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Assessment/investigation

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Initial assessment/investigation:

detailed history (urinary symptoms, bowel habit, family, psychosocial history);
- check for potentially reversible contributory factors:
  - factors include constipation, urinary tract infection, diet, stress, diabetes mellitus, and environmental factors such as access to the toilet during day and night, whether the light is left on at night and where the child sleeps (e.g. bunk bed, sharing bed or room with others). If any of these is found, it should be tackled first (1)
clinical examination (suggested possible components include growth parameters, examining the abdomen and genitalia, lower limb neurology, spinal examination and blood pressure measurement (which, if elevated, could indicate renal disease)) (1,2)
investigations include:
- urinalysis with dipstix
  - NICE state that (3):
    - do not perform urinalysis routinely, unless the child or young person has:
      - started bedwetting recently (in the last few days or weeks)
      - daytime symptoms
      - any signs of ill health
      - a history, symptoms or signs suggestive of urinary tract infection
      - a history, symptoms or signs suggestive of diabetes mellitus.
- urine culture
- where appropriate, further investigations should be carried out to exclude diabetes mellitus or renal disease

NICE have summarised the history taking in nocturnal enuresis (bedwetting) and suggested action (3):

Patterns of symptoms	Interpretation action
Patterns of bedwetting How many nights a week does bedwetting occur? How many times a night does bedwetting occur? Does there seem to be a large amount of urine? At what times of night does bedwetting occur? Does the child or young person wake up after bedwetting?	Bedwetting that occurs every night is severe bedwetting, which is less likely to resolve spontaneously than infrequent bedwetting A large volume of urine in the first few hours of the night is typical of bedwetting only A variable volume of urine, often more than once a night, is typical of bedwetting and daytime symptoms with possible underlying overactive bladder
Daytime symptoms Does the child or young person need to pass urine frequently (more than seven times) or infrequently (less than four times) during the day? Does the child or young person need to pass urine urgently during the day? Is the child or young person wetting during the day? Does the child or young person have abdominal straining when passing urine or a poor urinary stream? Does the child or young person have pain passing urine?	Daytime symptoms may indicate a bladder disorder such as overactive bladder Pain passing urine may indicate a urinary tract infection Perform urinalysis If daytime symptoms are severe: consider assessment, investigation and/or referral consider investigating and treating daytime symptoms before bedwetting this may rarely indicate an underlying urological disease
Toileting patterns Does the child or young person avoid using certain toilets, such as school toilets? Does the child or young person go to the toilet more or less often than his or her peers? Do daytime symptoms happen only in certain situations?	Give advice about encouraging normal toileting patterns
Fluid intake How much does the child or young person drink during the day? Are they drinking less because of the bedwetting? Are the parents or carers restricting drinks because of the bedwetting	Inadequate fluid intake may mask an underlying bladder problem and may impede development of adequate bladder capacity Give advice on fluid intake

Reference:

(1) Drug and Therapeutics Bulletin (2004);42(5):33-37.
(2) Prescriber (2001); 12 (5): 103-8.
(3) NICE (October 2010).Nocturnal enuresis - The management of bedwetting in children and young people

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