How to manage nocturnal enuresis in a premenarchal girl?

Management of Nocturnal Enuresis in Premenarchal Girls

Active treatment for nocturnal enuresis in premenarchal girls should not be started before age 6 years, and should begin with general lifestyle modifications followed by either an enuresis alarm (preferred for long-term cure) or desmopressin (for short-term management). 1, 2

Initial Assessment and General Approach

Before initiating treatment, a basic evaluation should include:

• Urinalysis to rule out diabetes, UTI, or kidney disease 2
• Frequency-volume chart documenting fluid intake, voided volumes, and wet/dry nights 1, 2
• Assessment of nocturnal urine production by weighing absorbent products 1
• Screening for constipation, which can significantly impact treatment success 2

First-Line Management

General Lifestyle Modifications

1. Regular voiding schedule during daytime:

   • Morning, at least twice during school, after school, at dinner, and before bed 1
   • Proper posture for complete bladder emptying 1

2. Fluid management:

   • Minimize evening fluid intake (less than 200ml after dinner) 2
   • Encourage liberal fluid intake during morning and early afternoon 1, 2
   • Avoid caffeinated beverages before bedtime 1

3. Constipation management:

   • Ensure soft daily bowel movements, preferably after breakfast 1
   • Consider polyethylene glycol if needed 1

4. Documentation:

   • Keep a calendar of dry and wet nights to establish baseline and monitor progress 1, 2
   • This documentation itself has therapeutic value 1

5. Supportive counseling:

   • Educate about the high prevalence and nonvolitional nature of enuresis 1
   • Emphasize that bedwetting is not the fault of the child or parents 1
   • Encourage normal activities despite the condition 1

Second-Line Treatment Options

Enuresis Alarm (Preferred for long-term cure)

• Effectiveness: 66% initial success rate with more than half experiencing long-term success 1
• Mechanism: Conditions the child to awaken to bladder fullness sensation 1
• Implementation:
  • Written contract and thorough instructions enhance success 1
  • Requires significant parental involvement to help awaken the child initially 1
  • Regular monitoring appointments (at least every 3 weeks) 1
• Best candidates: Children with frequent enuresis and motivated families 1, 2

Desmopressin

• Effectiveness: 30% full response, 40% partial response 1, 2
• Dosage: 0.2-0.4 mg taken 1 hour before bedtime 2
• Best candidates: Children with nocturnal polyuria (urine production >130% of expected bladder capacity) 1
• Safety concern: Risk of water intoxication if combined with excessive fluid intake 1
• Note: Low curative potential compared to alarm therapy 1

Treatment Monitoring and Adjustment

• Schedule monthly follow-up appointments to sustain motivation 2
• Evaluate response using the calendar of wet/dry nights 2
• If no improvement after 2-3 months, consider alternative or additional treatments 2
• For desmopressin, schedule regular drug holidays to assess continued need 2

Important Caveats and Pitfalls

1. Not all children require treatment: After ruling out underlying conditions, parents may choose to wait for spontaneous resolution 1

2. Avoid punitive approaches: These worsen psychological impact and treatment adherence 2

3. Don't ignore comorbidities: Treating constipation and other conditions improves success rates 2

4. Psychological impact: Untreated enuresis can significantly impair self-esteem during critical developmental periods 3

5. Avoid premature discontinuation: This leads to high relapse rates 2

6. Don't focus solely on medication: Combined approaches are more effective than medication alone 2

7. Recognize persistence risk: Without treatment, some children will remain bedwetters into adulthood 3

The management approach should be presented with confidence and enthusiasm, as the manner of presentation significantly affects treatment success rates 1. Regular follow-up and adjustments to the treatment plan are essential for achieving long-term dryness.