What is the first line of treatment for nocturnal enuresis (bedwetting)?

First-Line Treatment for Nocturnal Enuresis (Bedwetting)

The mainstays of primary therapy for nocturnal enuresis are bladder advice, the enuresis alarm, and/or desmopressin. 1

Initial Assessment and Behavioral Interventions

Behavioral interventions should be implemented first before considering pharmacological options:

• Education and demystification about enuresis for parents and children is essential, emphasizing that bedwetting is not the child's fault 2
• Establish regular voiding habits - children should void regularly during the day, and always at bedtime and upon awakening 1
• Implement fluid management - minimize evening fluid and solute intake while encouraging liberal water intake during morning and early afternoon hours 1
• Treat constipation if present - aim for soft bowel movements daily, preferably after breakfast; polyethylene glycol can help optimize bowel emptying 1
• Encourage physical activity 1
• Consider using reward systems such as star charts for dry nights 3

Enuresis Alarm Therapy

• Enuresis alarm therapy has a success rate of approximately 66%, with more than half experiencing long-term success 2
• Implementation should include:
  • A written contract with the family 2
  • Thorough instruction on proper use 2
  • Frequent monitoring of progress 2
  • Overlearning and intermittent reinforcement before discontinuation 2

Pharmacological Treatment

• Desmopressin is an evidence-based therapy (grade Ia evidence) for nocturnal enuresis 1

• Approximately 30% of children are full responders and 40% have a partial response 1

• Desmopressin is most effective for children with:

  • Nocturnal polyuria (nocturnal urine production >130% of expected bladder capacity for age) 1
  • Normal bladder reservoir function (maximum voided volume >70% of expected bladder capacity for age) 1
  • Cases where alarm therapy has failed or compliance is unlikely 1

• Dosing recommendations:

  • Tablets: 0.2-0.4 mg taken at least 1 hour before sleep 1
  • Oral melt formulation: 120-240 μg taken 30-60 minutes before bedtime 1
  • Dose is not influenced by body weight or age 1

Important Safety Considerations

• Fluid restriction is essential with desmopressin - evening intake should be limited to 200 ml (6 ounces) or less with no drinking until morning 1
• Polydipsia is a contraindication to desmopressin treatment 1
• Desmopressin combined with excessive fluid intake can cause water intoxication with hyponatremia and convulsions 1
• Nasal spray formulations are discouraged due to higher risk of hyponatremia 1

Treatment Algorithm for Therapy-Resistant Cases

• Re-evaluate for undetected non-monosymptomatic nocturnal enuresis 2
• Consider anticholinergic agents for children who don't respond to first-line therapies 2
• Combination therapy (desmopressin plus anticholinergic) may be more effective than desmopressin alone in resistant cases 2
• Imipramine may be considered in select cases but has significant side effects 2

When to Refer

• Referral to a pediatric urologist is indicated for:
  • Primary enuresis refractory to standard and combination therapies 4
  • Children with suspected urinary tract malformations 4
  • Recurrent urinary tract infections 4
  • Neurologic disorders 4

Treatment Monitoring

• Monitor effectiveness with a 2-week baseline record of wet and dry nights 2
• Regular short drug holidays should be scheduled when using desmopressin to assess whether medication is still needed 1