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nocturnal enuresis

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nocturnal enuresis children guideline evaluation treatment ICCS

Nocturnal enuresis means involuntary bed-wetting during sleep in a child aged 5 years or older. It is common, is not the child’s fault, and often improves with maturation. About 15% of affected children become dry each year without treatment. AAFP review

Types

  • Primary monosymptomatic enuresis: the child has never been consistently dry at night and has no daytime urinary symptoms. This is the commonest type.
  • Non-monosymptomatic enuresis: bed-wetting plus daytime urgency, frequency, leakage, painful urination, weak stream, etc.
  • Secondary enuresis: starts after at least 6 months of night dryness. It needs assessment for a trigger such as stress, constipation, urinary infection, diabetes, sleep-disordered breathing, or bladder dysfunction.

What helps

  1. Reassurance and no punishment or shaming.
  2. Treat constipation and daytime bladder symptoms first.
  3. Regular daytime fluids and toilet visits, with a toilet visit just before sleep. Avoid caffeine and large late-evening drinks, but do not severely restrict fluids.
  4. Bed-wetting alarm: best option for a sustained cure, but it requires consistent family involvement for weeks to months.
  5. Desmopressin: can reduce wet nights quickly, useful for camps or sleepovers, but relapse after stopping is common. It must be prescribed and accompanied by strict evening and overnight fluid restriction because of the rare risk of low blood sodium. AAFP treatment guidance

Seek medical assessment sooner if there is

  • Daytime wetting, urgency, recurrent urinary infection, pain or blood in urine
  • Excessive thirst, weight loss, or large urine volumes
  • New bed-wetting after a long dry period
  • Severe constipation
  • Snoring, breathing pauses in sleep, or marked daytime sleepiness
  • Weak stream, abnormal gait/leg weakness, or developmental/neurologic concerns
  • Persistence despite alarm or desmopressin treatment
A clinician usually starts with a focused history, examination, urine test, and assessment of bowel habits and sleep. Recent systematic reviews continue to evaluate alarm and medication strategies, including desmopressin, but treatment should be tailored to whether symptoms occur only at night and to family goals (PMIDs 39964278 and 40272475).

generalised anxiety disorder

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"generalized anxiety disorder" AND treatment

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generalized anxiety disorder NICE guideline diagnosis treatment

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Generalized anxiety disorder (GAD) is persistent, difficult-to-control worry about several areas of life, occurring more days than not for at least 6 months and causing distress or impairment. NICE diagnostic criteria

Common features

  • Excessive worry that is hard to stop
  • Feeling restless, tense, or “on edge”
  • Easy fatigue
  • Poor concentration or a “blank mind”
  • Irritability
  • Muscle tension, headaches, stomach symptoms
  • Sleep difficulty
For diagnosis in adults, the worry is usually accompanied by at least 3 of these symptoms. Clinicians also check for depression, panic disorder, substance or stimulant use, thyroid disease, medication effects, and other physical causes.

Treatment

Treatment is chosen with the person and often follows a stepped approach:
  1. Education, regular exercise, sleep routine, reducing caffeine/alcohol, and guided self-help for milder symptoms.
  2. Psychological therapy, particularly cognitive behavioural therapy (CBT) or applied relaxation.
  3. Medication if symptoms are persistent, severe, or if the person prefers it. SSRIs or SNRIs are usual first-line medicines; they are started low and increased gradually because anxiety can briefly worsen at the beginning. Textbook of Family Medicine, p. 1326.
  4. Benzodiazepines may relieve anxiety quickly but are generally not a long-term solution because of tolerance, dependence, sedation, and withdrawal risk. Textbook of Family Medicine, p. 1326.
NICE recommends a stepped-care approach, with high-intensity CBT/applied relaxation or medication for persistent GAD with significant functional impairment. NICE management recommendations Recent systematic reviews support psychotherapy, including CBT, for GAD (PMID 37851421).
Get urgent help now through local emergency services or a crisis line if anxiety comes with thoughts of self-harm, suicide, inability to stay safe, severe confusion, or inability to function.
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