Bedwetting in under 19s - NICE guideline

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This clinical guideline offers evidence-based advice on the assessment, care and treatment of children and young people up to the age of 19 with bedwetting.

Key recommendations

Multicomponent treatments

What elements of multicomponent treatments (for example dry‑bed training and retention control training) are clinically effective and cost effective for treating bedwetting in children and young people under 19 years old?

Why this is important

It is not known which of the elements of multicomponent treatments (for example dry‑bed training and retention‑control training) are clinically effective and cost effective for treating bedwetting in children and young people under 19 years old. Data from randomised controlled trials of dry‑bed training and retention‑control training suggest that the treatments may be clinically effective. However, certain elements of the multicomponent treatments studied are not acceptable as a form of treatment due to their punitive nature. Further research is needed to establish which elements could be used effectively to treat bedwetting.

Research should:

  • Use randomised controlled trials to test the effect of the different elements of dry‑bed training alone and in different combinations for the treatment of bedwetting.
  • Use randomised controlled trials to test the effect of the different elements of retention control training alone and in different combinations for the treatment of bedwetting.
  • Consider different age groups of children being treated, such as younger children (under 7 years) and older children (over 10 years), as the ability of children to take responsibility for their behaviour may be important.
  • Clearly describe the techniques used, including who gave the instructions, the timing of the treatments and the setting.

Outcomes of interest include: the number of children who achieved 14 consecutive dry nights, the number of children who remain dry at 6 months and 2 years after treatment, the mean number of wet nights after treatment, the change in the number of wet nights, the psychological effect of treatment, psychological effects (self‑esteem, self‑concept, PinQ, quality of life measures and drop outs.

Standard interventions

What is the clinical and cost effectiveness of standard interventions, for example alarm and desmopressin, for treating bedwetting in children and young people under 19 years old?

Why this is important

The evidence base for management of bedwetting is poor. Studies are inadequately powered, symptoms are poorly defined and study populations are commonly children seen in secondary and tertiary centres. Follow‑up periods are often inadequate.

Research should provide:

  • More subgroup data (for example, young children, children with daytime symptoms as well as bedwetting, children who were previously successful with subsequent relapse, children with sickle cell disease, children with severe wetting and children with special needs).
  • More robust statistical data in trials of standard interventions for treating bedwetting (for example, adequately powered to detect differences).
  • Data on longer term follow‑up.
  • Data from populations at a primary care/community care level.

Psychological functioning and quality of life

What is the impact of bedwetting upon the psychological functioning and quality of life of children and young people and their families? How do these change with treatment?

Why is this important?

There are relatively few studies that focus upon the psychological impact and health‑related quality of life of children who experience bedwetting. In addition, studies of effectiveness have focused on the achievement of dryness as the primary outcome rather than how treatment might affect social and psychological aspects as well as the quality of life of children and young people and their families.

Research should:

  • Examine the psychological impact and quality of life of children and young people and their families as well as the effectiveness of treatment upon these aspects.
  • Use standardised measures to assess the psychological impact of bedwetting on children and young people as well as the quality of life of the child or young person and family.
  • Use standardised measures to assess change associated with treatment for bedwetting.

Quality‑of‑life research of children and young people with bedwetting pre‑ and post‑treatment would also be very useful to inform further economic evaluation work.

Complementary therapies

What is the effectiveness of complementary therapies (acupuncture and hypnotherapy) for reducing the number of wet beds and improving self‑esteem in children and young people who wet the bed, when they are used independently or in conjunction with conventional treatments?

Why this is important

Many families consider the use of complementary and/or alternative medicine (CAM) as a treatment option when conventional treatment 'fails' or in order to avoid drug or other treatments. There is very little evidence about the efficacy of many CAM treatments, but the use of CAM is widespread and increasing across the developed world. There is a clear need for more effective guidance for health professionals, so that they can give evidence‑based advice to patients about what does and does not work and what is and is not safe, and for the public.

Research should:

  • Use randomised controlled trials to test the effect of using CAM therapies in addition to or instead of other treatments for bedwetting.
  • Clearly describe the CAM therapies tested, including the provision of the treatment for both the treatment and the control group.
  • Priority should be given to research on acupuncture and hypnotherapy but other CAM therapies should not be excluded.
  • If possible, the comparative effectiveness and cost effectiveness of different CAM therapies should be tested.

Outcomes of interest include: self‑esteem, number of dry nights, permanent or temporary nature of increased number of dry nights, quality of life, costs and social engagement.

Bedwetting in adolescents

What is the prevalence of wetting and/or soiling in adolescence and what are the long‑term consequences for adolescents with these problems?

Why this is important

There is evidence that, for an important minority of children, wetting and soiling problems persist into late childhood and sometimes beyond puberty, but their prevalence is not clearly known. It has also recently been reported that in children who experience more frequent bedwetting (more than three times a week) it is more likely to persist into late childhood and adolescence. These studies suggest that, contrary to popular belief, wetting and soiling problems do not always resolve with increasing age. If wetting and soiling problems remain unresolved or untreated they can become socially and psychologically debilitating.

There are no longitudinal cohort studies examining the impact of wetting and soiling on a wide range of outcomes in adolescence relating to mental health, education/school attainment, relationships with parents and peers, social activities and goals/aspirations for the future. Persistence of wetting and soiling problems into adolescence is likely to be accompanied by ridicule and bullying by peers and increasing intolerance from parents, especially if they believe that their child is to blame for the problem. Such reactions can only serve to exacerbate the young person's distress and may lead to delays in seeking help. In particular, teenagers who are unsuccessfully treated in childhood are often reluctant to seek help for wetting or soiling due to the severe embarrassment associated with the problem, and others may simply believe that no help is available.

Research should:

  • Use adolescents own self‑reports of frequency of bedwetting, daytime wetting and soiling.
  • Adapt existing trajectory models to incorporate information on the frequency of wetting and soiling to examine whether children with more frequent problems are more likely to experience continuing wetting and soiling into adolescence.

Outcomes of interest include: the examination of mental health, psychosocial and educational outcomes and whether adolescents who have combined wetting and soiling are at increased risk of negative outcomes compared to those with wetting or soiling alone.

What is bedwetting?

Bedwetting is a widespread and distressing condition that can have a deep impact on a child or young person's behaviour, emotional wellbeing and social life. It is also very stressful for the parents or carers. The prevalence of bedwetting decreases with age. Bedwetting less than 2 nights a week has a prevalence of 21% at about 4 and a half years and 8% at 9 and a half years. More frequent bedwetting is less common and has a prevalence of 8% at 4 and a half years and 1.5% at 9 and a half years.

The causes of bedwetting are not fully understood. Bedwetting can be considered to be a symptom that may result from a combination of different predisposing factors. There are a number of different disturbances of physiology that may be associated with bedwetting. These disturbances may be categorised as sleep arousal difficulties, polyuria and bladder dysfunction. Bedwetting also often runs in families.

You can read the guideline on NICE's website.