The usual recommendation is to have the child boost daily fluid intake substantially by carrying a water bottle throughout the day. The child is instructed to drink the liquid between 8:00 a.m. and 4:00 p.m.
each day. This hydration promotes the cycling of the bladder, so the clinician should place the child on a timed voiding schedule with intervals of no longer than two hours between micturition.

This process provides a solid connection and memory associating a full bladder with the act of voiding. For a child in school during the day, it is advised that a tactful note be sent to the teacher that explains the presence of the water bottle and requests that the child have access to a restroom when necessary.


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The last piece of homework assigned is to encourage healthy daily bowel elimination. If the child describes hard and painful bowel movements, a prescription for a mild laxative is usually given with instructions on titration to establish one to two soft stooling patterns each day.


The child should return to the clinic six to eight weeks later, at which point the clinician notes patterns and trends toward nocturnal dryness or the diminishment in volume of nighttime urine. Symptom improvement is typically noted, which in turn stimulates the child to continue the process.

If the symptoms worsen or if the child is resistant to the implementation of the clinician’s recommendations, the provider should suggest motivational rewards that are personal and interactive in nature rather than material. That is to say, the child is allowed to pick what movie the entire family watches together or is given “alone time” with the parent to read a book. Rewards should be accomplishments that reflect the child’s earnest effort at implementation of the urologic homework.


Waxing and waning of dry and continent nights are normal in the treatment of bedwetting, even in children that follow all recommendations. It is important that the clinician provides support at this time to improve the child’s self esteem.4

The provider may consider the use of desmopressin (DDAVP), a medication used to control the symptoms of a certain type of diabetes insipidus, or “water diabetes,” in which the body produces an abnormally large amount of urine. The oral dosing for this medication is to commence at 0.2 mg at bedtime and titrate up over several days to a total of 0.6 mg (i.e., three pills nightly). It is advised that the child should stay at one pill for a few nights to see if there is any impact upon promoting dryness or decrease in overnight urine output. If the patient is held effectively on one or two pills, this is the preferred dose.


Another option for resistant nocturnal enuresis is to incorporate a bedwetting alarm.5 These devices can be useful but require long-term commitment. Typically, the alarm takes three to four months to prove effective, and the child must be highly motivated to use it night after night. Consideration can be given to using the bedwetting alarm in tandem with desmopressin.


Sustained nighttime dryness over the course of several months suggests that the symptoms of nocturnal enuresis have been quelled. If the child is on desmopressin, it is recommended that the family titrate the dose down one month prior to the clinic visit to learn how the child will behave off the medication. 


At all times throughout the process of treating nocturnal enuresis, the clinician must provide the necessary reassurance and direction. This long-term guidance and support helps the family and the patient maintain the stamina required to stay the course of care to ensure the best outcome.

Coleen Weber Rosen DNP, APNP, FNP-C, is a family nurse practitioner specializing in pediatric urology at the Children’s Hospital of Wisconsin in Milwaukee. Teri Kaul PhD, MSN, APRN-BC, is the director of the Graduate Nursing Program and an associate professor at Concordia University, Mequon, Wisc.


References


  1. Su MS, Li AM, So HK, et al. Nocturnal enuresis in children: prevalence, correlates, and relationship with obstructive sleep apnea. J Pediatr. 2011;159:238-242.

  2. National Institute for Health and Clinical Excellence. Nocturnal enuresis – the management of bedwetting in children and young people. Available at www.nice.org.uk/guidance/CG111.

  3. DeFoor WR Jr, Tobias N. Simple behavioral modification may be effective first-line treatment in resolution of nocturnal enuresis. J Pediatr. 2009;155:760.

  4. Longstaffe S, Moffatt ME, Whalen JC. Behavioral and self-concept changes after six months of enuresis treatment: a randomized, controlled trial. Pediatrics. 2000;105(4 Pt 2):935-940. Available at pediatrics.aappublications.org/content/105/Supplement_3/935.long.

  5. Neveus T, Eggert P, Evans J, et al. Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the International Children’s Continence Society. J Urol. 2010;183:441-447.


All electronic documents accessed June 13, 2013.