What is the initial approach for a child with nocturnal enuresis (bedwetting) and a family history of the condition?

Initial Management of Nocturnal Enuresis with Positive Family History

Begin with reassurance that the family history (44% risk with one affected parent, 77% with both) confirms a genetic basis, then implement behavioral modifications while completing a frequency-volume chart to guide whether enuresis alarm therapy or desmopressin is most appropriate. 1, 2

Immediate First Steps

Reassure the family that bedwetting is involuntary and not the child's fault, emphasizing the strong genetic component—when one parent had enuresis, the child has a 44% chance, and when both parents were affected, the risk increases to 77%. 1, 3 This discussion often reveals that the affected parent was enuretic until a similar age, which normalizes the condition for the child. 1

Perform a urine dipstick test immediately to exclude diabetes mellitus (glycosuria) and kidney disease (proteinuria). 1, 4 If glycosuria is present, urgent blood glucose testing is mandatory. 4

Assess and aggressively treat constipation first, as this is a paramount cause of treatment resistance. 4, 2 Ask specifically about bowel frequency, stool consistency, and painful defecation. If constipation is present, prescribe polyethylene glycol as a stool softener (Grade Ia evidence) with the goal of one soft, comfortable bowel movement daily, preferably after breakfast. 1, 4

Essential Diagnostic Tool

Have the family complete a frequency-volume chart (bladder diary) for at least 2 days of measured fluid intake and voided volumes, plus 1 week of documenting wet/dry nights, daytime incontinence, and bowel movements. 1, 4 This objectively detects nocturnal polyuria (which predicts desmopressin response), identifies polydipsia, and distinguishes monosymptomatic from non-monosymptomatic enuresis. 1, 4

Weigh nighttime diapers to assess nocturnal urine production, as nocturnal polyuria indicates desmopressin would likely be successful. 1

Behavioral Modifications for All Patients

Implement these evidence-based lifestyle changes (Grade IV evidence) before or alongside active treatment: 1

• Instruct regular daytime voiding: morning, twice during school, after school, at dinner, and immediately before sleep (approximately 7 voids daily). 1, 2
• Restrict evening fluid and solute intake while maintaining liberal water intake during morning and early afternoon hours. 1, 2
• Encourage physical activity. 1
• Keep a calendar of dry and wet nights, which has an independent therapeutic effect (Grade Ib evidence). 1
• Inform parents that waking the child at night to void is allowed but only helps for that specific night, if at all. 1

Treatment Algorithm (Age 6+ Years)

Do not start active treatment before age 6 years, though general lifestyle advice should be given to all bedwetting children. 1

First-Line Treatment Choice:

Enuresis alarm therapy is first-line for monosymptomatic enuresis in children aged 6-7+ years, with a 66% initial response rate and >50% long-term cure rate, making it superior for sustained success. 4, 2 However, the alarm requires several weeks to be effective and needs strong commitment from both child and caregivers. 5, 6

Desmopressin may be used as first-line when rapid onset or short-term improvement is the priority, or when alarm therapy is inappropriate or undesirable (e.g., sleepovers, camp, low family motivation for alarm monitoring). 4, 5 Desmopressin achieves 30% full response and 40% partial response (Grade Ia evidence), but has low curative potential. 4

Desmopressin Dosing and Safety:

• Dose: 0.2-0.4 mg tablets (taken 1 hour before sleep) or 120-240 µg melt formulation (taken 30-60 minutes before sleep). 4
• Critical safety warning: Restrict fluid intake from 1 hour before the dose until 8 hours after to avoid water intoxication, hyponatremia, and convulsions. 4
• Families can choose daily use or only before important nights, with regular short drug holidays to assess ongoing need. 4

Follow-Up Requirements

Schedule monthly follow-up appointments to sustain motivation and assess response, as an individualized program with realistic goals between visits improves outcomes. 1, 4, 2

Continue treatment for at least 2-3 months before declaring failure. 4, 2

Critical Pitfalls to Avoid

• Failing to screen for and treat constipation, which causes treatment resistance in many cases. 4, 2
• Punitive parental responses, which worsen psychological impact—reinforce that bedwetting is involuntary. 2, 3
• Inadequate alarm monitoring, which requires frequent follow-up and high parental commitment. 2
• Excessive fluid intake on desmopressin, which increases hyponatremia risk. 4, 2
• Missing non-monosymptomatic enuresis (daytime urgency, holding maneuvers, interrupted micturition, weak stream, daytime incontinence), which requires treating underlying bladder dysfunction first. 2

When to Refer to Specialist

Urgent pediatric urology referral is needed if the child has: weak urinary stream, continuous incontinence, recurrent urinary tract infections, abnormal neurological findings (sacral dimple, vertebral anomalies), or non-monosymptomatic enuresis that doesn't respond to initial management. 4, 2