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A Consultant Paediatrician Led and Public Health Nurse (PHN) Provided Community Enuresis Clinic as a Model of Care   Back Bookmark and Share
D Noone,N van der Spek,M Waldron

 

Ir Med J. 2011 Feb;104(2):44-6.

D Noone, N van der Spek, M Waldron
Cavan General Hospital, Cavan Town, Co Cavan


Abstract
A dedicated Community Enuresis Clinic was established in 2004 in Cavan and Monaghan. The service was audited using ERIC (Education and Resources for Improving Childhood Continence) guidelines. There were 106 males and 47 females, giving an M: F ratio of 2.3:1. Monosymptomatic Nocturnal Enuresis (MNE) accounted for 127 (83%). Adequate follow-up was available for 108 children with MNE and in this group Initial Success was 49% (ERIC target 50%). 71% were dry at 1 year. There was a dropout rate of 20%in the MNE group (ERIC minimum standard < 25%). We believe the structure of this community based clinic and its approach to MNE management has been successful.


Introduction
Nocturnal enuresis (NE) is defined as the involuntary discharge of urine at night in a child aged 5 years or older in the absence of congenital or acquired defects of the central nervous system or urinary tract.1 NE has been redefined into Monosymptomatic (MNE), and Non Monosymptomatic (NMNE), by the International Children’s Continence Society. MNE is defined as enuresis in children with no lower urinary tract symptoms and no daytime bladder dysfunction. Children who have lower urinary tract symptoms, are defined as having NMNE.2 Classification based on careful initial history helps to ensure appropriate treatment strategies.3 There is a significant inheritable pattern to NE with up to 50% having an affected first degree relative.4 NE can cause significant distress and embarrassment for children and frustration for their parents when not fully understood.5,6



MNE is not an illness and while many theories have been put forward as to possible predisposing factors no one factor is consistently implicated.7-11 Therefore a thorough explanation of NE, the natural progression and normality of the condition, as well as basic advice is key to any management strategy. A model like the “Three Systems Approach” as proposed by Butler is useful.12 Community based clinics or Enuresis Teams have been promoted by ERIC (Education and Resources for Improving Childhood Continence). A recent study from Melbourne looked at the outcome measures and success of the management of MNE in a private community practice. Using just the body-worn alarm and supportive programmes they were able to achieve an almost 80% initial success rate.13 Our aim was to promote our model of service provision in Ireland for children with predominantly MNE, by evaluating the effectiveness of the clinic and educate by sharing our methods and experience.



Methods
The Cavan/Monaghan Enuresis Clinic in its current format was established in 2004. The service structures used are based on the experience gained at the Enuresis Clinic of Lifespan Health Care NHS Trust, Cambridge, UK and ERIC guidelines.14 There are two clinics held per month, one for each of the counties. Children are seen between the ages of 7 – 16 years. The ‘Enuresis Team’ in the Cavan/Monaghan region consists of two paediatricians, five specialist Public Health Nurses (PHN), about thirty general PHNs and an equivalent number of GPs. Defined referral pathways exist and patients can come via PHNs, GPs or paediatricians.


All new referrals have a standard initial questionnaire completed and a careful clinical assessment undertaken by the Paediatrician.  Detailed information and advice are provided and a decision is made regarding child’s suitability for referral to the Enuresis Nurse Specialist. When daytime symptoms are present appropriate investigations, which may include renal and bladder imaging are requested (NMNE group). The child and his/her parents are given an information booklet and are asked to complete some simple charts looking at fluid intake, voiding frequency and volumes prior to their second clinic visit the following month (Table 1). The purpose of these basic assessments is to classify the children as either MNE or Non MNE.  If possible an estimation of volume voided during night and time of wetting episode are recorded as this can help decide on possible benefit from Desmopressin.15



When the child returns to the clinic one month later, charts are reviewed by the PHN and explained to the child and parents. A treatment strategy is decided on and for most this initially includes the Enuresis Alarm. If the child or families are not keen to try the alarm, or if the child is not felt to be suitable for it, then star charts/reward charts or desmopressin are employed initially. Children are subsequently reviewed, either by home visits, clinic appointments or by telephone communication, at intervals of between 1-3 months to assess outcome measures and response to treatment. In 2008, an audit of the Enuresis service was undertaken in the form of a retrospective chart review of all children treated at the clinic since it began in 2004. The audit tool we used was based on the ERIC produced document entitled “Setting up an Enuresis Audit” and the Minimum Standards of Practice, as set out by ERIC. These guidelines provide Working Definitions, useful as Performance Indicators of a clinic (Table 2).14,16









Results
A total of 153 patients were audited. Of these, 127 (83%) had a diagnosis of MNE and 26 (17%) had NMNE. There were 106 males and 47females, giving an M: F ratio of 2.3:1. There was a positive family history (First degree relatives only) in 41%. Treatments already tried by these families included fluid restriction (81%) and “lifting” (50%). Constipation requiring treatment was found in 17 patients (11%).


