Home' Australian Pharmacist : May 2011 Contents Vol. 30 -- May #05
Continuing Professional Development
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Mrs RJ was counselled on the causes
and likely course of NE. She was
reassured that as Kaden was still only
six years old, his bedwetting was likely
to improve over time, and that at this
stage, based on his current symptoms
and history, medical treatment may
not be necessary. She was counselled
on the various behavioural strategies
recommended for bedwetting, and the
treatment options that were available
if Kaden's problem persisted. She
was also advised that if she was still
concerned, she may wish to consult
her GP for further investigation and to
This verbal advice was supplemented
by some written information on
bedwetting and suggested websites
where she could obtain further
Key practice points
• Nocturnal enuresis is a common
problem in children but in the
majority of cases will clear over
time without treatment.
• The psychological impact of
bedwetting on the child and the
family can be significant and must
be considered when deciding on
• Behavioural strategies and
education may be the only
treatment required for children
under seven years of age with
primary monosymptomatic NE.
• Enuresis alarm therapy is the most
effective treatment for nocturnal
enuresis with the lowest relapse rate.
Desmopressin is an effective second
line treatment, however, the risk of
hyponatraemia must be considered.
• Although they may be effective,
tricyclic antidepressants are no
longer recommended for nocturnal
enuresis due to problems with side
effects and toxicity.
1. Kiddoo D. Nocturnal enuresis. BMJ Clinical Evidence.
2. Porter R, Kaplan J, Eds. The Merck Manuals Online
Medical Library [online]. At: www.merckmanuals.com/
3. Lane W, Robson M. Evaluation and management of
enuresis. NEJM. 2009; 360(14):1429.
4. Caldwell P, Edgar D, Hodson E, et al. Bedwetting and
toileting problems in children. eMJA. 2005; 182(4):190--5.
5. Caldwell P, Edgar D. Nocturnal enuresis in children and
adolescents. Aust Doc. 24 Nov 2006; 25--32.
6. Nunes V, O'Flynn N, Evans J, et al. Management of
bedwetting in children and young people: summary of
NICE guidance. BMJ. 2010; 341:936--38.
1. What percentage of five year
old children are estimated to be
affected by nocturnal enuresis?
2. According to the three system
model, what are the three
main factors that can lead to
a) Nocturnal polyuria, bladder dysfunction
and impaired sleep arousal.
b) Nocturnal polyuria, constipation,
c) Nocturnal polyuria, constipation,
impaired sleep arousal.
d) Bladder dysfunction, impaired sleep
arousal, psychological stress.
e) Bladder dysfunction, Type 1 diabetes,
3. Which of the following
statements regarding the use
of desmopressin for nocturnal
enuresis is CORRECT?
a) Desmopressin is a synthetic
analogue of vasopressin and acts
by decreasing water reabsorption
in the kidneys.
b) Desmopressin is about 70% less
effective than alarm therapy in the
treatment of nocturnal enuresis.
c) The effect of desmopressin is
normally sustained on cessation of
d) In Australia, desmopressin nasal
spray is indicated in children with
nocturnal enuresis only when
the oral or sublingual route is
e) Children using desmopressin
should restrict fluids from three
hours before to eight hours after
4. Which of the following
statements regarding alarm
treatment for nocturnal
enuresis is CORRECT?
a) It is thought that alarm treatments
work by converting the signal
to promote urination to one of
inhibition of urination or of waking.
A score of 4 out of 5 attracts 1 CPD credit.
b) An advantage of alarm treatments
is that they work quickly to relieve
c) The bedwetting relapse rate with
alarm treatments is much higher
than with desmopressin treatment.
d) A large amount of urine is required
to trigger an enuresis alarm.
e) Alarm treatments should be
discontinued if there is no
response within one week.
5. Which of the following is
NOT recommended as a
behavioural strategy to assist a
child with nocturnal enuresis?
a) Fluid restriction for two to three
hours prior to bed.
b) Training programs that involve
'holding on' and waiting before
c) Rewards for dry nights, e.g. a
bedwetting chart for a young child.
d) Avoidance of constipation.
e) Avoiding caffeine-containing and
7. Van de Walle J, Van Herzeele C, Raes A. Is there
still a role for desmopressin in children with primary
monosymptomatic nocturnal enuresis? Drug Safety.
8. Lordelo P, Benevides I, Kerner E, et al. Treatment
of non-monosymptomatic nocturnal enuresis by
transcutaneous parasacral electrical nerve stimulation.
Journal of Pediatric Urology. 2010; 6(5):486--89.
9. Australian Drug Information for the Health Professional
Online. Drug monograph for desmopressin.
10. Bower WF, Moore KH, Shepherd RB, et al. The
epidemiology of childhood enuresis in Australia. British
Journal of Urology. 1996; 78(4):602--6.
11. Psychotropic Expert Group. Therapeutic guidelines,
Psychotropic, Version 6. Melbourne: Therapeutic
12. Butler R, Gasson S. Enuresis alarm treatment.
Scandinavian Journal of Urology and Nephrology. 2005;
13. Rossi S, Ed. Australian Medicines Handbook. Adelaide:
Australian Medicines Handbook; 2011.
14. Therapeutic Goods Administration. Australian Adverse
Drug Reactions Bulletin. Aug 2008; 27(4):15.
15. MIMS Online. CMP Medica Australia. 2010.
16. Robson W, Leung A, Norgaard J. The comparative
safety of oral versus intranasal desmopressin for the
treatment of children with nocturnal enuresis. Journal
of Urology. 2007; 178(1):24--30.
17. Neveus T. Reboxetine in therapy-resistant enuresis --
results and pathogenetic implications. Scandinavian
Journal of Urology and Nephrology. 2006; 40:31--4.
18. Better Health Channel Fact Sheet -- Bedwetting
[online]. 2010. At: www.betterhealth.vic.gov.au
19. The Continence Foundation of Australia [online]. 2010.
20. International Children's Continence Society [online].
2010. At: www.i-c-c-s.org
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