What is the initial approach to treating nocturnal (nighttime) enuresis?

Initial Management of Nocturnal Enuresis

The initial approach to treating nocturnal enuresis should focus on behavioral interventions including education, reward systems, regular voiding schedules, and fluid management, before considering alarm therapy or medications. 1, 2

Assessment and Education

• Educate parents about the prevalence of enuresis (15-20% of 5-year-olds) and the high spontaneous remission rate (approximately 14% per year) to reduce parental guilt and avoid punitive responses 1
• Reassure families that bedwetting is not the child's fault and is a common condition 1
• Complete a frequency-volume chart or bladder diary for at least 1 week to establish baseline patterns 1, 2
• Perform a urinalysis to rule out conditions like diabetes mellitus, urinary tract infection, or kidney disease 1, 3
• Assess for constipation, as treating it can lead to resolution of urinary symptoms in up to 63% of cases 2

First-Line Behavioral Interventions

• Implement a reward system (sticker chart) for dry nights to increase motivation and awareness 1, 2
• Establish regular daytime voiding schedules (morning, at least twice during school, after school, dinner time, and bedtime) 1, 2
• Minimize evening fluid intake, particularly caffeinated beverages, while ensuring adequate hydration earlier in the day 4, 1
• Involve the child in changing wet bedding to raise awareness (not as punishment) 4, 1
• Encourage physical activity during the day 1, 2
• Address constipation aggressively with polyethylene glycol if needed 1, 2

Second-Line Treatments (for children 6 years and older)

• Enuresis alarm therapy is the most benign and successful treatment with approximately 66% initial success rate 4, 1
• Provide written instructions, establish a contract, and schedule frequent monitoring appointments (at least every 3 weeks) to enhance success with enuresis alarms 4, 2
• Expect treatment to continue for at least 2-3 months before attempting to wean 2
• Consider desmopressin for children with nocturnal polyuria when alarm therapy has failed or is unlikely to be successful 1, 2

Important Considerations and Pitfalls

• Avoid punishment, shaming, or creating control struggles around bedwetting as it can worsen the situation and create psychological distress 4, 1
• Recognize that waking the child during the night to void is allowed but only helps for that specific night and may not be effective long-term 4, 1
• Be aware that some studies suggest night lifting may be less successful than no treatment 4
• Understand that supportive approaches may not have strong empirical support but carry no risk or expense and may be helpful in individual cases 4
• Schedule regular follow-up (monthly) to sustain motivation and assess treatment response 2
• Consider that conditioning treatment (alarm therapy) has been shown to be more effective than pharmacological treatments like imipramine and desmopressin in comparative studies 4

When to Consider Referral

• Refer to a specialist if there is no improvement after 1-2 months of consistent therapy 2
• Consider referral for children with primary enuresis refractory to standard and combination therapies 3
• Refer children with suspected secondary causes of enuresis, including urinary tract malformations, recurrent urinary tract infections, or neurologic disorders 3