What is the best approach to managing enuresis (bedwetting) in children?

Management of Childhood Enuresis

Enuresis alarm therapy should be your first-line treatment for children over 7 years old with primary monosymptomatic nocturnal enuresis, as it achieves approximately 66% initial success with superior long-term cure rates compared to medications. 1

Initial Evaluation

Essential History Components

• Distinguish monosymptomatic from non-monosymptomatic enuresis by specifically asking about daytime urgency, holding maneuvers (standing on tiptoe, pressing heel into perineum), interrupted micturition, weak stream, and any daytime incontinence 1
• Assess frequency and pattern: every night versus sporadic, primary (never dry) versus secondary (dry for ≥6 months then relapsed) 1, 2
• Screen for comorbidities: constipation and fecal impaction (paramount causes of treatment resistance), sleep apnea symptoms (habitual snoring, witnessed apneas, gasping, restless sleep), ADHD, diabetes 1, 3
• Obtain family history: 44% risk with one affected parent, 77% with both parents affected 3
• Review medications: lithium, valproic acid, clozapine, and theophylline can cause secondary enuresis 1

Physical Examination Essentials

• Abdomen: palpate for bladder distention and fecal impaction 1
• Genitalia: examine for meatal abnormalities, epispadias, phimosis 1
• Back: inspect for sacral dimple or vertebral anomalies suggesting spinal cord issues 1
• Complete neurologic exam to rule out subtle dysfunction 1

Required Testing

• Urinalysis and urine culture in all patients to exclude infection, diabetes, and kidney disease 1, 4
• No routine imaging needed unless history reveals continuous wetting, abnormal voiding pattern, recurrent UTIs, or positive urinalysis 1

Treatment Algorithm

Step 1: Behavioral Modifications (All Patients)

• Educate parents that enuresis is nonvolitional, has high spontaneous cure rate (14% annually), and is not the child's fault 1, 5
• Implement regular daytime voiding schedule (every 2-3 hours) 4, 3
• Restrict evening fluids, especially caffeinated beverages 1, 4
• Void immediately before sleep 4
• Treat constipation aggressively if present, as this is a major cause of treatment failure 1, 4
• Keep dry bed chart with child involvement in changing sheets (consciousness-raising) 1

Step 2: First-Line Active Treatment (Choose Based on Context)

Option A: Enuresis Alarm (Preferred for Long-Term Cure)

• Best for children ≥7 years with frequent bedwetting and motivated families 1, 2
• Success rate: 66% initial response, >50% long-term cure - superior to all medications 1
• Requires significant parental commitment to awaken child initially and ensure they finish voiding in toilet 1
• Treatment duration: minimum 2-3 months, with overlearning phase (every other day use) before discontinuation 4
• Monitor every 3 weeks with written contract and thorough instructions to maximize success 1
• Common pitfall: inadequate parental help awakening the child is the major reason for failure 1

Option B: Desmopressin (For Rapid/Short-Term Response)

• Best when rapid onset is priority (sleepovers, camp) or alarm is inappropriate/undesirable 2, 4
• Effective for nocturnal polyuria: 30% full response, 40% partial response 4, 3
• Critical safety warning: restrict fluids while on desmopressin to prevent hyponatremia 4
• Assess response after 1-2 months, continue minimum 2-3 months before weaning 4
• Higher relapse rate compared to alarm therapy 1

Step 3: Resistant Cases

• Combination therapy: desmopressin plus alarm for refractory cases 4
• Re-evaluate thoroughly for missed comorbidities (constipation, sleep apnea, ADHD, anatomical abnormalities) before declaring treatment failure 4, 6
• Refer to pediatric urology for: primary enuresis refractory to standard and combination therapies, suspected urinary tract malformations, recurrent UTIs, neurologic disorders, continuous daytime wetting 7, 5

Special Considerations

Non-Monosymptomatic Enuresis (Daytime Symptoms Present)

• Requires different approach: treat underlying bladder dysfunction first 1
• Urgent specialty referral needed if child has weak stream, uses abdominal pressure to void, or has continuous incontinence 1
• May require anticholinergics and urotherapy in addition to standard enuresis treatment 6

Secondary Enuresis

• Investigate psychological stressors: parental divorce, school trauma, sexual abuse, hospitalization 1
• Treat underlying cause (UTI, diabetes, sleep apnea) before addressing enuresis 1, 3
• Consider surgical correction if obstructive sleep apnea identified, as this can cure enuresis 3

Critical Pitfalls to Avoid

• Failing to screen for constipation - this is a paramount cause of treatment resistance and must be aggressively treated 1, 4
• Inadequate treatment duration before declaring failure - minimum 2-3 months required 4
• Excessive fluid intake on desmopressin - increases hyponatremia risk 4
• Punitive parental response - reinforces that bedwetting is involuntary, not behavioral 1
• Insufficient alarm monitoring - requires frequent (every 3 weeks) follow-up and parental commitment 1
• Missing sleep apnea - specifically ask about snoring, witnessed apneas, and daytime sleepiness 3