Introduction & Definitions
Introduction Definitions Background. Enuresis, also referred to as nocturnal enuresis, is characterised by discrete episodes of urinary incontinence during sleep in children aged ≥5 years in the absence of congenital or acquired neurological disorders. This guideline is an update of the 2017 version. Recommendations. The guideline provides recommendations and suggestions for various therapeutic o
Background. Enuresis, also referred to as nocturnal enuresis, is characterised by discrete episodes of urinary incontinence during sleep in children aged ≥5 years in the absence of congenital or acquired neurological disorders. This guideline is an update of the 2017 version.
Recommendations. The guideline provides recommendations and suggestions for various therapeutic options for enuresis available in South Africa (SA). These options include behavioural modification, urotherapy, pharmaceutical therapy, alarm therapy, alternative therapies, neuromodulation, psychological support and biofeedback. Additionally, it explores the role of a voiding diary, additional investigations and mobile phone applications (apps) in treating enuresis. The document also outlines standardised definitions for clarity.
Conclusion. This is an updated guideline endorsed by relevant key opinion leaders in SA, with additional input from international experts in the field.
Keywords: bedwetting, nocturnal enuresis, enuresis, South African, treatment guidelines, mobile phone applications (apps), expert review
Introduction
This updated guideline is intended for general practitioners, urologists, paediatricians, paediatric nephrologists and hospital administrators in South Africa (SA). Local challenges in implementing these guidelines include drug unavailability, lack of resources, high costs and medical staff shortages. Recommended dosages should be adjusted based on patient characteristics, weight and renal function. The dosages should be verified with an updated, reliable medical reference. This guideline provides an update to the previous comprehensive guideline published in 2017.[1]
Definitions and terminology[2,3]
Enuresis (also referred to as nocturnal enuresis (NE)) is defined as episodes of involuntary urinary passage during sleep in children aged ≥5 years without congenital or acquired neurological disorders. Enuresis would only be considered in children with developmental delays who are >5 years old once they reach the cognitive level of a 4-year-old.
Monosymptomatic enuresis (MSE). Bedwetting at night without other daytime lower urinary tract symptoms (nocturia excluded) and without bladder dysfunction is defined as MSE.
Primary enuresis (PMSE)
- Children who have never achieved a dry period of at least 6 months.
Secondary enuresis (SMSE)
- Children who achieved a dry period of ≥6 months, then incontinence resumed.
- Non-monosymptomatic enuresis (NMSE). Children with enuresis with other lower urinary tract symptoms, such as daytime wetting or urgency, may also have bladder dysfunction, which can include abnormalities in emptying or storage.
- For this guideline, PMSE will be discussed unless otherwise specified.
Severity of enuresis
Is defined based on the frequency of voiding:
- Frequent (>4 per week) or infrequent (<4 per week).[4]
- Expected bladder capacity (EBC) is determined with the widely used Hjälmås’s formula to determine bladder capacity: EBC (mL) = 30 + (age in years × 30).[5]
- Nocturnal (night-time) polyuria (NP) is defined as nocturnal urine production >130% of the EBC.[5]
- NP is present in <50% of bedwetting children.[6]
Nocturia
- Is the complaint that the child wakes at night to void.
- Unlike enuresis, nocturia does not lead to incontinence, and nocturia does not necessarily indicate pathology.
The South African Medical Journal_The South African guidelines on enuresis: 2024 update_November 2024; Vol. 114, No. 11