Outcome Data
Table 3 gives an overview of the initial treatments used in the first 16 weeks for MNE. At the end of this period initial success rates are recorded. Due to incomplete chart records only 108 of these could be included in the analysis (Figure 1). The Initial Success as defined above was 49% (53 patients dry out of 108). Although not an ERIC Performance Indicator, looking at those who completed the full 16 week program, 53 of 86 (62%) achieved dryness. Two thirds (35 of 53) of these achieved this standard with the alarm (Table 3).












Looking at the 65 children for whom there was data available at one year, 46 (71%) were dry. Complete success as defined by ERIC16 indicates those that are dry at 2 years. Owing to insufficient follow-up data to calculate these we therefore used those that were dry at one year as a surrogate marker of longer-term success. Twenty two children (20%) dropped out of the Enuresis clinic service in Cavan/Monaghan prior to completion of the 16 week programme (Figure 1). The mean age of those who dropped out was 10.2 ± 2.5 years (mean ± SD). The numbers were small in the NMNE group and therefore no meaningful conclusions could be made about this group other than the fact that their management is complex and they are best managed in a separate clinic.




Figure 1: Flow Diagram of Patients with MNE






Discussion
Several evidence based treatment modalities are available for NE management, but it remains a challenge for paediatricians and families. Good general advice in regard today time fluid intake, voiding routine and management of possible aggravating factors such as constipation17 is essential.  Fluid restriction and lifting as a means to improve bladder control at night should be avoided18 and was not employed as a treatment strategy in our clinic. The most effective and well studied intervention is the enuresis alarm. It is safe, inexpensive as compared to medicines, and has been shown to help children achieve both initial and more sustained, long-term success and dryness.19,20 It’s success is dependent on the age of the child, the family situation, and any stressors that may be present. It is important that the child is motivated and not just the parent(s). The alarm will only work when the child has reached a level of maturity and motivation to be able to alert and wake to an expected sound; i.e. they must anticipate that the alarm is going to go off. Otherwise the child sleeps sound and the rest of the family are wakened. We advise a trial of the alarm for up to one month and where the child is unable to wake, a retrial after three to four months. Persisting in the face of ongoing failure serves only to enhance anxiety for the child.




For families not keen to use the alarm, in children whom the alarm has failed or occasionally for short term use to cover holidays or sleepovers, we use desmopressin. Although sometimes useful in these situations it will not affect the natural history of NE and relapse on discontinuing it is common.21 It has been shown to be quite safe, the main limiting adverse effect being headaches, which are infrequent at the recommended starting doses. Recommended courses of treatment would be 3-6 months for desmopressin. Where relapse occurs a retrial of the drug or a trial of the alarm may be appropriate. The most worrying side effect of desmopressin is hyponatraemia associated with inappropriate fluid intake.22 Education of parents and the child with regard to medication effects and side effects is important. In those NME who do not respond to the initial Basic Advice and an Alarm, combinations of treatment usually including desmopressin is used.




Our Initial Success (Calculated as per ERIC guidelines to include dropouts) was 49%, just short of the target of 50%. However we did not have sufficient data for 19 patients and if only 2 of these actually achieved dryness then we would have attained 50% Initial Success. For those who regularly attended the Cavan/Monaghan Enuresis clinic success rates were above the standards set by ERIC. We believe the structure of this community based clinic and its approach to NE management has been very successful. The dropout rate although better than the minimum standard, did not reach the target of< 15% and a further study of reasons for non-attendance at clinic would provide useful feedback and assist us in reviewing our initial management protocol. Following this audit we have implemented a policy change whereby all patients are phoned by the PHN at two months from the initial visit. A further audit in a year’s time should help us to reduce non-attendance in those who would benefit from additional clinic support. We would also have more accurate follow up data on the success or otherwise of our intervention.  As expected the audit process undertaken highlighted key areas for improvement and appropriate changes have been made.  NE can become a real problem for many families if not understood and managed properly. We have shown that MNE can be managed effectively by a nurse provided dedicated clinic such as ours, and we hope we have provided a valuable educational resource for a common childhood condition.



