What is the next step in managing primary nocturnal enuresis (PNE) in a 6-year-old child who has never been dry at night and has a family history of the condition?

Management of Primary Nocturnal Enuresis in a 6-Year-Old

At age 6 with primary monosymptomatic nocturnal enuresis and positive family history, initiate behavioral interventions with education and supportive measures, then proceed to alarm therapy as first-line active treatment if the family desires intervention beyond observation. 1, 2

Initial Approach: Education and Behavioral Modifications

At exactly age 6, active treatment becomes appropriate, though not mandatory if the family prefers watchful waiting. 1, 3 The spontaneous remission rate is approximately 14-16% annually at this age, so reassurance alone is a valid option. 1, 3

Begin with these evidence-based behavioral interventions:

• Educate the family that bedwetting is not the child's fault, occurs in 15-20% of 5-year-olds, and has a strong genetic component (the brother's history confirms this). 1, 2

• Implement a reward system using a sticker chart for dry nights to increase motivation and awareness, which has independent therapeutic effects. 1, 2

• Establish regular voiding schedules: morning, twice during school, after school, at dinner, and immediately before bed (not just "at bedtime" but when lights go out). 1, 2

• Minimize evening fluid intake (especially caffeinated beverages) while ensuring liberal hydration during morning and early afternoon hours. 1, 2

• Screen for and treat constipation with polyethylene glycol if needed, as this can resolve enuresis in up to 63% of cases when present. 1, 4

• Complete a frequency-volume chart for at least 1 week to establish baseline patterns and detect nocturnal polyuria. 1, 2

• Perform urinalysis to exclude diabetes mellitus, urinary tract infection, or kidney disease. 1

First-Line Active Treatment: Alarm Therapy

If the family desires active treatment beyond behavioral measures, alarm therapy is the definitive first-line choice. 1, 2, 5

The evidence strongly favors alarm therapy over other options:

• Initial success rate of 66% with the most durable long-term outcomes. 1, 2

• At 12 months, 56% of children remain dry after alarm therapy compared to only 10-16% with medications. 5

• Alarm therapy demonstrates persistent effectiveness (p < 0.001) unlike pharmacological options which show high relapse rates after discontinuation. 5

Critical implementation details for alarm success:

• Provide written instructions and establish a treatment contract with the family. 4

• Schedule frequent monitoring appointments (monthly) to sustain motivation. 1, 4

• Expect treatment duration of at least 2-3 months before attempting to wean. 4

• Ensure the child (not parents) responds to the alarm to condition arousal to bladder fullness. 1

When to Consider Desmopressin Instead

Desmopressin is second-line therapy but may be considered first-line in specific circumstances: 1, 2

• Nocturnal polyuria documented on bladder diary (weighing diapers shows excessive nighttime urine production). 1

• Short-term situational needs such as sleepovers or camp. 6

• Family preference when alarm therapy is deemed impractical or has failed. 4

Desmopressin dosing and expectations:

• 0.2-0.4 mg tablets or 120-240 mg melt formulation, taken 1 hour before bedtime. 4

• Immediate effect with 30% full response and 40% partial response rates. 1, 2

• Strict fluid restriction: maximum 200 ml (6 ounces) in evening and nothing until morning to prevent hyponatremia. 4

• High relapse rate after discontinuation (only 10% remain dry at 12 months off medication). 5

Common Pitfalls to Avoid

• Do not wake the child at night to void—this only helps that specific night and does not condition arousal. 1, 2

• Never use punitive approaches—this worsens psychological distress and is contraindicated. 1, 2, 3

• Do not start with desmopressin unless nocturnal polyuria is documented or alarm therapy is impractical. 1, 5

• Do not overlook constipation—treat this first as it may resolve the enuresis entirely. 1, 4

Answer to Multiple Choice Question

The correct answer is D - alarm therapy for this 6-year-old with primary monosymptomatic nocturnal enuresis and family history, assuming the family desires active treatment. 1, 2, 5

• Option A (reassure) is acceptable if the family prefers observation given the 14-16% annual spontaneous cure rate, but active treatment is now appropriate at age 6. 1, 3

• Option B (desmopressin) is second-line unless nocturnal polyuria is documented or alarm therapy fails/is impractical. 1, 5

• Option C (toilet training) is not applicable—this child has primary nocturnal enuresis, not a daytime training issue. 1

• Option D (alarm) provides the highest long-term cure rate (56% at 12 months) with persistent effectiveness. 1, 5