What treatments are available for individuals experiencing movement issues and nocturnal enuresis (bed wetting)?

Treatment of Movement Issues and Nocturnal Enuresis

When a patient presents with both movement problems and bedwetting, immediately perform a urine dipstick test to exclude diabetes mellitus, as this combination of symptoms represents a potential medical emergency. 1

Initial Urgent Evaluation

The combination of movement issues and nocturnal enuresis requires immediate metabolic screening, as this presentation may indicate serious underlying conditions:

• Perform urine dipstick testing immediately - glycosuria mandates urgent blood glucose testing to exclude diabetes mellitus, which can present with both neurological symptoms and enuresis 1
• Screen for red flag symptoms including weight loss, polydipsia (excessive thirst), and polyuria, as these indicate diabetes or kidney disease requiring immediate investigation 1, 2
• Assess the movement disorder specifically by asking: "Do you have any problems controlling your legs? Do you experience slowness of movement? Have you noticed a tremor in your hands?" 3

Systematic Neurological Assessment

Movement problems accompanying enuresis warrant thorough neurological evaluation:

• Examine for lower limb weakness, abnormalities of gait or speech, and tremor during physical examination 3
• Inspect the back for sacral dimple or other signs of vertebral/spinal cord anomalies, as these may indicate neurogenic bladder 2
• Perform a complete neurological examination to rule out subtle dysfunction that could explain both symptoms 2
• Consider sleep-related movement disorders by asking: "Does your bed partner complain that you have twitchy legs or make kicking movements in your sleep?" This screens for periodic limb movements of sleep (PLMS) or restless legs syndrome (RLS), which can disrupt sleep and contribute to enuresis 3

Baseline Investigations

Once urgent conditions are excluded, complete the following workup:

• 72-hour bladder diary to document voiding patterns and fluid intake 3
• Blood tests: electrolytes/renal function, thyroid function, calcium, and HbA1c 3
• Urine culture to rule out urinary tract infection (95-98% negative predictive value) 2
• Blood pressure assessment 3
• If proteinuria is present on dipstick, repeat samples and investigate for kidney disease before treating the enuresis 2

Treatment Algorithm Based on Underlying Cause

If Neurological Dysfunction is Identified:

• Refer to neurology without delay if the child voids with a weak stream or has continuous incontinence, as these suggest neurogenic bladder 2
• Treat any identified constipation aggressively with polyethylene glycol, as constipation can worsen both neurogenic bladder and enuresis 2

If Sleep Disorder is Contributing:

• Screen for obstructive sleep apnea by asking: "Do you snore and sometimes wake up choking? Does your partner say that you stop breathing?" 3
• Evaluate for RLS/PLMS as these disorders can fragment sleep and prevent arousal to bladder fullness 3
• Refer to sleep medicine if sleep disorder is suspected, as treating the underlying sleep pathology may resolve the enuresis 3

If Primary Enuresis Without Serious Underlying Cause:

First-line treatment:

• Implement behavioral modifications: regular daytime voiding schedule (every 2-3 hours), proper voiding posture, and restrict evening fluid intake 2, 4
• Use enuresis alarm therapy as first-line treatment with superior long-term success rates compared to medication 2, 4

Second-line treatment:

• Desmopressin 0.4 mg orally is an alternative, particularly for children with nocturnal polyuria, with approximately 30% full response rate and 40% partial response 2, 4, 5
• Critical safety measures with desmopressin: Limit fluid intake to a minimum from 1 hour before administration until 8 hours after administration to prevent life-threatening hyponatremia 6
• Monitor serum sodium within 1 week and approximately 1 month of initiating desmopressin, and periodically thereafter 6
• Desmopressin is contraindicated in patients with polydipsia, hyponatremia, moderate to severe renal impairment, or concomitant use with loop diuretics or glucocorticoids 6

For resistant cases:

• Consider adding tolterodine 4 mg if daytime symptoms persist and suggest detrusor overactivity, or if desmopressin alone fails 5
• Combination therapy with alarm plus desmopressin may be effective for resistant cases 4
• Reassess diagnosis and consider specialist referral if no response after 2-3 months of appropriate therapy 2, 4

Common Pitfalls to Avoid

• Do not attribute bedwetting to behavioral causes when accompanied by movement problems, weight loss, or polydipsia—these are red flag symptoms requiring metabolic investigation 1
• Do not delay dipstick testing by ordering comprehensive metabolic panels or scheduling follow-up appointments first—the dipstick can be done immediately and may reveal a life-threatening condition 1
• Do not fail to screen for constipation, as it contributes to enuresis and must be treated aggressively before enuresis therapy will succeed 2, 4
• Do not allow excessive fluid intake while on desmopressin, as this increases the risk of hyponatremia, which can cause seizures, coma, or death 6
• Do not declare treatment failure prematurely—continue treatment for at least 2-3 months before attempting to wean or change therapy 4

Follow-up and Monitoring

• Regular follow-up ideally monthly to sustain motivation and assess response to therapy 4
• Assess response after 1-2 months of therapy 4
• Most patients (92%) require maintenance therapy to prevent relapse 5