Acknowledgements
We would like to acknowledge the hard work and dedication of the PHNs who make the clinic possible.
Correspondence: D Noone
Department of Nephrology, Great Ormond Street Hospital, London, UK
Email: dnoone@O2.ie




References 
1. Glazener CM, Evans JH, Peto RE. Alarm interventions for nocturnal enuresis in children. Cochrane Database Syst Rev. 2005 Apr 18:CD002911.
2. Neveus T, von Gontard A, Hoebeke P,Hjalmas K, Bauer S, Bower W, Jorgensen TM, Rittig S, Walle JV, Yeung CK, Djurhuus JC. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. J Urol.2006 Jul;176:314-24
3. Kajiwara M, Kato M, Mutaguchi K, UsuiT. Overactive bladder in children should be strictly differentiated from monosymptomatic nocturnal enuresis. Urologia Internationalis 2008;80:57-61.
4. Wang QW, Wen JG, Zhang RL, Yang HY, SuJ, Liu K, Zhu QH, Zhang P. Family and segregation studies: 411 Chinese children with primary nocturnal enuresis. Pediatrics International 2007;49:618-22.
5. Joinson C, Heron J, Emond A, Butler R. Psychological problems in children with bedwetting and combined (day and night) wetting: A UK population-based study. Journal of Pediatric Psychology 2007;32:605-16.
6. Egemen A, Akil I, Canda E, Ozyurt BC, Eser E. An evaluation of quality of life of mothers of children with enuresis nocturna. Pediatr Nephrol. 2008;23:93-8.
7. Jackson EC, Jackson EC. Is lack of bladder inhibition during sleep a mechanism of nocturnal enuresis? Journal of Pediatrics 2007;151:559-60.
8. Erdogan A, Akkurt H, Boettjer NK, Yurtseven E, Can G, Kiran S. Prevalence and behavioural correlates of enuresis in young children. Journal of Paediatrics & Child Health 2008;44:297-301.
9. Neveus T. Enuretic sleep: deep, disturbed or just wet? Pediatr Nephrol. 2008 Aug;23:1201-2
10. Liu YL, Wen FQ, Sun F, Liu Y-L, WenF-Q, Sun F. Functional bladder capacity in 1,500 children with nocturnal enuresis. Zhongguo Dangdai Erke Zazhi 2008;10:170-2.
11. Van Hoeck KJ, Bael A, Van Dessel E, Van Renthergem D, Bernaerts K, Vandermaelen V, Lax H, Hirche H, van Gool JD. Do holding exercises or antimuscarinics increase maximum voided volume in monosymptomatic nocturnal enuresis? A randomized controlled trial in children. Journal of Urology 2007;178:2132-6.
12. Butler RJ, Robinson JC, Holland P, Doherty-Williams D. Investigating the three systems approach to complex childhood nocturnal enuresis--medical treatment interventions. Scand J Urol Nephrol. 2004;38(2):117-21 
13. Cutting DA, Pallant JF, Cutting FM. Nocturnal enuresis: application of evidence-based medicine in community practice. Journal of Paediatrics & Child Health2007;43:167-72.
14. Morgan R. Guidelines on Minimum Standards of Practice in the Treatment of Enuresis: Education and Resources for Improving Childhood Continence. ERIC,1993.
15. Glazener CM, Evans JH, Peto RE. Treating nocturnal enuresis in children: review of evidence. Journal of Wound, Ostomy, & Continence Nursing 2004;31:223-34.
16. Hunt S. Setting up an Enuresis Audit: Education and Resources for Improving Childhood Continence. ERIC,1997.
17. McGrath KH, Caldwell PH, Jones MP, McGrath KH, Caldwell PHY, Jones MP. The frequency of constipation in children with nocturnal enuresis: a comparison with parental reporting. Journal of Paediatrics & Child Health2008;44:19-27.
18. Glazener CM, Evans JH. Simple behavioural and physical interventions for nocturnal enuresis in children. Update of Cochrane Database Syst Rev. 2002;CD003637; PMID:12076495.
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