From the Guidelines
For a 14-year-old with bedwetting (nocturnal enuresis), I strongly recommend starting with behavioral strategies, including fluid restriction in the evening and scheduled bathroom visits, and potentially adding desmopressin (DDAVP) as the first-line medication option, due to its efficacy and safety profile as evidenced by the most recent and highest quality study 1.
Behavioral Strategies
Begin with fluid restriction in the evening (no fluids 2-3 hours before bedtime) and scheduled bathroom visits before sleep. Using a bedwetting alarm that awakens the child when moisture is detected can also be beneficial. Maintaining a voiding diary to track patterns and progress is crucial for understanding the condition and adjusting the treatment plan as needed.
Medication
For medication, desmopressin (DDAVP) is the preferred option, typically starting at 0.2 mg orally at bedtime, which can be increased to 0.4 mg if needed after 2 weeks, as supported by 1. Desmopressin works by reducing nighttime urine production and is generally used for 3-6 months before attempting to discontinue. It's essential to monitor for potential side effects, such as water intoxication, especially if the child has excessive fluid intake.
Additional Considerations
If desmopressin is unsuccessful, anticholinergics like oxybutynin (5 mg at bedtime) may be added, particularly if daytime urgency symptoms are present. A thorough evaluation to rule out underlying conditions such as urinary tract infections, diabetes, sleep apnea, or neurological issues is important before starting treatment. Reassurance and psychological support are crucial, as bedwetting can significantly impact self-esteem, especially in adolescents.
Key Points
- Start with behavioral strategies including fluid restriction and scheduled bathroom visits.
- Desmopressin (DDAVP) is the first-line medication option due to its efficacy and safety profile.
- Monitor for potential side effects of desmopressin, such as water intoxication.
- Consider adding anticholinergics if desmopressin is unsuccessful and daytime urgency symptoms are present.
- Rule out underlying conditions before starting treatment.
- Provide reassurance and psychological support to the child.
From the FDA Drug Label
Safety and effectiveness in the pediatric population other than pediatric patients with nocturnal enuresis have not been established The safety and effectiveness of the drug as temporary adjunctive therapy for nocturnal enuresis in pediatric patients less than 6 years of age has not been established The safety of the drug for long-term, chronic use as adjunctive therapy for nocturnal enuresis in pediatric patients 6 years of age or older has not been established; consideration should be given to instituting a drug-free period following an adequate therapeutic trial with a favorable response.
The treatment of bedwetting in a 14-year-old with imipramine is not established for long-term use.
- Key considerations:
- The safety of imipramine for long-term use in pediatric patients 6 years of age or older has not been established.
- A drug-free period should be considered after an adequate therapeutic trial with a favorable response.
- The dose should not exceed 2.5 mg/kg/day in childhood, and ECG changes of unknown significance have been reported in pediatric patients with doses twice this amount 2.
From the Research
Treatment Options for Bedwetting in a 14-Year-Old
- The treatment of bedwetting, also known as nocturnal enuresis, can be managed through various methods, including behavioral therapy, use of alarms, and medications such as desmopressin and imipramine 3.
- Desmopressin is well accepted as first-line medical therapy for enuresis, and if ineffective, combination therapy of desmopressin + oxybutynin or desmopressin + imipramine has been used 4.
- A study comparing the use of alarms, desmopressin, and imipramine in the treatment of monosymptomatic nocturnal enuresis found that the use of alarms is the most effective treatment, with superior results compared to imipramine and desmopressin 3.
Comparison of Treatment Outcomes
- A retrospective chart review of patients with enuresis found that combination therapy with desmopressin and imipramine was more effective in reducing wet nights compared to desmopressin and oxybutynin, with a complete response rate 42.5 times greater 4.
- A prospective and randomized study found that the alarm group achieved success in 100% of cases, while the desmopressin group achieved success in 63.6% of cases, and the imipramine group achieved success in 73.7% of cases 3.
- Another study found that there is no significant difference between monotherapy with desmopressin, imipramine, or oxybutynin in children with enuresis, although oxybutynin showed a higher response rate and a lower relapse rate compared to other medications 5.
Medication Options
- Desmopressin has an antidiuretic effect and is available in various formulations, including an oral tablet and an oral lyophilisate (MELT), which has higher bioavailability and guarantees the same therapeutic response with lower doses 6.
- Imipramine is another medication option for treating nocturnal enuresis, although its mechanism of action is not fully understood 4, 3.
- Oxybutynin is also used to treat nocturnal enuresis, particularly in combination with desmopressin, although its effectiveness compared to other medications is still being studied 4, 5.