issue date : october 2010
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Start
CONTINENCE STUDY AFTERNOON
Paul Watson
Lets Talk About Enuresis
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
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.
Guidelines for children with Enuresisbeing referred to the School Nurse Enuresis service
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Letter to referrerNew Patient Apt Health screening Apt
Please make new Apt
Please contact us/ or discharge
Your appointment is overdue
DNA’d 1st Apt.Contact or close
Alarm Loan Agreement
Please rebook or return alarm 1
Please rebook or return alarm 2
GP request for Desmo
Discharge letter to GP
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Bed wetting Guide Childhood soiling
Enuresis Booklet
Daytime wettingAdvice tick list
Talk about bedwetting Nights away
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Tick List Progress Chart Fluid Chart
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Decline referral. Referrer to refer to Specialist
Enuretic Service or other specialist service ie. CAMHS.
Specialist Enuresis service CAMHS
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Decline referral.Referrer advised to
refer to GP/ paediatrician
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Self Help Measures
6-7 drinks/ day6-7 voids/ daySmall drink before bedEasy access to toiletPositive thinkingContact ERIC
Bed wetting Guide
Enuresis Booklet
Advice tick list
Nights away
ERIC
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
AssessmentHistory•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
Continue
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
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
Advice Alarm Drug
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Advice
Does the child have some dry nights?
Yes No
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Advise parents or carers to try reward
system alone
The child is Appropriate for
clinic
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
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
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Offer an alarm as first-line treatment
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
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)
Yes No
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Offer desmopressin for children and young people
over 7 years
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Start alarm treatment.
Assess response by 4 weeks
Early signs of response?
Yes No
Recurrence following success
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Continue with alarm.
Have there been 2 weeks uninterrupted dry nights achieved?
Yes No
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Stop alarm treatment.
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Continue with alarm
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Assess progress at 3 months
Is bedwetting improving and are
the child and parents/carers motivated to
continue?
Yes No
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Consider restarting alarmTreatment if the child
Starts regularly Bedwetting again
Recurrence Repeated recurrence
Stop treatment with alarm alone
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Repeated recurrence
Is alarm treatment still acceptable?
Yes No
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Offer desmopressin combined with
an alarm
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Offer desmopressin
alone
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Start desmopressin
treatment
Is complete dryness
achieved after 1-2 weeks?
Yes No
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Assess response at 4 weeks
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Consider increasing dose
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
1
Response Partial or noresponse
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
2
Response Partial or noresponse
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
3
Response Partial or noresponse
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Continue treatment for3 months
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
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
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Consider stopping desmopressin treatment
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Refer for further review and assessment of factors
associated with poor response (e.g. overactive bladder,
underlying disease or social and emotional factors)
Furthertreatments
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Blank page
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Stop desmopressin Treatment
unlessBedwetting recurs
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Consider continuing desmopressin treatment
(up to 6 months)
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Restart desmopressin and consider repeated courses of desmopressin for repeated
recurrences
•Withdraw every 3 months to assess response•Withdraw gradually if using repeated courses
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Follow child protection protocol & procedures
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Diagnosis – Three Systems Model
Lack of arousal from sleep.Inability to wake to bladder
sensations.Sleeping through wetting.
Bladder instability/ low functional bladder capacity
•Sense of urgency•Frequent daytime voiding•Low voided volume•Multiple wetting•Variable sized wet patch•Wakes after wetting
Nocturnal polyuria (Low Nocturnal vasopressin levels)
•Wets soon after sleep•Large wet patches•Dry nights only if child wakes•Weak urine
YES
YES
Both
YES
Letters page Referral page Advice leaflets Charts
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon
Referral pageLetters page Advice leaflets Charts
Self Help Measures
6-7 drinks/ day6-7 voids/ daySmall drink before bedEasy access to toiletPositive thinkingContact ERIC
Bed wetting Guide
Enuresis Booklet
Advice tick list
Nights away
ERICContinue
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Treatment Anticholinergernic medication and
bladder retraining.
Review by GP or specialist if medication required.
Review
Letters page Referral page Advice leaflets Charts
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Signs of improvement• Delays point of voiding to early
morning• Less wetting during episode• More dry nights• Parent/ child satisfied with
progress
Initial Review 2-4 weeks after treatment
Responding to treatment
Not responding to treatment
Letters page Referral page Advice leaflets Charts
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Continue Treatment 3-6 months
Signs of success• Dry nights
NOYES
Letters page Referral page Advice leaflets Charts
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Continue treatment max 6 weeks
Treatment a success?
YES NO
Letters page Advice leafletsReferral page Charts
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Success = 14 consecutive dry nights
NOYES
Letters page Referral page Advice leaflets Charts
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Continue treatment 3-9 months
Can be used as long as symptom control is required – reassess every three months
Treatment a success?
YES NO
Letters page Advice leafletsReferral page Charts
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Cease Treatment
Letters page Referral page Advice leaflets Charts
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Give break and retry as appropriate after 3-6 months
Letters page Referral page Advice leaflets Charts
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Issue date: October 2010
NICE clinical guideline 111Developed by the National Clinical Guideline Centre
Nocturnal enuresis
The management of bedwetting in
children and young people
Presentation based upon