Bedwetting in under 19s

Search and selection strategy

We searched for new evidence related to the whole guideline.

We found 43 studies in a search for randomised controlled trials, systematic reviews and non-randomised studies published between 26 August 2014 and 27 July 2018.

We also included:

From all sources, we considered 61 studies to be relevant to the guideline.

See appendix A: summary of evidence from surveillance for details of all evidence considered, and references.

Views of topic experts

We sent questionnaires to 9 topic experts and received 5 responses. The topic experts either:

The main areas that they highlighted for update included:

Other sources of information

We considered all other correspondence received since the guideline was published. As part of this surveillance review we actively engaged with the Cochrane Incontinence Group. The group helped to identify relevant systematic reviews and randomised controlled trials that potentially impacted on our review proposal.

The Cochrane Incontinence Group highlighted that the Standardisation Committee of the International Children's Continence Society (ICCS) has now updated their Standardisation of Terminology documents and recommend that all studies on nocturnal enuresis should conform to standardised terminology. The main impact for this guideline on children and young people with bedwetting is distinguishing those who wet only at night and those with other underlying bladder problems and daytime symptoms which may not respond to treatment. Before 2010, many papers did not distinguish between these 2 groups. NICE has checked the guideline recommendations which were based on both evidence and committee discussion and are confident that the guideline does reflect different management for these 2 groups where appropriate. This has been taken into account in the surveillance reviews of the guideline. NICE's surveillance team will ensure that terminology is also noted for future reviews of the guideline.

Views of stakeholders

Stakeholders are consulted on all surveillance decisions except if the whole guideline will be updated and replaced. Because this surveillance decision was to not update the guideline, we consulted on the decision.

Overall, 7 stakeholders commented (including representation from professional bodies, universities and NHS trusts). Three stakeholders provided comments on the surveillance review proposal and the remaining 4 stakeholders stated that they had no substantive comments to make.

Four of the 7 stakeholders disagreed with the decision to not update the guideline, however 2 of these gave no reasons for disagreeing. We considered the suggestions for why the guideline is out of date but decided it did not need updating for the following reasons.

One stakeholder stated that further clarity was needed around the recommendations on desmopressin treatment and the age of child, referring to recommendation 1.10.1 (Offer desmopressin to children and young people over 7 years, if rapid onset and/or short-term improvement in bedwetting is the priority of treatment or an alarm is inappropriate or undesirable). The stakeholder stated that 5–7 years age grouping may discourage clinicians from starting treatment before a child is 7 years old.

However, recommendation 1.10.2 clearly states: 'Consider desmopressin for children aged 5–7 years if treatment is required and rapid onset and/or short-term improvement in bedwetting is the priority of treatment or an alarm is inappropriate or undesirable'. Furthermore the guideline states 'Do not exclude younger children (for example, those under 7 years) from the management of bedwetting on the basis of age alone' (recommendation 1.1.3). At present, we do not believe that the wording of these recommendations needs clarification. However, for interpretation of the guideline, users of NICE guidance should refer to the NICE Pathway on bedwetting in children and young people which brings together all of the nocturnal enuresis recommendations in an easy to follow format.

One stakeholder stated that adequate evidence was now available to include electrical nerve stimulation in the guideline. However, relevant studies identified in this surveillance review were small and the targeted populations were wider than the population for this guideline. Therefore, the evidence in these studies was deemed insufficient to inform new recommendations in this area.

One stakeholder suggested considering the body shape distortion in the recommendation about assessing a child or young person for any comorbidities (recommendation 1.3.9). The stakeholder stated that constipation can be a consequence of body shape distortion and this is avoidable with the right postural care. Postural care is outside the scope of this guideline but the guideline recommends that assessment, investigation and/or referral should be considered when bedwetting is associated with comorbidities and other risk factors such as constipation and/or soiling. Furthermore, it states that children or young people with soiling or constipation should be investigated and treated in line with the NICE guideline on constipation in children and young people. Managing problems with movement and posture in children and young people with cerebral palsy, was addressed in the NICE guideline on spasticity in under 19s.

One stakeholder expressed concern about the lack of service provision for children with bedwetting following the move of school nursing to Public Health. A commissioning guide prepared by the Paediatric Continence Forum and accredited by NICE addresses local service provision for children and young people with continence difficulties across England. This guide provides support for the local implementation of NICE guidance through commissioning and should be read together with the NICE guideline on bedwetting in under 19s.

See appendix B for full details of stakeholders' comments and our responses.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.