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Improving clinical practice and patient care in nocturnal enuresis
Launch of Nocturnal Enuresis Resource Kit in lead up to World Bedwetting Day
Release of a new report addressing the need for children to have timely access to appropriate healthcare for the management of urinary incontinence1 coincides with today’s launch of the second edition of the Australian Nocturnal Enuresis Resource Kit in the lead up to World Bedwetting Day (Tuesday May 29 2018).
The Agency for Clinical Innovation (ACI) report, developed in partnership with the Sydney Children’s Hospitals Network (SCHN) and Continence Foundation of Australia (CFA) to improve the management and health outcomes for children and young people living with urinary incontinence, focuses on delayed access to specialist care post-diagnosis and insufficient information available to young people and their families.1
Designed to help fill this void, the Nocturnal Enuresis Resource Kit serves as an invaluable resource for Australian healthcare professionals, patients and carers involved in the treatment journey of nocturnal enuresis.2
Nocturnal enuresis, or bedwetting, is defined as the intermittent leakage of urine during sleep.3
According to Nocturnal Enuresis Resource Kit co-authors, Paediatrician and Staff Specialist at The Children’s Hospital at Westmead, Associate Professor Patrina Caldwell, Sydney, and Paediatric Urologist, Department of Paediatric Urology and Surgery, John Hunter Children’s Hospital, Dr Aniruddh Deshpande, Newcastle, resources such as the Nocturnal Enuresis Resource Kit are essential in providing additional support to all those affected by nocturnal enuresis.
'We know there are delays diagnosing and treating nocturnal enuresis. Patients and their families require support throughout the treatment journey. Healthcare professionals sometimes need additional help to support their patients, particularly when initial attempts at treatments fail. The Nocturnal Enuresis Resource Kit is designed to offer this support, by providing current and relevant information on nocturnal enuresis management and how to address the challenges and barriers that may present,' said A/Prof Caldwell.
'There is a common assumption that bedwetting resolves spontaneously. However, the impact of bedwetting on those who continue to experience nocturnal enuresis is often ignored. Bedwetting can significantly impact sleep quality,self-esteem, emotional wellbeing and daytime functioning, both at school and socially.4-9 This stigmatising condition is often not talked about, as children are usually very embarrassed about it, leading to feelings of shame, guilt, and helplessness.'2
The risk of bedwetting increases if the child’s mother, more so than their father, experienced enuresis as a child.10 As many as 20 per cent of children continue to wet the bed at five years of age,2 while nocturnal enuresis, which has a male skew, affects as many as 10 per cent of 10 year olds2 and is considered common in children aged 5 years and above.10-15
World Bedwetting Day aims to raise awareness of childhood nocturnal enuresis among healthcare professionals and the community as a common medical condition that can, and should, be treated.16
Continence Foundation of Australia Chief Executive Officer, Rowan Cockerell, Melbourne, believes the common assumption that children will always simply outgrow bedwetting needs to be addressed.
'Bedwetting is commonly overlooked as a simple condition that a child will eventually outgrow.1 However, the growing body of evidence suggests nocturnal enuresis is a complex disorder involving several factors, such as difficulty arousing from sleep, urine over-production during sleep, and bladder dysfunction.'17
'The impact of nocturnal enuresis is often under-estimated and trivialised, so help is neither sought, nor offered.16 Bedwetting children may be reprimanded by their parents, which can compromise their mental wellbeing and personal development,'18-19 said Mrs Cockerell.
'Many parents initially resort to lifestyle changes, while almost half fail to seek help for children aged five years and above.8 World Bedwetting Day shines a light on the problem, reinforcing nocturnal enuresis as a treatable condition for which parents should proactively seek healthcare professional advice and support.'
'The Continence Foundation of Australia offers free resources and support to patients, carers and healthcare professionals to assist with the treatment of [childhood] nocturnal enuresis, including the National Continence Helpline on 1800 330 066, staffed by continence nurses,' Mrs Cockerell said. 'We now know how nocturnal enuresis affects a child’s psychosocial development and perceived quality of life. This impact is not severity dependent, but rather, age and gender dependent,'20 said Dr Deshpande.
'Although the negative impact is broadly felt by all affected children, it appears to be perceived significantly more by girls and older children. This is perhaps counter intuitive and mandates an appropriate response at the primary care level. Research also suggests children who are treated for nocturnal enuresis show improvements in their working memory and other daily activities.'21
About the Nocturnal Enuresis Resource Kit
The second edition of the Nocturnal Enuresis Resource Kit outlines the prevalence, pathophysiology, impact on quality of life, required assessment, initial management of nocturnal enuresis and cautionary red flags that warrant specialist referral. Building on the previous edition, the four sections of the revised Nocturnal Enuresis Resource Kit anticipate the problems that patients, their carers, and healthcare practitioners may encounter at different stages of the diagnosis and treatment journey of nocturnal enuresis.
The Kit focuses on factors for consideration, including family history, sleep disordered breathing, obesity, attention deficit hyperactivity disorder, bowel problems, developmental delay or physical and/or intellectual disability.2,22 The Nocturnal Enuresis Resource Kit’s parents and carers printable section contains practical and reliable information, enabling this audience to become functional members of the treatment team.
