A. Painful or difficulty Urinating

1. Assess symptoms to include frequency, type of discomfort and duration. Obtain vital signs.
2. Obtain clean catch urine.
3. Dip urine or send to lab for urinalysis. If positive leucocyte esterase or the presence of WBCs are noted in the dip or urinalysis, send for culture. Report the results to M.D.

B. Nocturnal Enuresis Protocol

Nocturnal enuresis is repeated, accidental bed-wetting during the night. Children will vary in the age at which they are physically ready to have complete control over their bladders. About thirty percent of 4 year olds, ten percent of 5 year olds, five percent of 10 year olds, and one percent 18 year olds wet the bed.

a. Of those children with night time wetting, only a small proportion (~ 1-2%) have a problem that requires medical attention. Such medical conditions may include anatomical abnormalities, chronic infections, nerve abnormalities or diabetes.
b. Symptoms that may indicate an underlying medical condition include persistent or new wetting, painful or difficult urination and constant thirst.
It is important for team members to notify the medical department if a student develops any new symptoms.

c. Nocturnal enuresis may also have psychological causes, as bed-wetting tends to be more common in children who have suffered traumatic or stressful life experiences.

4. Protocol:
a. After the initial evaluation, which includes a visit with the pediatrician, psychiatrist and urine specimen for testing, each student will be educated about the nature of nocturnal enuresis and possible treatments including alarms and or medications. Education will be provided in an individualized manner by either a nurse or professional. Youth Development Professionals involved in student’s care will also have an opportunity to review specifics of treatment plan with team.
b. Extra linen and a way to discreetly dispose of dirty linens will be provided for each student.
c. Student should avoid all carbonated drinks, caffeine or chocolate containing drinks throughout the day. These have been associated with bladder irritation and/or increased urine production and may make bed-wetting worse.
d. Student should restrict fluids of all kinds after 7 PM. ~ 4 oz. of water or juice with medication or during athletic events is acceptable.
e. All students should empty their bladder just prior to going to bed.
f. “Tripping” at certain times through the night should ideally be coordinated with the student and team
g. When a student wets the bed (e.g. student wakes on own or bed-wetting alarm goes off), student should be encouraged to change clothes and sheets as well as shower. This will decrease urine smell and help preserve student’s self-esteem.
h. Behavior modification plan will reward dry nights as well as cooperation with changing wet bedding, restricting fluids, and emptying bladder before bed. This may be worked into student’s motivational plan from discussions in team.

6. Treatment:

Treatment of nocturnal enuresis can be difficult and usually involves a multifaceted approach that includes all members of the treatment team. Various combinations of suggested interventions may be necessary to support the student’s individual needs. Options regarding the use of alarms and medications along with staff support in waking and maintaining a clean environment should be discussed and changed when indicated.
In extremely difficult cases, it may be appropriate to have a student wear pull-ups while sleeping. This might be necessary after other measures had been exhausted and only with involvement of student and student’s guardian.