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Start. Issue date : October 2010. Nocturnal enuresis The management of bedwetting in children and young people. NICE clinical guideline 111 Developed by the National Clinical Guideline Centre. CONTINENCE STUDY AFTERNOON Paul Watson Lets Talk About Enuresis. Presentation based upon.

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slide1

Start

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

CONTINENCE STUDY AFTERNOON

Paul Watson

Lets Talk About Enuresis

Presentation based upon

slide2

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Guidelines for children with Enuresisbeing referred to the School Nurse Enuresis service

The child has severe learning or physical disabilities.

The child has an underlying bladder or bowel condition.

The child is going through or is still suffering from a traumatic

or emotional situation.

The child is younger than seven years of age.

The child is seven years of age or older with none of the above.

Presentation based upon

slide3

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

New Patient Apt

Letter to referrer

Health screening Apt

Please make new Apt

DNA’d 1st Apt.

Contact or close

Your appointment is

overdue

Alarm Loan

Agreement

Please rebook or

return alarm 1

Please rebook or

return alarm 2

Please contact us/

or discharge

GP request for

Desmo

Discharge letter

to GP

Presentation based upon

slide4

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Bed wetting Guide

Childhood soiling

Advice tick list

Daytime wetting

Enuresis Booklet

Talk about bedwetting

Nights away

Presentation based upon

slide5

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Tick List

Progress Chart

Fluid Chart

Presentation based upon

slide6

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Decline referral.

Referrer to refer to Specialist Enuretic Service or other specialist service ie. CAMHS.

Specialist Enuresis

service

CAMHS

Presentation based upon

slide7

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Decline referral.

Referrer advised to refer to GP/ paediatrician

Presentation based upon

slide8

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Self Help Measures

Bed wetting Guide

6-7 drinks/ day

6-7 voids/ day

Small drink before bed

Easy access to toilet

Positive thinking

Contact ERIC

Enuresis Booklet

Advice tick list

Nights away

ERIC

Presentation based upon

slide9

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Assessment

  • History
  • No. of voids per day (frequency/ urgency)
  • Fluid intake (type/ quantity)
  • Bowels
  • Daytime wetting
  • Age at onset/ symptom duration
  • Arousal from sleep
  • Size/ Number of wet patches/ night
  • Family history
  • History of UTI’s

Suspicion of abuse

Behaviour problems

History of UTI’s

Presentation based upon

Continue

slide10

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

  • Child or young person with bedwetting
  • Advise on fluid intake, diet and toileting behavior
  • Address excessive or insufficient fluid intake and abnormal toileting patterns before starting other treatments
  • Advise on using a reward system
  • Suggest a trial without nappies or pull-ups for children and young people wearing them at night. Offer advice on alternative bed protection
  • Consider whether alarm or drug treatment is appropriate, depending on age, maturity and abilities of the child or young person, the frequency of bedwetting and the motivation and needs of the family
  • Assess the ability of the family to cope with an alarm

Advice

Advice

Presentation based upon

Advice

Alarm

Drug

slide11

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Advice

Does the child have some dry nights?

Yes

No

Presentation based upon

slide12

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Advise parents or

carers to try reward

system alone

The child is

Appropriate for

clinic

Presentation based upon

slide13

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Alarm Treatment

  • Bedwetting has not responded to advice on fluids, toileting and an appropriate reward system and
  • Alarm treatment is desirable and appropriate

Yes

No

Presentation based upon

slide14

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Offer an alarm as

first-line treatment

Presentation based upon

slide15

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Drug Treatment

  • Rapid-onset and/or short-term dryness is a priority OR
  • Alarm treatment is undesirable OR
  • Alarm treatment is inappropriate (particularly if parents or carers are having emotional difficulty coping or are expressing anger, negativity or blame)

No

Yes

Presentation based upon

slide16

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Offer desmopressin

for children and

young people

over 7 years

Presentation based upon

slide17

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Start alarm treatment.

Assess response by 4 weeks

Early signs of response?

Yes

No

Recurrence following success

Presentation based upon

slide18

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Continue with alarm.

Have there been 2 weeks uninterrupted dry nights achieved?

Yes

No

Presentation based upon

slide19

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Stop alarm treatment.

Presentation based upon

slide20

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Continue with alarm

Presentation based upon

slide21

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Assess progress at 3 months

Is bedwetting improving and are the child and parents/carers motivated to continue?

