How to manage enuresis (bedwetting) of less than 3 months duration without signs of urinary tract infection (UTI)?

Management of Recent-Onset Enuresis (<3 Months) Without UTI Signs

For enuresis of less than 3 months duration without signs of UTI, the first step should be a thorough evaluation for underlying medical causes, including urinalysis and urine culture, before initiating any specific treatment. 1, 2

Initial Evaluation

Required Assessments:

• Urinalysis and urine culture: Essential to rule out UTI, even without obvious symptoms 1
• Fasting blood glucose: To exclude diabetes mellitus 2
• Detailed history focusing on:
  • Pattern of bedwetting (primary vs. secondary)
  • Daytime symptoms (suggests non-monosymptomatic enuresis)
  • Family history of enuresis
  • Sleep patterns
  • Fluid intake patterns
  • Bowel habits (constipation can contribute)
  • Developmental history
  • Recent psychological stressors 2

Physical Examination:

• Abdominal exam (for bladder distention, fecal impaction)
• Genital examination (for abnormalities)
• Back examination (for signs of spinal cord anomalies)
• Neurological examination 1

Management Algorithm

1. For Recent-Onset Enuresis (<3 months):

• Rule out medical causes first - recent onset suggests potential underlying condition 2, 3
• Look for:
  • Urinary tract infection (even without obvious symptoms)
  • Diabetes mellitus or diabetes insipidus
  • Constipation
  • Sleep disorders (especially obstructive sleep apnea)
  • Psychological stressors (significant life changes)
  • Neurological disorders

2. If Medical Evaluation is Negative:

First-Line Approaches:

• Behavioral modifications:
  • Establish regular voiding schedule (every 2-3 hours during daytime)
  • Limit evening fluid intake (after dinner)
  • Avoid caffeinated beverages
  • Create a dry night chart with positive reinforcement
  • Involve child in changing wet bedding (for awareness, not punishment) 2
  • Awaken child to void during the night 1

If No Improvement After 4 Weeks:

• For monosymptomatic nocturnal enuresis:

  1. Enuresis alarm: First-line treatment with 50-70% success rate 4, 5

     • Continue until 14 consecutive dry nights
     • Regular monitoring appointments (every 3 weeks)

  2. Desmopressin: Alternative first-line treatment 2

     • Dosage: 0.2-0.4 mg tablets or 120-240 μg melt formulation
     • Timing: 1 hour before bedtime (tablets) or 30-60 minutes (melt)
     • Fluid restriction crucial (200 ml or less in evening, none after medication)
     • Schedule regular drug holidays (2 weeks every 3 months)

• For non-monosymptomatic enuresis (with daytime symptoms):

  • Treat constipation if present
  • Address daytime voiding habits first
  • Then proceed with treatments for nocturnal enuresis 5

Important Considerations

1. Recent evidence challenges basic bladder advice effectiveness:

   • Studies show limited efficacy of basic bladder advice alone 6, 7
   • Only 18% full response after 3 months of bladder training 6

2. Treatment should not begin before age 6 unless significant distress 2

3. Avoid punitive approaches - they worsen psychological impact and decrease treatment adherence 2

4. Monitor for comorbidities:

   • Constipation
   • Sleep disorders
   • Psychological/psychiatric conditions 2, 4

5. When to refer to specialist:

   • Enuresis refractory to standard treatments
   • Suspected urinary tract malformations
   • Recurrent UTIs
   • Neurological disorders 3

For recent-onset enuresis (<3 months), the focus should be on identifying and treating underlying causes rather than immediately implementing long-term enuresis treatments, as this pattern suggests a potential medical or psychological trigger that should be addressed first.