What is the management plan for nocturnal (night-time) incontinence in an 8-year-old female with normal daytime continence?

Management of Nocturnal Enuresis in an 8-Year-Old Female with Normal Daytime Continence

Start with standard urotherapy (education, timed voiding, fluid management, constipation treatment) as first-line treatment, and if this fails after 2-3 months, escalate to enuresis alarm therapy, which has the highest cure rate and lowest relapse rate for monosymptomatic nocturnal enuresis. 1, 2

Initial Evaluation

Before initiating treatment, complete a focused assessment to exclude underlying pathology and identify treatable comorbidities:

• Obtain a detailed voiding history specifically asking about urgency, holding maneuvers, interrupted micturition, weak stream, frequency of bedwetting (every night vs. sporadic), and whether this is primary (never dry) or secondary enuresis 1
• Complete a frequency-volume chart for at least 2 days measuring fluid intake and voided volumes, with notation of wet/dry nights for at least 1 week to provide objective data and detect nocturnal polyuria 1
• Assess bowel function thoroughly as constipation must be treated first or achieving dryness will be difficult; ask about stool frequency (every 2 days or less suggests constipation), consistency, and fecal incontinence 1
• Perform urinalysis to exclude urinary tract infection, diabetes, or kidney disease 1
• Physical examination should include abdominal palpation and observation of the lumbosacral spine; rectal examination is no longer routinely recommended as it can be distressing and is unreliable 1

First-Line Treatment: Standard Urotherapy

Begin with standard urotherapy for all children, which should be maintained for at least 2-3 months before considering escalation 1, 3:

Education and Behavioral Modifications

• Educate the family that bedwetting is neither the child's nor parents' fault, that it is common, and provide realistic expectations about treatment timeline 1
• Implement a reward calendar for dry nights (star charts), which has independent therapeutic effect and provides baseline to judge treatment response 1, 2
• Establish regular daytime voiding schedule: morning, twice during school, after school, dinner time, and immediately before bed (typically 6-7 times daily) 1
• Optimize toilet posture with buttock support, foot support, and comfortable hip abduction to enable relaxed pelvic floor during voiding 1

Fluid and Dietary Management

• Encourage liberal fluid intake during morning and early afternoon, but minimize evening fluid and solute intake while remaining flexible for social activities 1
• Limit evening fluid to 200 ml (6 ounces) or less after dinner, with no drinking until morning 1

Constipation Management (Critical)

• Treat any constipation aggressively with initial disimpaction using oral laxatives (polyethylene glycol has grade Ia evidence), followed by maintenance bowel management for many months 1
• Goal is soft daily bowel movement without discomfort, preferably after breakfast 1

Additional Behavioral Strategies

• Discourage routine lifting/waking by parents, as this only helps for that specific night and does not promote long-term dryness 1
• Encourage physical activity 1

Second-Line Treatment: Enuresis Alarm Therapy

If standard urotherapy fails after 2-3 months, escalate to enuresis alarm therapy, which is the most effective treatment with cure rates significantly higher than other interventions and the lowest relapse rate 1, 2, 4:

• Alarm therapy requires commitment from both child and family but has superior long-term outcomes compared to pharmacological options 2, 4
• The alarm should be used correctly with proper instruction and follow-up 1

Pharmacological Options (Third-Line or Specific Indications)

Desmopressin

Consider desmopressin if alarm therapy fails, family is unlikely to comply with alarm, or for specific situations (sleepovers, camps) 1:

• Most effective in children with nocturnal polyuria (identified on frequency-volume chart) and normal bladder capacity (maximum voided volume >70% expected for age) 1
• Dosing: 0.2-0.4 mg oral tablets taken at least 1 hour before sleep, or 120-240 mcg oral melt tablets 30-60 minutes before bed 1
• Response rate: approximately 30% full responders, 40% partial response, but low curative potential with high relapse after discontinuation 1
• Critical safety warning: Contraindicated in children with polydipsia due to risk of water intoxication, hyponatremia, and convulsions; avoid nasal spray formulation 1
• Effect is immediate; families can choose daily use or only before important nights 1

Anticholinergics (Oxybutynin, Tolterodine, Propiverine)

Reserve anticholinergics only for therapy-resistant cases where standard treatment and alarm have failed, particularly if detrusor overactivity is suspected 1:

• Before prescribing: ensure regular voiding habits established, constipation treated, and post-void residual urine excluded via uroflowmetry with ultrasound 1
• Dosing: 2 mg tolterodine, 5 mg oxybutynin, or 0.4 mg/kg propiverine at bedtime (may double if needed) 1
• Useful in approximately 40% of therapy-resistant children, often requiring combination with desmopressin 1
• Monitor for constipation (most bothersome side effect) and post-void residual urine causing UTIs 1

Imipramine

Imipramine is only relevant as third-line therapy at tertiary care facilities due to safety concerns and side effects, despite 50% response rate 1

Treatment Algorithm Summary

1. Months 0-3: Standard urotherapy (education, behavioral modifications, fluid management, constipation treatment) 1, 3
2. If failure at 3 months: Add enuresis alarm therapy 1, 2
3. If alarm fails or family cannot comply: Consider desmopressin, especially if nocturnal polyuria present 1
4. If still refractory: Refer to specialized center for consideration of anticholinergics or combination therapy 1

Important Caveats

• Never start active treatment before age 6 years unless there are specific concerns 1
• Constipation must be addressed first or treatment success is unlikely 1
• Monthly follow-up is essential to sustain motivation and adjust treatment 1
• Psychiatric comorbidities (especially ADHD) are more common in therapy-resistant cases and may require parallel treatment 1
• Simple behavioral interventions alone (rewards, lifting) appear inferior to alarm therapy and some drug therapies, but can be tried as initial first-line before more demanding treatments 2