Yes

No

Presentation based upon

slide22

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Repeated recurrence

Recurrence

Consider restarting alarm

Treatment if the child

Starts regularly

Bedwetting again

Stop treatment with

alarm alone

Presentation based upon

slide23

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Repeated recurrence

Is alarm treatment still acceptable?

Yes

No

Presentation based upon

slide24

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Offer

desmopressin

combined with

an alarm

Presentation based upon

slide25

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Offer

desmopressin

alone

Presentation based upon

slide26

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Start desmopressin treatment

Is complete dryness achieved after 1-2 weeks?

Yes

No

Presentation based upon

slide27

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Assess response

at 4 weeks

Presentation based upon

slide28

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Consider increasing dose

Presentation based upon

slide29

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

1

Response

Partial or no

response

Presentation based upon

slide30

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

2

Response

Partial or no

response

Presentation based upon

slide31

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

3

Response

Partial or no

response

Presentation based upon

slide32

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Continue treatment for

3 months

Presentation based upon

slide33

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Consider advising that desmopressin is taken 1-2 hours before bedtime, instead of at bedtime, if the child can comply with fluid restriction

Yes

No

Presentation based upon

slide34

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Consider stopping

desmopressin treatment

Presentation based upon

slide35

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Refer for further review and assessment of factors associated with poor response (e.g. overactive bladder, underlying disease or social and emotional factors)

Further

treatments

Presentation based upon

slide36

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Blank page

Presentation based upon

slide37

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Stop desmopressin

Treatment

unless

Bedwetting recurs

Presentation based upon

slide38

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Consider continuing

desmopressin treatment

(up to 6 months)

Presentation based upon

slide39

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

  • Restart desmopressin and consider repeated courses of desmopressin for repeated recurrences
  • Withdraw every 3 months to assess response
  • Withdraw gradually if using repeated courses

Presentation based upon

slide40

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Follow child protection protocol & procedures

Presentation based upon

diagnosis three systems model

Letters page

Referral page

Advice leaflets

Charts

Diagnosis – Three Systems Model

Lack of arousal from sleep.

Inability to wake to bladder sensations.

Sleeping through wetting.

YES

Bladder instability/ low functional bladder capacity

Nocturnal polyuria (Low Nocturnal vasopressin levels)

  • Sense of urgency
  • Frequent daytime voiding
  • Low voided volume
  • Multiple wetting
  • Variable sized wet patch
  • Wakes after wetting
  • Wets soon after sleep
  • Large wet patches
  • Dry nights only if child wakes
  • Weak urine

Both

YES

YES

slide42

Letters page

Referral page

Advice leaflets

Charts

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Self Help Measures

Bed wetting Guide

6-7 drinks/ day

6-7 voids/ day

Small drink before bed

Easy access to toilet

Positive thinking

Contact ERIC

Enuresis Booklet

Advice tick list

Nights away

Continue

ERIC

Presentation based upon

treatment

Letters page

Referral page

Advice leaflets

Charts

Treatment

Anticholinergernic medication and bladder retraining.

Review by GP or specialist if medication required.

Review

initial review 2 4 weeks after treatment

Letters page

Referral page

Advice leaflets

Charts

Initial Review 2-4 weeks after treatment

Signs of improvement

  • Delays point of voiding to early morning
  • Less wetting during episode
  • More dry nights
  • Parent/ child satisfied with progress

Responding to

treatment

Not responding

to treatment

continue treatment 3 6 month s

Letters page

Referral page

Advice leaflets

Charts

Continue Treatment 3-6 months

Signs of success

  • Dry nights

YES

NO

slide46

Letters page

Referral page

Advice leaflets

Charts

Continue treatment max 6 weeks

Treatment a success?

YES

NO

slide47

Letters page

Referral page

Advice leaflets

Charts

Success = 14 consecutive dry nights

YES

NO

continue treatment 3 9 months

Letters page

Referral page

Advice leaflets

Charts

Continue treatment 3-9 months

Can be used as long as symptom control is required – reassess every three months

Treatment a success?

YES

NO

slide49

Letters page

Referral page

Advice leaflets

Charts

Cease Treatment

slide50

Letters page

Referral page

Advice leaflets

Charts

Give break and retry as appropriate after 3-6 months

slide51

Issue date: October 2010

Nocturnal enuresis

The management of bedwetting in children and young people

NICE clinical guideline 111

Developed by the National Clinical Guideline Centre

Presentation based upon