An updated guideline has been released on enuresis (bedwetting), intended for general practitioners, urologists, paediatricians, paediatric nephrologists and hospital administrators in South Africa, and replacing the previous guideline published in 2017.
In their report in the SA Medical Journal, the compilers say that local challenges in implementation include drug unavailability, lack of resources, high costs and medical staff shortages.
They said recommended dosages should be adjusted based on patient characteristics, weight and renal function, and should be verified with an updated, reliable medical reference.
In a guest editorial in the same edition, urologists Jeff John and paediatrician Ann Wright write that significant progress has been made since the 1960s, when enuresis was classified as a “psychophysiological symptom of psychopathology” by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, 2nd edition (DSM-II.).
They write:
Contemporary evidence suggests that the aetiology is complex and involves a combination of physiological, psychological, genetic and environmental components. Although epidemiological studies have consistently reported high prevalence rates, this condition is often underdiagnosed and undertreated, as only half of the patients seek medical care.
Failure to seek care can be driven by the patient’s sense of embarrassment, or the carer’s misconception that enuresis is incurable or that the child will eventually “grow out of it”.
In a developing country, where most of the population has limited education, these situations are particularly prevalent.
Many individuals in this setting lack a comprehensive understanding of the condition and mistakenly view it exclusively as a behavioural problem. Children often share beds with other people, including adults, and anger, frustration and disgust are just some emotions directed against the child by others in their ignorance.
Youngsters are often subjected to punishment or public humiliation after episodes of enuresis, with the intention of teaching them a lesson. Such children become isolated, lack self-esteem, and have poor academic and occupational performance.
When medical help is intentionally sought for the patient, urotherapy, alarms and medication are expensive, making compliance and treatment success a challenge in developing countries.
New statistical methods applied to longitudinal population studies have shed important light on certain aspects of enuresis. Under the age of 10 years, bedwetting less than every night is common, with a tendency to improve and resolve spontaneously.
However, nightly wetting is uncommon at any age (1% of children at 7.5 years of age), and is associated with a low spontaneous resolution rate and underlying bladder dysfunction.
A child bedwetting nightly after 10 years old almost invariably has compromised nocturnal bladder capacity, most commonly due to bladder overactivity, but also other bladder dysfunction. The presence of bladder dysfunction is a poor prognostic feature for spontaneous resolution and is not always apparent from the history.
Bladder outlet obstruction can also be missed in boys, and careful questioning about the urinary stream is important. In addition, secondary-onset enuresis in the 6th/7th year of life is a recognised pattern and often remains persistent.
It was traditionally associated with emotional/behavioural triggers, but it is mirrored in daytime urinary incontinence trajectories, so it is more likely to be caused by the onset of bladder dysfunction.
Finally, if a child has monosymptomatic nocturnal enuresis at 9.5 years of age, their odds ratio for enuresis at 14-years-old is 3.5, and 23 in the case of non-monosymptomatic nocturnal enuresis.
There is therefore no guarantee that the older child with bedwetting will “grow out of it”, and skilled assessment and directed management are warranted in this group.
In view of the high prevalence of enuresis, its psychological impact, adverse effects on quality of life for both the child and the family, and long-term consequences in adulthood, the new guideline on primary monosymptomatic enuresis (PMNE) is important.
Deficiencies in undergraduate and postgraduate training have resulted in lack of confidence on the part of doctors in managing urinary incontinence in children. Clinicians typically lack the necessary expertise to detect psychopathology during a brief 10-20-minute consultation.
Furthermore, they do not have the time or specific techniques to encourage parents and children to comply with therapy effectively. The updated guideline will be invaluable to healthcare practitioners at all levels of care.
Enuresis is not the child’s fault, and healthcare practitioners need to empower themselves and advocate for the child who has this problem, while appreciating the burden that may be placed on the parents and family.
Jeff John, Division of Urology, Department of Surgery, Frere Hospital and Faculty of Health Sciences, Walter Sisulu University, East London, South Africa; Division of Urology, Department of Surgery, Faculty of Health Sciences, University of Cape Town;
Anne Wright Children’s Bladder Clinic, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, UK; Department of Paediatrics, Faculty of Health Sciences, University of Cape Town.
Study details
This updated guideline is intended for general practitioners, urologists, paediatricians, paediatric nephrologists and hospital administrators in South Africa. Local challenges in implementing these guidelines include drug unavailability, lack of resources, high costs and medical staff shortages. Recommended dosages should be adjusted based on patient characteristics, weight and renal function. The dosages should be verified with an updated, reliable medical reference. This guideline provides an update to the previous comprehensive guideline published in 2017.
Background
Enuresis, or nocturnal enuresis, is characterised by episodes of urinary incontinence during sleep in children aged ≥5 years in the absence of congenital or acquired neurological disorders.
Recommendations
The guideline provides recommendations and suggestions for various therapeutic options for enuresis available in South Africa (SA). These options include behavioural modification, urotherapy, pharmaceutical therapy, alarm therapy, alternative therapies, neuromodulation, psychological support and biofeedback. Additionally, it explores the role of a voiding diary, additional investigations and mobile phone applications (apps) in treating enuresis. The document also outlines standardised definitions for clarity.
Conclusion
This is an updated guideline endorsed by relevant key opinion leaders in SA, with additional input from international experts in the field.
SA Medical Journal article – Nocturnal enuresis: A call for advocacy (Creative Commons Licence)