What is the treatment for adult nocturnal enuresis (bedwetting)?

Treatment of Adult Nocturnal Enuresis

Start with behavioral modifications and desmopressin as first-line therapy, as these are the most evidence-based approaches for adult bedwetting. 1, 2

Initial Evaluation - Key Points to Identify

Before initiating treatment, rule out the following underlying conditions that require specific management:

• Nocturnal polyuria (nighttime urine production >35% of total daily output) - most responsive to desmopressin 2, 3
• Bladder outlet obstruction in men (prostate enlargement with chronic retention) - may require surgical intervention 3
• Detrusor overactivity on urodynamic studies - may benefit from anticholinergic addition 2, 4
• Hypnotic medication use - frequently overlooked cause that impairs awakening on bladder distension 3
• Constipation - creates mechanical pressure on bladder 2
• Sleep disorders particularly sleep apnea 2

First-Line Treatment Algorithm

Step 1: Behavioral and Lifestyle Modifications

Implement these foundational interventions simultaneously:

• Establish regular voiding schedule: void regularly during the day, always at bedtime and upon awakening 1, 2
• Fluid management: liberal water intake during morning and early afternoon, but minimize evening fluid and solute intake 1, 2
• Treat constipation aggressively: aim for soft daily bowel movements, preferably after breakfast; use polyethylene glycol to optimize bowel emptying 1, 2
• Discontinue hypnotics if being used for insomnia, as these impair arousal mechanisms 3
• Encourage physical activity 1

Step 2: Pharmacological Therapy - Desmopressin

Desmopressin is the drug of choice for adult nocturnal enuresis, particularly when nocturnal polyuria is confirmed. 2

Dosing Options:

• Oral tablets: 0.2-0.4 mg taken at least 1 hour before sleep 1, 2
• Oral melt tablets (lyophilisate): 120-240 μg taken 30-60 minutes before bedtime 1, 2
• Dosing is not influenced by body weight or age 2

Expected Efficacy:

• Approximately 30% achieve full response, 40% have partial response 5
• Overall effectiveness ranges from 10-65% with potential for relapse 1, 2
• Most effective for patients with nocturnal polyuria (>130% of expected bladder capacity for age) 5

Critical Safety Requirements:

Fluid restriction is mandatory with desmopressin therapy - this is the most important safety consideration:

• Limit evening fluid intake to 200 ml (6 ounces) or less 1, 5, 2
• No drinking from desmopressin administration until morning 1, 5, 2
• Polydipsia is an absolute contraindication 1, 5, 2
• Desmopressin combined with excessive fluid intake can cause water intoxication with hyponatremia and convulsions 1, 5, 2
• Avoid nasal spray formulations due to higher risk of hyponatremia 1, 5, 2

Monitoring:

• Schedule regular short drug holidays to assess whether medication is still needed 1, 5, 2

Step 3: Add Anticholinergic Therapy if Desmopressin Fails

If desmopressin alone is ineffective after 1 month, add anticholinergic medication:

• Tolterodine 4 mg at bedtime 4
• Alternative options: oxybutynin or propiverine 2
• Particularly effective when detrusor overactivity is present on urodynamic studies 2, 4
• Combination therapy (desmopressin + anticholinergic) may achieve continence in patients who fail monotherapy 4

Step 4: Consider Enuresis Alarm Therapy

Enuresis alarm therapy has approximately 66% success rate with better long-term outcomes than medications alone, as more than half experience sustained success. 5, 2

• Can be used as alternative to or adjunct with pharmacotherapy 2
• Requires greater effort and commitment but has lower relapse rates than medications 6

Step 5: Alternative Pharmacological Options

If above treatments fail:

• Imipramine: 40-60% effectiveness but higher relapse rates and more side effects than desmopressin 2
• Consider only after desmopressin and anticholinergic combinations have failed 1

Special Considerations for Adults

Adult nocturnal enuresis is usually multifactorial, requiring identification and treatment of multiple contributing causes simultaneously. 3

• 50% of adults with primary nocturnal enuresis have detrusor instability on urodynamic studies 4
• 40% have bladder hypocompliance 4
• Urodynamic studies may be beneficial to identify abnormalities, though treatment efficacy is not necessarily predicted by urodynamic findings 4
• Most patients (92%) require maintenance therapy rather than achieving cure with short-term treatment 4

Common Pitfalls to Avoid

• Do not use desmopressin without strict fluid restriction - this is the most common cause of serious adverse events 1, 5, 2
• Do not overlook hypnotic medication use as a reversible cause 3
• Do not assume single etiology - most adult cases have multiple contributing factors requiring simultaneous management 3
• Do not continue ineffective monotherapy indefinitely - add anticholinergic therapy after 1 month if desmopressin alone fails 4