What are the treatment options for nocturnal enuresis (bed wetting)?

Treatment Options for Nocturnal Enuresis (Bed Wetting)

The most effective treatment approach for nocturnal enuresis includes behavioral interventions as first-line therapy, with enuresis alarms and desmopressin as second-line options for children over 6 years of age who don't respond to initial management. 1, 2

Initial Assessment

• Complete a thorough evaluation to distinguish between monosymptomatic enuresis (bedwetting without daytime symptoms) and non-monosymptomatic enuresis (bedwetting with daytime symptoms) 1
• Perform a urine dipstick test to rule out diabetes mellitus, urinary tract infection, or kidney disease 1
• Complete a frequency-volume chart or bladder diary for at least 1 week to establish baseline patterns, detect underlying issues, and provide prognostic information 1, 2
• Assess for constipation, which can contribute to enuresis and decrease treatment success 1, 2

First-Line Treatment: Behavioral Interventions

General Lifestyle Advice

• Educate families that bedwetting is common (15-20% of 5-year-olds) with a spontaneous remission rate of approximately 14% per year 2, 3
• Establish regular daytime voiding schedule (morning, at least twice during school, after school, dinner time, and before bedtime) 1, 2
• Minimize evening fluid intake while ensuring adequate hydration earlier in the day 1, 2
• Treat constipation if present, considering polyethylene glycol if needed 1, 2
• Encourage physical activity during the day 1, 2

Motivational Strategies

• Implement a reward system using a calendar or sticker chart for dry nights 2, 4
• Involve the child in changing wet bedding (not as punishment) to raise awareness 2
• Avoid punishment, shaming, or creating control struggles around bedwetting 2
• Set realistic goals with monthly follow-up to sustain motivation 1, 2

Second-Line Treatment (for children ≥6 years)

Enuresis Alarm Therapy

• Considered the most effective long-term treatment with success rates of approximately 66% 2, 5
• More effective than bladder training alone 4
• Requires consistent use and family commitment 6
• May take 6-8 weeks to show improvement 5

Pharmacological Treatment

Desmopressin

• Consider for children with nocturnal polyuria 2, 5
• Achieves full response in 30% and partial response in 40% of cases 2
• Important safety considerations:
  • Contraindicated in patients with hyponatremia or history of hyponatremia 7
  • Limit fluid intake from 1 hour before until 8 hours after administration 7
  • Monitor serum sodium within 1 week and approximately 1 month after initiating treatment 7
  • Discontinue during illnesses that can cause fluid or electrolyte imbalance 7

Special Considerations

• Active treatment should not typically be started before age 6 years unless the child and family are highly motivated 1, 2
• For non-monosymptomatic enuresis, focus treatment initially on daytime symptoms 3
• Consider referral to a specialist for children with:
  • Features of underlying bladder dysfunction 5
  • Anatomical anomalies 5
  • Neurological disorders 5
  • Treatment resistance 6

Common Pitfalls to Avoid

• Waking the child during the night to void only helps for that specific night and doesn't treat the underlying condition 1, 2
• Simple behavioral interventions appear inferior to enuresis alarm therapy and some medications but have fewer side effects 4
• Untreated enuresis can impact a child's self-esteem, interpersonal relationships, and school performance 3, 8
• Without treatment, some children will continue to experience bedwetting into adulthood 8