipation may resolve enuresis
Psychological, behavioral or psychiatric problems?
Evidence of ADHD, ADD, autism, etc
May predict treatment resistance
History of motor and/or learning disabilities or delayed development
Delayed development may be suggestive of central nervous system pathology
Drinking habits
Quantity and type of fluid intake?
Drinks more than one glass during the evening?
Drinks during the night?
Water turnover in children is reported to be 1500 ml/m2 body surface area per day42
Fluid intake in the evening (after the evening meal) should be minimized since
increased fluid intake results in higher dieresis volumes during the night
Fluid intake during the night should be avoided
Exclude diabetes mellitus (dipstick test)
Psychogenic polydipsia poses risk for water intoxication with desmopressin
Notes for physicians are given in gray text
Yes
Yes
No
No
Yes No
Yes No R
Yes No R
Yes No R
Yes No R
Yes No R
Yes No R
Yes No R
Yes No R
Yes
Yes
No
No
R
R
Yes No See Box 3;
may be
treated in
primary care
Yes No R
Yes
Yes
No
No
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