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Issue date : October 2010

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

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Issue date : October 2010

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

  2. Letters page Referral page Advice leaflets Charts Issue date: October 2010 Nocturnal enuresis The management of bedwetting in children and young people NICE clinical guideline 111 Developed by the National Clinical Guideline Centre Guidelines for children with Enuresisbeing referred to the School Nurse Enuresis service The child has severe learning or physical disabilities. The child has an underlying bladder or bowel condition. The child is going through or is still suffering from a traumatic or emotional situation. 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

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

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

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

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

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

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

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

  10. Letters page Referral page Advice leaflets Charts Issue date: October 2010 Nocturnal enuresis The management of bedwetting in children and young people NICE clinical guideline 111 Developed by the National Clinical Guideline Centre • 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 • Suggest a trial without nappies or pull-ups for children and young people wearing them at night. Offer advice on alternative bed protection • Consider whether alarm or drug treatment is appropriate, depending on age, maturity 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 Advice Advice Presentation based upon Advice Alarm Drug

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  41. 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. YES 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 • Wakes after wetting • Wets soon after sleep • Large wet patches • Dry nights only if child wakes • Weak urine Both YES YES

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

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

  44. 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

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

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

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

  48. 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

  49. Letters page Referral page Advice leaflets Charts Cease Treatment

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

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