What is the first line of treatment for nocturnal enuresis?

First-Line Treatment for Nocturnal Enuresis

The enuresis alarm is the first-line treatment for nocturnal enuresis, with superior long-term outcomes compared to pharmacological options. 1, 2

Evaluation Before Treatment

Before initiating treatment, a proper evaluation should include:

• Detailed history of bedwetting pattern
• Assessment for daytime urinary symptoms
• Voiding chart/frequency-volume diary
• Urinalysis to rule out diabetes, infection, or kidney disease
• Physical examination to rule out anatomical abnormalities
• Assessment of constipation (common comorbidity)
• Screening for sleep disorders (especially sleep apnea)

Treatment Algorithm

First-Line Treatments:

1. Enuresis Alarm Therapy

   • Most effective for children with frequent enuresis
   • Success rate of approximately 66% 1
   • Lower relapse rates compared to medications
   • Requires parental commitment and consistency
   • Regular monitoring appointments every 3 weeks 1

2. Behavioral Modifications (to be used alongside alarm therapy)

   • Establish regular voiding schedules
   • Create a dry night chart with positive reinforcement
   • Limit evening fluid intake to 200 ml or less after dinner
   • Avoid caffeinated beverages before bedtime
   • Treat constipation if present

3. Desmopressin

   • Alternative first-line option when:
     • Alarm therapy has failed or is refused
     • Child has nocturnal polyuria with normal bladder capacity
   • Dosage: 0.2-0.4 mg taken 1 hour before bedtime 1
   • Higher relapse rate than alarm therapy when discontinued

Second-Line Treatments (for therapy-resistant cases):

1. Anticholinergics

   • Consider for children with signs of bladder overactivity
   • Often combined with desmopressin 1
   • Not a first-line therapy for uncomplicated nocturnal enuresis

2. Imipramine

   • Consider only after other treatments have failed 3
   • Efficacy rate of 40-60% but high relapse rate 2
   • Dosage for children: 25-75 mg/day (age-dependent) 4
   • Requires cardiac monitoring due to potential side effects

Treatment Selection Based on Pathophysiology

• For children with nocturnal polyuria: Consider desmopressin
• For children with reduced functional bladder capacity: Alarm therapy is most effective
• For children with high arousal threshold: Alarm therapy is preferred

Common Pitfalls to Avoid

1. Starting treatment too early: Treatment should not begin before age 6 years 1

2. Punitive approaches: These worsen psychological impact and decrease treatment adherence 1

3. Ignoring comorbid conditions: Constipation, sleep disorders, and neuropsychiatric disorders like ADHD can decrease treatment success 1

4. Premature discontinuation: This leads to high relapse rates, especially with medication 1

5. Focusing only on medication: Neglecting behavioral strategies reduces effectiveness 1

6. Water intoxication risk: Can occur if desmopressin is combined with excessive fluid intake 1

7. Inadequate follow-up: Regular monitoring is essential for treatment success 1

The evidence strongly supports enuresis alarm therapy as the first-line treatment due to its superior long-term outcomes and curative potential, despite requiring more effort than pharmacological options 2, 1, 3. Desmopressin is an appropriate alternative first-line treatment when alarm therapy is not feasible or for short-term management (e.g., sleepovers, camps) 2, 1.