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Why a paediatric continence service is more than just a NICE to have! June Rogers MBE The rationale for an integrated service, early intervention and savings with a robust service. Nocturnal enuresis (NE)is the most common type of urinary incontinence in children and is defined as wetting during sleep in a child aged 5 years or older. Studies have identified that as many as 1 in 5 children wet the bed with figures decreasing by 15% each year of age dropping to around 6 % at age 11 years (Kilicoglu et al 2013) There are three commonly proposed mechanisms that contribute towards bedwetting including: Excessive production of night time urine Bladder over-activity or small capacity Failure to wake in response of bladder signals (lack of arousal) The exact cause of bedwetting in individual children may be
interlinked with one or all of above and may also involve other factors such as family history, fluid intake and constipation. Bedwetting could also be a symptom of an underlying problem that parents fail to recognise as significant. For example, many parents dismiss day time bladder problems such as urgency, frequency and the odd pair of wet pants as part of the natural maturation process so do not seek help – it is only when they come forward with the bedwetting problem that these potentially serious underlying bladder problems are identified. Other comorbidities, such as diabetes or the presence of UTIs, can also be excluded at this point. Constipation can also be a contributory factor and once resolved the bedwetting has been shown to improve (Borch et al 2013) It is therefore important that all children
who present with bedwetting have a comprehensive assessment which will not only exclude or identify any underlying pathology, such as constipation or bladder problems, but will also help inform the initial choice of treatment (Cederblad et al 2015, NICE 2014). Early intervention and active management is recommended for all children with bedwetting from aged 5 years (NICE 2014). A large British cohort study (Butler & Heron 2008) identified that those children who are considered to have either severe bedwetting (i.e. wet every night at age 4.5 - 5 years) or the non monosymptomatic form are likely to persist with the bedwetting throughout childhood and into adolescence if it is left untreated. NICE (2014) recommended that either desmopressin or the alarm should be considered as first line
treatment if lifestyle changes alone did not result in resolution of the problem. The choice of initial treatment should be informed by the assessment, and should take into account the preference of the child and their parents or carers. Factors such as age, associated functional difficulties and disabilities, financial burdens and living situations may affect their preferences. Unfortunately continence services for children with problems such as bedwetting are often fragmented and inconsistent which can result in children being neither assessed appropriately nor offered timely appropriate treatment. Also is the concern that any underlying co-morbidities such as constipation or bladder problems are not being identified and treated at an early stage. Often it is only when such problems have escalated, with the child ending up in A&E or 41 / NIHR / 2016