What are the treatment options for enuresis?

Treatment Options for Enuresis

Conditioning therapy with a modern, portable, battery-operated alarm is the most effective first-line treatment for uncomplicated monosymptomatic nocturnal enuresis in cooperative, motivated families. 1

Initial Assessment and Specific Treatments

Before initiating treatment, it's important to identify any underlying causes:

• Urologic referral is indicated for children with daytime wetting, abnormal voiding, history of urinary tract infections, or genital abnormalities 1
• Constipation or fecal impaction should be treated as they can cause mechanical pressure on the bladder 1
• Sleep apnea should be evaluated and treated - surgical correction of upper airway obstruction can lead to improvement or cure of enuresis 1
• Psychological factors should be addressed when enuresis begins during periods of stress (e.g., parental divorce, abuse, hospitalization) 1

First-Line Treatments for Uncomplicated Enuresis

Supportive Approaches

• Education and demystification about enuresis for parents and children 1
• Ensuring parents do not punish the child for enuretic episodes 1
• Journal keeping or dry bed charts 1
• Fluid restriction before bedtime 1
• Night awakening to void 1

Conditioning Therapy (Enuresis Alarm)

• Success rate of approximately 66%, with more than half experiencing long-term success 1
• Most effective when implemented with:
  • Written contract 1
  • Thorough instruction 1
  • Frequent monitoring (at least every 3 weeks) 1
  • Overlearning and intermittent reinforcement before discontinuation 1
• Requires significant parental involvement to help awaken the child 1
• More effective than pharmacological treatments in comparative studies 1

Pharmacological Options

Desmopressin (DDAVP)

• Synthetic analogue of antidiuretic hormone (ADH) that decreases nighttime urine production 1
• Dosage: 0.2-0.6 mg orally at bedtime or 10-40 μg intranasally 1
• Success rates of 10-65% with relapse rates up to 80% 1
• Best suited for children with nocturnal polyuria and normal bladder capacity 1
• Water intoxication is a rare but serious side effect requiring electrolyte monitoring during intercurrent illness 1
• Useful for short-term use (e.g., overnight camps) 1

Imipramine

• FDA-approved for temporary adjunctive therapy in children aged 6 years and older 2
• Dosage: 1.0-2.5 mg/kg as a single bedtime dose 1
• Effectiveness: 40-60% with relapse rates up to 50% 1
• Mechanism of action for enuresis is unknown 1
• Requires pretreatment electrocardiogram to detect underlying rhythm disorders 1
• Serious risk of toxicity if ingested by younger siblings 1
• Consider only after conditioning therapy and/or desmopressin have failed 1

Treatment Algorithm for Therapy-Resistant Cases

For children who don't respond to first-line therapies:

1. Re-evaluate for undetected NMNE (non-monosymptomatic nocturnal enuresis) 1
2. Consider anticholinergic agents (if constipation is excluded or treated) 1
3. Try combination therapy:
   • Desmopressin plus anticholinergic agent may be more effective than desmopressin alone 1
   • Imipramine plus oxybutynin is more effective than imipramine alone with lower relapse rates 3
4. Consider referral to a pediatric urologist for refractory cases 4

Important Considerations

• Behavioral interventions are less invasive than pharmacotherapy and should generally be tried first 5
• Enuresis alarms are superior to bladder training exercises 5
• Combination therapy may reduce relapse rates by about 20% compared to monotherapy 3
• Treatment effectiveness should be monitored with a 2-week baseline record of wet and dry nights 1
• Bladder-stretching exercises have inconsistent evidence of effectiveness 1
• Hypnotherapy, dietary manipulation, and desensitization to allergens lack empirical evidence of efficacy 1