Start CONTINENCE STUDY AFTERNOON Paul Watson Issue date

Start CONTINENCE STUDY AFTERNOON Paul Watson Issue date: October 2010 Lets Talk About Enuresis Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 1

Letters page Referral page Advice leaflets Charts Guidelines for children with Enuresis being referred to the School Nurse Enuresis service The child has severe learning or physical disabilities. Issue date: October 2010 The child has an underlying bladder or bowel condition. Nocturnal enuresis The child is going through or is still suffering from a traumatic or emotional situation. The management of bedwetting in children and young people The child is younger than seven years of age. The child is seven years of age or older with none of the above. Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 2

Letters page Referral page Advice leaflets Charts New Patient Apt Letter to referrer Health screening Apt Please make new Apt Your appointment is overdue DNA’d 1 st Apt. Contact or close Please rebook or return alarm 1 Please rebook or return alarm 2 GP request for Discharge letter to GP Issue date: October 2010 Alarm Loan Agreement Nocturnal enuresis Please contact us/ management or. The discharge of bedwetting Desmo in children and young people Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 3

Letters page Referral page Advice leaflets Charts Bed wetting Guide Childhood soiling Advice tick list Daytime wetting Issue date: October 2010 Nocturnal enuresis Enuresis Booklet The management of bedwetting in children and young people Talk about bedwetting Nights away Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 4

Letters page Referral page Tick List Advice leaflets Progress Charts Fluid Chart Issue date: October 2010 Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 5

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

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

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

Letters page Referral page Advice leaflets Charts Assessment History • No. of voids per day (frequency/ urgency) Suspicion of abuse • Fluid intake (type/ quantity) • Bowels Issue date: October 2010 • Daytime wetting • Age at onset/ symptom duration Nocturnal enuresis Behaviour problems • Arousal from sleep The management of bedwetting in • Size/ Number of wet patches/ night children and young people • Family history History of UTI’s • History of UTI’s Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Continue

Letters page Referral page Advice leaflets Charts 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 Issue date: Octoberwithout 2010 • Suggest a trial nappies or pull-ups for children and young people wearing them at night. Offer advice on alternative bed Nocturnal enuresis protection • Consider whether alarm or drug treatment The management of bedwetting in is appropriate, depending on age, maturity children and young people 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 Presentation based upon NICE clinical guideline 111 Advice Developed by the National Clinical Guideline Centre Alarm Advice Drug

Letters page Referral page Advice leaflets Charts Advice Issue date: October 2010 Does the child have some dry nights? Nocturnal enuresis Yes The management of bedwetting in No children and young people Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 11

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

Letters page Referral page Advice leaflets Charts Alarm Treatment • Bedwetting has not responded to advice on fluids, toileting and an appropriate reward system and Issue date: October 2010 • Alarm treatment Nocturnal enuresisis desirable and appropriate The management of bedwetting in children and young people Yes No Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 13

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

Letters page Referral page Advice leaflets Charts 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 Nocturnal enuresis having emotional difficulty coping The management of bedwetting in or are expressing children and young peopleanger, negativity or blame) Issue date: October 2010 Yes No Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 15

Letters page Referral page Advice leaflets Charts Offer desmopressin for children and young people Nocturnalover enuresis 7 years Issue date: October 2010 The management of bedwetting in children and young people Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 16

Letters page Referral page Advice leaflets Charts Start alarm treatment. Assess response by 4 weeks Early signs of response? Issue date: October 2010 Nocturnal enuresis The management of bedwetting in Yes children and young people No Recurrence following success Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 17

Letters page Referral page Advice leaflets Charts Continue with alarm. Have there been 2 weeks uninterrupted dry nights achieved? Issue date: October 2010 Nocturnal enuresis The management of bedwetting in Yes children and young people No Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 18

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

Letters page Referral page Advice leaflets Charts Continue with alarm Issue date: October 2010 Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 20

Letters page Referral page Advice leaflets Charts Assess progress at 3 months Is bedwetting improving and are the child and Nocturnal enuresis parents/carers The management of bedwetting in to motivated children and young people continue? Issue date: October 2010 Yes No Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 21

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

Letters page Referral page Advice leaflets Charts Repeated recurrence Is alarm treatment still acceptable? Nocturnal enuresis Issue date: October 2010 The management of bedwetting in children and young people Yes No Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 23

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

Letters page Referral page Advice leaflets Charts Offer desmopressin alone Issue date: October 2010 Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 25

Letters page Referral page Advice leaflets Charts Start desmopressin treatment Is complete dryness Nocturnal enuresis achieved after 1 The management of bedwetting in children and young 2 people weeks? Issue date: October 2010 Yes No Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 26

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

Letters page Referral page Advice leaflets Charts Consider increasing dose Issue date: October 2010 Nocturnal enuresis The management of bedwetting in children and young people Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 28

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

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

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

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

Letters page Referral page Advice leaflets Charts Consider advising that desmopressin is taken 1 -2 hours before bedtime, instead of at bedtime, if the child can comply with fluid restriction Issue date: October 2010 Nocturnal enuresis The management of bedwetting in children and young people Yes No Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 33

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

Letters page Referral page Advice leaflets Charts Refer for further review and assessment of factors associated with poor response (e. g. overactive bladder, underlying disease or social and emotional Nocturnal enuresis factors) Issue date: October 2010 The management of bedwetting in Further treatments children and young people Presentation based upon NICE clinical guideline 111 Developed by the National Clinical Guideline Centre 35

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

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

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

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

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

Letters page Referral page Advice leaflets Charts Diagnosis – Three Systems Model Lack of arousal from sleep. Inability to wake to bladder sensations. Sleeping through wetting. Bladder instability/ low functional bladder capacity Nocturnal polyuria (Low Nocturnal vasopressin levels) • Sense of urgency • Frequent daytime voiding • Low voided volume • Multiple wetting • Variable sized wet patch YES • Wets soon after sleep • Large wet patches Both • Dry nights only if child wakes • Weak urine • Wakes after wetting YES 41

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

Letters page Referral page Advice leaflets Charts Treatment Anticholinergernic medication and bladder retraining. Review by GP or specialist if medication required. Review 43

Letters page Referral page Advice leaflets Charts Initial Review 2 -4 weeks after treatment Signs of improvement • Delays point of voiding to early morning • Less wetting during episode • More dry nights • Parent/ child satisfied with progress Responding to treatment Not responding to treatment 44

Letters page Referral page Advice leaflets Charts Continue Treatment 3 -6 months Signs of success • Dry nights YES NO 45

Letters page Referral page Advice leaflets Charts Continue treatment max 6 weeks Treatment a success? YES NO 46

Letters page Referral page Advice leaflets Charts Success = 14 consecutive dry nights YES NO 47

Letters page Referral page Advice leaflets Charts Continue treatment 3 -9 months Can be used as long as symptom control is required – reassess every three months Treatment a success? YES NO 48

Letters page Referral page Advice leaflets Charts Cease Treatment 49

Letters page Referral page Advice leaflets Charts Give break and retry as appropriate after 3 -6 months 50

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