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

First-Line Treatment for Enuresis (Bedwetting) in Children

The first-line treatments for nocturnal enuresis in children are behavioral interventions and, for children 6 years and older, either an enuresis alarm or desmopressin. 1, 2

Initial Assessment and Education

• Educate families that bedwetting is common (15-20% of 5-year-olds) with a spontaneous remission rate of approximately 14% per year to reduce parental guilt and avoid punitive responses 1, 3
• Complete a frequency-volume chart or bladder diary for at least 1 week to establish baseline patterns 1, 2
• Perform 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 with nocturnal enuresis 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 1, 2
• Address constipation aggressively if present 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 Medical Treatments (for children ≥6 years)

Enuresis Alarm Therapy

• Considered first-line treatment for children 6 years and older 1, 2
• Success rates of approximately 66% with proper use 1
• Provide written instructions, establish a contract, and schedule frequent monitoring appointments 2
• Expect treatment to continue for at least 2-3 months before attempting to wean 2, 4

Desmopressin

• Consider for children with nocturnal polyuria when alarm therapy has failed or is unlikely to be successful 2
• Typical oral dose: 0.2 to 0.4 mg tablets (taken 1 hour before bedtime) or 120 to 240 mg melt formulation (taken 30-60 minutes before bedtime) 5, 2
• Limit fluid intake to 200 ml (6 ounces) or less in the evening and no drinking until morning to prevent hyponatremia 2
• Expect immediate anti-enuretic effect with approximately 30% full response and 40% partial response rates 1, 2
• The anti-enuretic effect is seen immediately, and families may choose between daily medication or administration before important nights only 5

Second-Line Treatments

Anticholinergics

• Consider for children with suspected detrusor overactivity when standard treatments have failed 5, 2
• Options include oxybutynin (5 mg), tolterodine (2 mg), or propiverine (0.4 mg/kg) at bedtime 5, 2
• Monitor for constipation and post-void residual urine that may cause UTIs 5, 2
• Expect anti-enuretic effect within a maximum of 2 months 5
• Often combined with desmopressin at standard dose 5

Combination Approaches for Resistant Cases

• Combine alarm therapy with desmopressin for children not responding to single modalities 2, 6
• Consider treating constipation first before escalating urinary treatments if constipation and urinary symptoms coexist 2

Third-Line Treatment

Tricyclic Antidepressants (Imipramine)

• Only relevant as third-line therapy at tertiary care facilities due to safety concerns 5
• Approximately 50% of children with therapy-resistant enuresis respond to imipramine 5, 2
• Dosage: 25 to 50 mg at bedtime (larger dose for children older than 9 years) 5
• Potentially cardiotoxic; overdose may be fatal; keep securely locked away from smaller siblings 5
• Regular drug holidays of at least 2 weeks every third month to decrease risk of tolerance 5

Important Considerations and Pitfalls

• Avoid punishing, shaming, or creating control struggles around bedwetting as it can worsen the situation and create psychological distress 1, 2
• Schedule monthly follow-up appointments to sustain motivation and assess treatment response 1, 2
• Reassess diagnosis and consider referral to a specialist if no improvement occurs after 1-2 months of consistent therapy 2, 3
• Waking the child during the night to void is allowed but only helps for that specific night 1
• Simple behavioral interventions may be superior to no active treatment but appear to be inferior to enuresis alarm therapy and some drug therapies 7