What are the treatment options for nocturnal enuresis in children?

Treatment of Nocturnal Enuresis in Children

The first-line treatments for monosymptomatic nocturnal enuresis in children are enuresis alarm therapy and desmopressin, with behavioral strategies as foundational interventions. 1

Initial Evaluation

• Assess for:

  • Pattern of bedwetting
  • Daytime symptoms (to distinguish monosymptomatic from non-monosymptomatic enuresis)
  • Family history of enuresis
  • Sleep patterns
  • Fluid intake patterns
  • Bowel habits (constipation can worsen enuresis)
  • Developmental history
  • Psychological stressors

• Laboratory evaluation:

  • Urinalysis and urine culture (to rule out UTI, diabetes)
  • Consider fasting blood glucose if polyuria/polydipsia present

Treatment Algorithm

Step 1: Behavioral Interventions

• Establish regular voiding schedule
• Limit evening fluid intake (especially 1-2 hours before bedtime)
• Avoid caffeinated beverages
• Create a dry night chart with positive reinforcement
• Involve child in changing wet bedding (not as punishment)
• Regular toileting before bedtime

Step 2: First-line Active Treatments

Option A: Enuresis Alarm

• Most effective long-term solution with lowest relapse rates
• Continue until 14 consecutive dry nights
• Regular monitoring appointments (at least every 3 weeks)
• Success rate of approximately 50-70%

Option B: Desmopressin

• Dosage: 0.2-0.4 mg tablets or 120-240 μg melt formulation
• Administration: 1 hour before bedtime (tablets) or 30-60 minutes before bedtime (melt)
• Important safety measures:
  • Restrict evening fluid intake to 200 ml or less
  • No fluid intake after medication until morning
  • Schedule regular drug holidays (at least 2 weeks every 3 months)
• Success rate of approximately 30-40% with significant reduction in wet nights

Step 3: For Treatment-Resistant Cases

Option A: Combination Therapy

• Combine alarm therapy with desmopressin
• May be more effective than either treatment alone

Option B: Add Anticholinergics

• Consider if standard treatments fail
• Options:
  • Tolterodine (2 mg at bedtime)
  • Oxybutynin (5 mg at bedtime)
  • Propiverine (0.4 mg/kg at bedtime)
• Important: Exclude or treat constipation before starting anticholinergics
• Monitor for side effects, especially constipation

Option C: Imipramine (Third-line)

• Only after other treatments have failed
• Dosage:
  • Children 6 years and older: 25 mg/day
  • Children over 12 years: up to 50 mg/day
• Safety concerns:
  • Potentially cardiotoxic
  • Keep medication securely locked
  • Consider ECG before treatment if family history of cardiac issues
  • Do not exceed 2.5 mg/kg/day 2
  • Regular drug holidays to assess continued need

Common Pitfalls to Avoid

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

2. Neglecting comorbid conditions:

   • Untreated constipation significantly reduces treatment success
   • ADHD and other neuropsychiatric disorders may complicate treatment

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

4. Premature discontinuation: High relapse rates occur with early stopping, especially with medication

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

6. Focusing only on medication: Neglecting behavioral strategies reduces effectiveness

Special Considerations

• The spontaneous resolution rate is only 14-16% annually 1, justifying active treatment
• Simple behavioral methods may be tried first before more demanding interventions like alarms or medications 3
• For children with non-monosymptomatic enuresis (daytime symptoms present), additional evaluation by a specialist may be needed
• Regular follow-up using a wet/dry night calendar helps monitor progress and maintain motivation

Remember that nocturnal enuresis can significantly impact a child's self-esteem and social functioning, making effective treatment important for psychological well-being as well as dryness.