Bladder Symptoms in Children

Overview

If constipation if the primary concern please see the Constipation in Children page.

This page gives advice about management of enuresis and bladder problems.These can usually be managed in primary care.

General Principles

• Always treat constipation before trying to manage enuresis unless there are red flags.
• All children need a full history and urine dip by their GP

Community Support

The Sirona Children's Bladder & Bowel Service page has links to resources. There is also a clinically-led, specialist service which works to support children and young people up to the age of 18 years with bladder and bowel problems which cannot be managed in primary care.

Management in Primary Care

Always treat constipation first.

Children presenting with Primary Nocturnal Enuresis without daytime symptoms

• Bedwetting (enuresis) | CKS | NICE - Includes advice on use of enuresis alarms and desmopressin*.
• GP clinical assessment to identify any underlying organic cause (urine dip, daytime symptoms, spine and lower limb neurology) and make a referral to secondary care if appropriate.
• Optimise fluids: 6-8 non fizzy, un-caffeinated drinks a day (blackcurrant and fruit juices can exacerbate symptoms).
• Encourage 4-7 voids a day, discuss toilet position (including sitting for boys).
• Signpost parents or carers to ERIC (the children’s bowel and bladder. Charity) and Bladder and Bowel UK (see details in resources below). They also offer helplines, and specific areas for children and teens.
• If the child relapses or fails to get dry using the above management over three months, consider referral to the Sirona Bladder and Bowel service (see criteria and how to refer in section below).
• *Desmopressin - If prescribing desmopressin ensure that you follow the advice in CKS. Desmopressin is green on the BNSSG Paediatric formulary, ensure the preparation with the lowest acquisition cost is selected where appropriate.

Children presenting with Primary Enuresis with Daytime Symptoms

• Bedwetting (enuresis) | CKS | NICE - section on daytime symptoms including frequency, urgency and daytime wetting, poor urinary stream, dysuria 
• GP clinical assessment including 
  • spine, lower limb neurology
  • urine analysis
  • abdominal mass, large bladder
  • faltering growth.
  • Please see following link to the Pier Network website for more information

• If abnormal examination or constant dribbling refer to secondary care

• If normal examination and under 5,

• • Optimise fluids (6-8 non fizzy, un-caffeinated drinks a day, blackcurrant and fruit juices can exacerbate symptoms)
  • Encourage 4-7 voids a day, discuss toilet position (including sitting for boys).
  • Assess for and treat constipation.
  • Signpost parents or carers to ERIC (the children’s bowel and bladder. Charity) and Bladder and Bowel UK (see details in resources below). They also offer helplines, and specific areas for children and teens.
• If normal examination and over 5,
  • Advice as for under 5s and follow up with GP after 3 months.
  • If no improvement at follow up consider referral to Children’s Bladder and Bowel Service if the child/young person is following all advice and any constipation has been appropriately managed (see referral criteria above).

 Secondary Nocturnal Enuresis (having been dry for a period of at least 6 months)

• Bedwetting (enuresis) | CKS | NICE - section on secondary bedwetting.
• These children are more likely to have pathology
• GP assessment
  • History including recent psychological or family issues, developmental problems, neurological symptoms especially those affecting lower limbs, increased thirst
  • Examination, growth, abdominal mass, spine and neurological examination of lower limbs, urine analysis for sugar or UTI

• If examination and history unremarkable treat as for primary enuresis above

Red Flags

Consider more urgent referral in the following scenarios:

• Spine, lower limb neurology - see Children & Young People - USC (2WW) or discuss with paediatric ED.
• Abdominal mass, large bladder - see Children & Young People - USC (2WW) or discuss with paediatric ED.
• Abnormal examination or constant dribbling  - refer to secondary care via eRS or consider paediatric advice and guidance.
• Children with secondary enuresis, having been dry for a period of at least 6 months, are more likely to have pathology - refer to secondary care via eRS or consider paediatric advice and guidance.

Bladder and Bowel Service - Sirona

The Sirona Children's Bladder & Bowel Service is a nurse-led service which works to support children and young people up to the age of 18 years with bladder and bowel problems. 

Specialist Nurses who are experienced in children’s continence issues will provide assessment, support, advice and treatment recommendations to children and young people with the following issues:

• Children/young people who are still experiencing difficulties following initial support and intervention at tier 1 (fluid optimisation/bladder training, assessment and treatment of constipation, toilet routines, diet and lifestyle advice). This support and intervention must have been followed for a minimum of 3 months and reviewed within 6 months of the referral
  • Constipation aged 6 months -17 years
  • Daytime wetting aged 5-17 years
  • Night-time wetting aged 5-17 years
  • Delayed toilet training aged 3.5-17 years
• Children/young people with significant medical complexity where they are unable to become continent independently and therefore are dependent on continence products

Please note: The Children’s Bladder and Bowel Service may recommend medication/s as a form of treatment, but nurses cannot prescribe this. Medication must be prescribed by a GP.

Referral

Community Referral

To refer to the Children's Bladder and Bowel service, please use the Single Point of Entry (SPE) form .This is also available as an EMIS template.

Please ensure you complete ALL sections of the SPE form and attach any relevant information to prevent the referral being rejected and treatment being delayed.

Email to: sirch.singlepointofentry@nhs.net

Secondary Care Referral

Consider secondary care referral via eRS for children with red flags or consider paediatric advice and guidance for other concerns.

Resources

Self help

ERIC - the Children's Bowel and Bladder Charity Offers a helpline service for families to talk to an expertly trained continence advisor, a website with information on childhood bowel and bladder problems plus downloadable resources and an online shop.

Bladder and Bowel UK Offers advice and information on all bladder and bowel issues in children and young people, including those with additional needs.

Children’s Bladder & Bowel Service – Children and Young People’s Services (sirona-cic.org.uk)  Sirona website

Kelly Mahler's Interoception Training: Boost Body Awareness (kelly-mahler.com)  Interoception

Web videos

Childhood constipation and soiling (thepoonurses.uk) A 15-minute video, great for explaining constipation/soiling and the use of macrogols to adults and older children.

The Pooh Song CBEEBIES (youtube.com) A fun clip by CBeebies Dr Ranj designed for young children and children with special needs to encourage toileting.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.