1. Issue date: October 2010 NICE clinical guideline 111 Developed 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 1

2. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts 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 Enuresis being referred to the School Nurse Enuresis service 2

3. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Letter to referrerNew Patient Apt Health screening Apt Please make new Apt Please contact us/ or discharge Your appointment is overdue DNA’d 1 st 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 3

4. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Bed wetting GuideChildhood soiling Enuresis Booklet Daytime wettingAdvice tick list Talk about bedwetting Nights away 4

5. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Tick ListProgress ChartFluid Chart 5

6. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Decline referral. Referrer to refer to Specialist Enuretic Service or other specialist service ie. CAMHS. Specialist Enuresis service CAMHS 6

7. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Decline referral. Referrer advised to refer to GP/ paediatrician 7

8. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Self Help Measures 6-7 drinks/ day 6-7 voids/ day Small drink before bed Easy access to toilet Positive thinking Contact ERIC Bed wetting Guide Enuresis Booklet Advice tick list Nights away ERIC 8

9. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts 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 Continue

10. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts 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 AlarmDrug

11. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Advice Does the child have some dry nights? YesNo 11

12. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Advise parents or carers to try reward system alone 12 The child is Appropriate for clinic

13. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Alarm Treatment Bedwetting has not responded to advice on fluids, toileting and an appropriate reward system and Alarm treatment is desirable and appropriate YesNo 13

14. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Offer an alarm as first-line treatment 14

15. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts 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 15

16. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Offer desmopressin for children and young people over 7 years 16

17. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Start alarm treatment. Assess response by 4 weeks Early signs of response? YesNo Recurrence following success 17

18. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Continue with alarm. Have there been 2 weeks uninterrupted dry nights achieved? YesNo 18

19. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Stop alarm treatment. 19

20. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Continue with alarm 20

21. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Assess progress at 3 months Is bedwetting improving and are the child and parents/carers motivated to continue? YesNo 21

22. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Consider restarting alarm Treatment if the child Starts regularly Bedwetting again Recurrence Repeated recurrence Stop treatment with alarm alone 22

23. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Repeated recurrence Is alarm treatment still acceptable? YesNo 23

24. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Offer desmopressin combined with an alarm 24

25. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Offer desmopressin alone 25

26. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Start desmopressin treatment Is complete dryness achieved after 1-2 weeks? YesNo 26

27. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Assess response at 4 weeks 27

28. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Consider increasing dose 28

29. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts 1 Response Partial or no response 29

30. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts 2 Response Partial or no response 30

31. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts 3 Response Partial or no response 31

32. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Continue treatment for 3 months 32

33. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Consider advising that desmopressin is taken 1-2 hours before bedtime, instead of at bedtime, if the child can comply with fluid restriction YesNo 33

34. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Consider stopping desmopressin treatment 34

35. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts 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 35

36. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Blank page 36

37. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Stop desmopressin Treatment unless Bedwetting recurs 37

38. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Consider continuing desmopressin treatment (up to 6 months) 38

39. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Restart desmopressin and consider repeated courses of desmopressin for repeated recurrences Withdraw every 3 months to assess response Withdraw gradually if using repeated courses 39

40. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Follow child protection protocol & procedures 40

41. 41 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 Both YES Letters pageReferral pageAdvice leafletsCharts

42. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon Referral pageLetters pageAdvice leafletsCharts Self Help Measures 6-7 drinks/ day 6-7 voids/ day Small drink before bed Easy access to toilet Positive thinking Contact ERIC Bed wetting Guide Enuresis Booklet Advice tick list Nights away ERIC 42 Continue

43. 43 Treatment Anticholinergernic medication and bladder retraining. Review by GP or specialist if medication required. Review Letters pageReferral pageAdvice leafletsCharts

44. 44 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 pageReferral pageAdvice leafletsCharts

45. 45 Continue Treatment 3-6 months Signs of success Dry nights NOYES Letters pageReferral pageAdvice leafletsCharts

46. 46 Continue treatment max 6 weeks Treatment a success? YESNO Letters pageAdvice leafletsReferral pageCharts

47. 47 Success = 14 consecutive dry nights NOYES Letters pageReferral pageAdvice leafletsCharts

48. 48 Continue treatment 3-9 months Can be used as long as symptom control is required – reassess every three months Treatment a success? YESNO Letters pageAdvice leafletsReferral pageCharts

49. 49 Cease Treatment Letters pageReferral pageAdvice leafletsCharts

50. 50 Give break and retry as appropriate after 3-6 months Letters pageReferral pageAdvice leafletsCharts

51. Issue date: October 2010 NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon 51