Management of Enuresis
Conditioning therapy with enuresis alarms is the most effective first-line treatment for uncomplicated monosymptomatic nocturnal enuresis, with initial success rates of approximately 66% and better long-term outcomes than pharmacological options. 1, 2
Initial Evaluation
Before initiating treatment, a thorough evaluation should include:
- Urinalysis and urine culture to rule out infection or diabetes
- Assessment of enuresis pattern (primary vs. secondary, nocturnal vs. diurnal)
- Family history of enuresis
- Sleep patterns and fluid intake patterns
- Bowel habits (constipation can contribute to enuresis)
- Developmental history and psychological stressors
- Neurological examination
- 2-week voiding diary to document frequency and patterns 2
Red Flags Requiring Further Investigation
- Continuous wetting (vs. intermittent episodes)
- Abnormal voiding patterns
- Recurrent urinary tract infections
- Daytime symptoms (urgency, frequency)
- Recent onset after period of dryness (secondary enuresis)
- Neurological symptoms 1
Treatment Algorithm
Step 1: Supportive Approaches and Behavioral Modifications
- Educate parents about prevalence (15-20% of five-year-olds) and spontaneous resolution rate (14-16% annually) 2
- Emphasize non-volitional nature of symptom to avoid punishment
- Implement dry bed chart with positive reinforcement
- Reduce fluid intake before bedtime, especially caffeinated beverages
- Establish regular voiding schedule
- Have child participate in changing wet bedding
- Treat constipation if present (can decrease treatment success) 1, 2
Step 2: First-Line Active Treatment (for children ≥6 years)
Enuresis Alarm Therapy
- Most effective long-term treatment with curative potential
- Success rate approximately 66% with >50% experiencing long-term success
- Requires written contract, thorough instructions, and frequent monitoring
- Continue until 14 consecutive dry nights achieved
- More effective than pharmacological options in comparative studies 1, 2
Step 3: Pharmacological Treatment (if alarm therapy fails or isn't feasible)
Desmopressin
- Dosage: 0.2-0.4 mg tablets or 120-240 μg melt formulation
- Timing: 1 hour before bedtime (tablets) or 30-60 minutes before bedtime (melt)
- Faster response than alarm therapy but higher relapse rates
- Requires fluid restriction to prevent water intoxication and hyponatremia
- Schedule regular drug holidays to assess continued need 2
Anticholinergics (for treatment-resistant cases)
- Consider tolterodine (2 mg), oxybutynin (5 mg), or propiverine (0.4 mg/kg) at bedtime
- Ensure constipation is excluded or treated before starting 2
Imipramine (last resort)
- FDA-approved for temporary adjunctive therapy in children ≥6 years
- Dosage: 25 mg/day for children 6 years and older
- Use only after other treatments have failed
- Potentially cardiotoxic - requires careful monitoring and secure storage
- Effectiveness may decrease with continued administration 2, 3
Step 4: Combination Therapy for Resistant Cases
- Alarm + desmopressin for treatment-resistant cases
- Consider adding anticholinergics if bladder capacity is reduced 2, 4
Important Caveats
- Treatment should not begin before age 6 years 2
- Premature discontinuation leads to high relapse rates, especially with medication 2
- Imipramine has serious acute toxicity risks - strict rules regarding storage and use must be enforced 5
- Punitive approaches worsen psychological impact and decrease treatment adherence 2
- Regular follow-up appointments (at least every 3 weeks) help sustain motivation and allow treatment adjustment 1, 2
- Consider referral to pediatric urology for refractory cases or when secondary causes are suspected 6
By following this structured approach to enuresis management, focusing first on behavioral interventions and alarm therapy before progressing to pharmacological options, most children can achieve significant improvement in this distressing condition.