What are the treatment options for nocturnal enuresis?

Treatment Options for Nocturnal Enuresis

The first-line treatment for nocturnal enuresis should include behavioral interventions such as alarm therapy for children over 6 years old, with desmopressin as an alternative first-line option for those with nocturnal polyuria. 1, 2

Initial Assessment

• A thorough evaluation should include a frequency-volume chart or bladder diary for at least 1 week to establish baseline patterns and detect underlying issues 1, 2
• Urinalysis is mandatory to rule out conditions like diabetes mellitus, urinary tract infection, or kidney disease 1, 2
• Physical examination is usually normal in monosymptomatic nocturnal enuresis (MNE) but should include examination of the back and external genitals 1
• Assess for comorbid conditions such as constipation, attention deficit hyperactivity disorder, and sleep disorders which may decrease treatment success 1

Behavioral Interventions

• Implement a reward system (sticker chart) for dry nights to increase motivation and awareness 2
• Establish regular daytime voiding schedules (morning, at least twice during school, after school, dinner time, and before bedtime) 1, 2
• Minimize evening fluid intake (200 ml or less) with no drinking until morning, while ensuring adequate hydration earlier in the day 1, 2
• Address constipation if present, using polyethylene glycol if needed 1, 2
• Involve the child in changing wet bedding to raise awareness (not as punishment) 1, 2
• Encourage physical activity during the day 1, 2

First-Line Active Treatments (for children ≥6 years)

Alarm Therapy

• Enuresis alarm is the most effective first-line treatment with initial success rates of approximately 66% and better long-term outcomes than medications 1, 2
• Requires commitment and proper instruction for success 1
• Most effective when presented with written contract, thorough instructions, and regular follow-up 1

Desmopressin

• Oral desmopressin is indicated for children with nocturnal polyuria or when alarm therapy has failed 1, 2, 3
• Dosage: 0.2-0.4 mg tablets or 120-240 μg melt formulation taken 1 hour before bedtime for tablets or 30-60 minutes before bedtime for melt formulation 1
• Response rates: approximately 30% full response and 40% partial response 2
• Safety concern: risk of water intoxication with hyponatremia if combined with excessive fluid intake 1
• Regular drug holidays should be scheduled to assess whether medication is still needed 1

Second-Line Treatments

Anticholinergics

• Consider for therapy-resistant cases, particularly when detrusor overactivity is suspected 1
• Options include oxybutynin, tolterodine, and propiverine 1
• Often combined with desmopressin for better results 1, 4
• Typical dosage: 2 mg tolterodine, 5 mg oxybutynin, or 0.4 mg/kg propiverine at bedtime 1
• Monitor for side effects, particularly constipation 1

Tricyclic Antidepressants (Imipramine)

• Third-line therapy due to safety concerns 1
• Initial dosage for children aged 6 and older: 25 mg/day one hour before bedtime 5
• May increase to 50 mg nightly in children under 12 years; up to 75 mg nightly for children over 12 5
• Do not exceed 2.5 mg/kg/day due to potential ECG changes 5
• Response rate approximately 50% 1

Treatment Algorithm

1. Start with behavioral interventions for all ages 2
2. For children ≥6 years with persistent enuresis:
   • First choice: Enuresis alarm therapy 1, 2
   • Alternative first choice (especially with nocturnal polyuria): Desmopressin 1, 3
3. For treatment failures:
   • Reassess for undiagnosed comorbidities 3, 6
   • Consider combination therapy (alarm + desmopressin) 3
   • Add anticholinergics if detrusor overactivity is suspected 1, 4
4. For therapy-resistant cases:
   • Consider imipramine as third-line therapy 1, 5
   • Referral to specialist (pediatric urologist) 7

Special Considerations

• Treatment should not typically be started before age 6 years unless significant distress exists 1, 2
• Moderate learning disability is not a contraindication to treatment 1
• Adult enuresis often has multiple contributing factors requiring detailed investigation 8, 4
• Regular follow-up (monthly) with realistic goals helps sustain motivation and improves outcomes 1, 2
• Avoid punishment or creating control struggles around bedwetting 1, 2

Common Pitfalls

• Failing to identify comorbid conditions like constipation or sleep disorders 1, 3
• Not addressing psychological impact of enuresis on the child 1
• Excessive fluid restriction beyond recommendations 1
• Inadequate commitment to alarm therapy leading to treatment failure 1
• Using desmopressin nasal spray (higher risk of hyponatremia than oral formulations) 1
• Not scheduling regular drug holidays with desmopressin to assess continued need 1