The Nocturnal Enuresis Resource Kit features the latest clinical evidence for the condition, including non-pharmacological approaches, such as pelvic floor training and transcutaneous electrical nerve stimulation (TENS) therapy.2 The updated pharmacotherapy section also reflects current, evidence-based practice recommendations and algorithms.2
Given a significant proportion of children can be treated for nocturnal enuresis at the primary care level, and in the absence of any cautionary red flags (including conditions such as refractory incontinence, recurrent urinary tract infections, known or suspected physical or neurological problems, comorbid conditions such as faecal incontinence or diabetes, significant attention, developmental, behavioural, or emotional problems, all of which require specialised management approaches), early GP referral to a specialist is not recommended.2 However, should there be no response, or sub-optimal response after three months, GP referral to a specialist is required.2
Head to https://www.neresourcekit.com.au to download a copy of the Nocturnal Enuresis Resource Kit.
About the Continence Foundation of Australia
The Continence Foundation of Australia aims to represent the interests of Australians affected by, or at risk of, bladder and bowel control problems, and to act as an advocate for their interests. The organisation coordinates a wide range of educational and awareness raising activities and events with support from the Federal Department of Health under the National Continence Program. To learn more about childhood nocturnal enuresis, contact the National Continence Helpline on 1800 33 00 66 or visit https://www.continence.org.au/. To coordinate an interview with A/Prof Patrina Caldwell, Dr Aniruddh Deshpande or Rowan Cockerell, please contact Kirsten Bruce or Bella Poidevin from VIVA! Communications on 02 9968 3741 or 0401 717 566 / 0423 041 631.
1. NSW Agency for Clinical Innovation (2018) PISCES Report. Young people with urinary incontinence: co-design patient experience. Transition care and urology networks.
2. Caldwell P & Deshpande A (2018) Nocturnal Enuresis Resource Kit (2nd Edition). The Children’s Hospital at Westmead and John Hunter Children’s Hospital.
3. Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children’s Continence Society. Neurourol Urodynam. 2016; 35(4):471–81.
4. Jönson Ring I, Nevéus T, Markström A, Arnrup K, Bazargani F. Nocturnal enuresis impaired children’s quality of life and friendships. Acta Paediatr. 2017;106(5):806–11.
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6. Equit M, Hill J, Hübner A, von Gontard A. Health-related quality of life and treatment effects on children with functional incontinence, and their parents. J Pediatr Urol. 2014;10(5):922–8.
7. Ching CB, Lee H, Mason MD, Clayton DB, Thomas JC, Pope JCI, et al. Bullying and lower urinary tract symptoms: why the pediatric urologist should care about school bullying. Journal of Urology. 2015;193(2):650-4.
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9. Sa CA, Paiva ACG, de Menezes MCLB, de Oliveira LF, Gomes CA, de Figueiredo AA, et al. Increased risk of physical punishment among enuretic children with family history of enuresis. Journal of Urology. 2016;195(4):1227–31.
10. Von Gontard A, Heron J, Joinson C. Family history of nocturnal enuresis and urinary incontinence: results from a large epidemiological study. Journal of Urology. 2011;185(6):2303–6.
11. Heron J, Grzeda MT, von Gontard A, Wright A, Joinson C. Trajectories of urinary incontinence in childhood and bladder and bowel symptoms in adolescence: prospective cohort study. BMJ Open. 2017;7(3): e014238.
12. Niemczyk J, Equit M, Braun-Bither K, Klein A-M, von Gontard A. Prevalence of incontinence, attention deficit/ hyperactivity disorder and oppositional defiant disorder in preschool children. Eur Child Adolesc Psychiatry. 2015;24(7):837–43.
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14. Yeung CK, Sreedhar B, Sihoe JDY, Sit FKY, Lau J. Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU International. 2006;97(5):1069–73.
15. Von Gontard A, Cardozo L, Rantell A, Djurhuus J-C. Adolescents with nocturnal enuresis and daytime urinary incontinence –How can pediatric and adult care be improved—ICI-RS 2015. Neurourol Urodynam. 2017;36(4):843–9.
16. World Bedwetting Day (2017) Bedwetting media factsheet. Available at: https://www.worldbedwettingday.com/uploads/WBD%202018%20Factsheet%20Bedwetting.pdf
17. Vande Walle J, Rittig S, Bauer S, Eggert P, Marschall-Kehrel D, Tekgul S. Practical consensus guidelines for the management of enuresis. Eur J Pediatr. 2012;171:971-983.
18. Al-Zaben FN, Sehlo MG Punishment for bedwetting is associated with child depression and reduced quality of life. Child Abuse Negl. 2015;43:22-9.
19. Ferrara P, Di Giuseppe M, Fabrizio GC, Sbordone A, Amato M, Cutrona C, Verrotti A. Enuresis and Punishment: The Adverse effects on Child development and on Treatment. Urol Int. 2016;97:410-415.
20. Deshpande AV et al Factors Influencing the Quality of life in Children with Urinary Incontinence. J Urol. 2011;186(3): 1048-1052.
21. Van Herzeele C, Dhondt K, Roels SP, Raes A, Hoebeke P, Groen LA, Vande Walle J. (2016) Desmopressin (melt) therapy in children with monosymptomatic nocturnal enuresis and nocturnal polyuria results in improved neuropsychological functioning and sleep. Pediatr Nephrol. 2016;31(9):1477-84.
22. Von Gontard A, Pirrung M, Niemczyk J, Equit M. Incontinence in children with autism spectrum disorder. J Pediatr Urol. 2015;11(5):264.e1-7.