What is the first-line medication for nocturnal enuresis in children?

First-Line Medication for Nocturnal Enuresis in Children

The first-line medications for nocturnal enuresis in children are the enuresis alarm (non-pharmacological) and desmopressin, with the choice between them depending on the child's specific voiding pattern. 1, 2

Initial Assessment to Guide Treatment Selection

Before selecting medication, a proper evaluation should include:

• Detailed history of bedwetting pattern
• Assessment for daytime symptoms (which would suggest non-monosymptomatic enuresis)
• 2-week voiding diary and frequency-volume chart
• Urinalysis to rule out infection and diabetes
• Physical examination to rule out neurological abnormalities

Treatment Algorithm

Step 1: Determine Enuresis Pattern

• For children with nocturnal polyuria and normal bladder capacity: Desmopressin is the preferred first-line medication
• For children with normal urine production but reduced bladder capacity: Enuresis alarm is preferred

Step 2: First-Line Medication Options

Option A: Desmopressin

• Dosage: 0.2-0.4 mg tablets or 120-240 μg melt formulation
• Timing: Take 1 hour before bedtime (tablets) or 30-60 minutes before bedtime (melt formulation)
• Efficacy: Immediate effect with 77.8% success rate during treatment 3
• Caution: Higher relapse rate (50%) after discontinuation compared to alarm therapy 3
• Important safety note: Restrict fluid intake 2 hours before bedtime to prevent water intoxication 2

Option B: Enuresis Alarm

• Efficacy: 82% success rate during treatment with only 12% relapse rate 3
• Best for: Well-motivated families and children with low voided volume
• Follow-up: Regular monitoring appointments (at least every 3 weeks) 2

Second-Line Treatment Options

If the first-line treatment fails after adequate trial (typically 3 months):

1. Switch to the alternative first-line option (from alarm to desmopressin or vice versa)

   • Success rate of approximately 70% with crossover treatment 3

2. For therapy-resistant cases:

   • Anticholinergics (oxybutynin, tolterodine, propiverine) may be considered, often in combination with desmopressin 1, 4
   • Usual doses: 2 mg tolterodine, 5 mg oxybutynin, or 0.4 mg/kg propiverine at bedtime 1

3. Third-line option:

   • Imipramine (25-50 mg at bedtime) may be considered only after other treatments have failed 1, 5
   • Dosage: 25 mg/day for children 6 years and older; may increase to 50 mg for children under 12 years or up to 75 mg for children over 12 years 5
   • Important safety warning: Potentially cardiotoxic; requires careful monitoring and secure storage 1

Common Pitfalls to Avoid

1. Starting treatment too early (before age 6) is not recommended 2
2. Punitive approaches worsen psychological impact and decrease treatment adherence 2
3. Premature discontinuation leads to high relapse rates, especially with medication 2
4. Ignoring comorbid conditions such as constipation can decrease treatment success 2
5. Failing to recognize non-monosymptomatic enuresis which requires different management

Treatment Duration and Follow-up

• For desmopressin: Schedule regular drug holidays to assess continued need
• For enuresis alarm: Continue until 14 consecutive dry nights are achieved
• For both: Regular follow-up using wet/dry night calendar to monitor progress

The choice between desmopressin and enuresis alarm should be based on the child's specific voiding pattern, family preference, and motivation level, with the understanding that alarm therapy offers better long-term outcomes despite requiring more effort.