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

Next Step: Enuresis Alarm Therapy

For this 6-year-old with primary monosymptomatic nocturnal enuresis and positive family history, the answer is D - alarm therapy, which should be initiated as first-line treatment now that the child has reached age 6. 1, 2

Why Alarm Therapy is the Correct Answer

• Alarm therapy is the first-line treatment for monosymptomatic nocturnal enuresis in children 6 years and older, with success rates of approximately 66% and the highest long-term cure rates compared to other interventions 2, 3
• Active treatment should not be started before age 6 years, but this child has now reached the appropriate age for intervention 1
• The alarm works by developing an unconscious inhibitory reflex through conditioning, with most children (77%) becoming dry within 12 weeks 4

Why Other Options Are Incorrect

Reassurance alone (Option A) is inadequate because:

• While spontaneous remission occurs at approximately 14% per year, many enuretic children will remain bedwetters for life if left untreated 5
• The condition significantly impairs self-esteem and threatens optimal personality development 5
• Treatment is not only justified but mandatory given the psychological impact 1

Desmopressin (Option B) is second-line therapy because:

• It should be reserved for cases where alarm therapy has failed or is unlikely to be successful 6
• While desmopressin provides 30% full response and 40% partial response rates, alarm therapy produces superior long-term success 1, 2
• Desmopressin is more appropriate for children with documented nocturnal polyuria 1

Toilet training (Option C) is not the issue because:

• This child has primary nocturnal enuresis (never been dry at night), not a daytime voiding problem 1
• Regular daytime voiding schedules are part of general lifestyle advice but not the primary treatment 1

Essential Steps Before Starting Alarm Therapy

Complete initial evaluation including:

• Urinalysis to exclude diabetes mellitus (glycosuria) and kidney disease (proteinuria) 1
• Frequency-volume chart or bladder diary for at least 1 week to confirm monosymptomatic pattern and establish baseline 1, 2
• Assessment for constipation, which must be treated first if present 1, 6
• Confirmation that there are no daytime symptoms (urgency, holding maneuvers, weak stream, daytime incontinence) that would indicate non-monosymptomatic enuresis requiring different management 1

Provide concurrent behavioral interventions:

• Educate family that bedwetting is not the child's fault and is common 1, 2
• Implement reward system (sticker chart) for dry nights 2, 6
• Establish regular daytime voiding schedule (morning, twice during school, after school, dinner time, bedtime) 2, 6
• Minimize evening fluid intake while ensuring adequate daytime hydration 2, 6
• Encourage the child to void at bedtime and upon awakening 1

Critical Implementation Details for Alarm Success

• Provide written instructions and establish a contract with the family 6
• Schedule frequent monitoring appointments (monthly follow-up) to sustain motivation 1, 6
• Expect treatment to continue for at least 2-3 months before attempting to wean 6
• The child should be involved in changing wet bedding to raise awareness (not as punishment) 2, 6

Common Pitfalls to Avoid

• Do not punish, shame, or create control struggles around bedwetting, as this worsens the situation and creates psychological distress 2, 6
• Waking the child at night to void is allowed but not necessary and only helps for that specific night 1, 2
• Do not delay treatment based on the positive family history - this indicates hereditary delay in maturation but does not change the treatment approach 5
• If no improvement occurs after 1-2 months of consistent alarm therapy, reassess the diagnosis and consider combination therapy with desmopressin 6