What are the initial steps and treatment options for managing anuresis in children?

Management of Enuresis in Children

The first-line approach for managing enuresis in children should include a thorough assessment followed by behavioral interventions, with conditioning alarm therapy being the most effective non-pharmacological treatment option for motivated families. 1

Initial Assessment

Essential Diagnostic Steps:

• History-specific elements:

  • Pattern of wetting (frequency, timing, primary vs. secondary)
  • Presence of daytime symptoms (indicates non-monosymptomatic enuresis)
  • Family history of enuresis (44-77% genetic correlation)
  • Sleep patterns and potential sleep disorders (especially snoring/sleep apnea)
  • Psychological stressors (particularly for secondary enuresis)
  • Fluid intake patterns
  • Bowel habits (constipation often coexists with enuresis)

• Physical examination focus:

  • Enlarged adenoids or tonsils (sleep apnea association)
  • Abdominal examination for bladder distention or fecal impaction
  • Genital examination for abnormalities
  • Neurological examination
  • Spinal examination for sacral dimple or anomalies

• Basic laboratory tests:

  • Urinalysis (screening for infection, diabetes)
  • Urine culture if indicated
  • First-morning urine specific gravity (may predict DDAVP response)

• Baseline monitoring:

  • 2-week record of wet and dry nights before starting treatment 1

Treatment Algorithm

1. Address Specific Underlying Causes:

• For urologic abnormalities: Refer to urologist if daytime wetting, abnormal voiding, or UTI history exists 1
• For constipation: Disimpaction and bowel regimen (often resolves enuresis) 1, 2
• For sleep apnea: Consider ENT referral; surgical correction of airway obstruction may cure enuresis 1
• For psychological stressors: Individual psychotherapy or family therapy for secondary enuresis with clear psychological triggers 1

2. First-Line Treatments for Uncomplicated Enuresis:

A. Behavioral Interventions:

• Education and demystification:

  • Explain prevalence (15-20% at age 5) to reduce guilt 1, 3
  • Emphasize non-volitional nature to prevent punishment 1
  • Discuss spontaneous resolution rate

• Supportive approaches:

  • Journal/chart keeping of dry nights
  • Child involvement in changing wet bedding
  • Fluid restriction before bedtime (especially caffeinated beverages)
  • Scheduled nighttime awakening to void 1
  • Regular timed voiding during daytime 2

B. Conditioning Alarm Therapy:

• Most effective non-pharmacological treatment with 66% initial success rate and better long-term outcomes than medication 1
• Implementation requires:
  • Written contract with child
  • Modern portable alarm device
  • Thorough instruction on use
  • Frequent monitoring (every 3 weeks)
  • Overlearning (continuing use after initial dryness)
  • Intermittent reinforcement before discontinuation 1

3. Pharmacological Options (if behavioral approaches fail or aren't feasible):

A. Desmopressin:

• Mechanism: Synthetic ADH analog that reduces nighttime urine production
• Dosing: Available as oral tablets
• Efficacy: 40-60% effective but high relapse rate when discontinued
• Important safety precautions:
  • Limit fluid intake from 1 hour before to 8 hours after administration
  • Monitor for hyponatremia, especially in first week and first month
  • Contraindicated in patients with hyponatremia, excessive fluid intake, or using loop diuretics 4

B. Imipramine (second-line):

• Dosing: 1.0-2.5 mg/kg as single bedtime dose
• Efficacy: 40-60% effective with 50% relapse rate
• Caution: Consider ECG before treatment due to cardiac arrhythmia risk 1

Special Considerations

For Non-Monosymptomatic Enuresis:

• Treat underlying daytime bladder dysfunction first 5
• Consider anticholinergics for overactive bladder symptoms 5

For Therapy-Resistant Cases:

• Re-evaluate for missed comorbidities
• Consider combination therapy (alarm + medication)
• Rule out occult constipation 6

Common Pitfalls to Avoid:

1. Punishing the child for wetting episodes (counterproductive and harmful)
2. Neglecting comorbid conditions (constipation, sleep apnea, psychological issues)
3. Inadequate alarm therapy instruction (reduces effectiveness)
4. Excessive fluid intake with desmopressin (risk of hyponatremia)
5. Treating non-monosymptomatic enuresis like monosymptomatic enuresis

Referral Indications

• Refractory to standard treatments
• Suspected urinary tract malformations
• Recurrent UTIs
• Neurological disorders
• Complex cases with multiple comorbidities 7

By following this structured approach to assessment and treatment, most children with enuresis can achieve dryness and improved quality of life.