At what age should treatment for enuresis (bedwetting) in children be considered?

When to Treat Childhood Enuresis

Treatment for enuresis should be considered starting at age 5 years when the child meets diagnostic criteria, but active therapy is most appropriate beginning at age 6 years. 1, 2

Diagnostic Age Threshold

• Enuresis is formally defined as repeated voiding of urine into bed or clothes at least twice weekly for at least three consecutive months in a child who is at least 5 years of age. 1
• Before age 4-5 years, bedwetting is considered a normal developmental variant, as the spontaneous cure rate is approximately 30% annually in children aged 2-4 years, compared to a steady 14-16% annual spontaneous resolution rate after age 4. 1
• This developmental shift in spontaneous cure rates provides the biological rationale for considering enuresis a clinical problem warranting evaluation after age 4-5 years. 1

When to Initiate Active Treatment

Active therapy should begin at age 6 years or older. 2

However, treatment timing should be modified based on these critical factors:

Immediate Evaluation Required (Any Age ≥5 Years)

• If there is associated distress or functional impairment (e.g., anxiety, impaired self-esteem, inability to attend sleepovers or camp), treatment should be considered even if frequency/duration criteria are not fully met. 1
• Secondary enuresis (resumption of wetting after ≥6 months of dryness) warrants prompt evaluation regardless of age, as this may indicate underlying medical conditions, psychological stressors, or life events requiring separate treatment. 1, 3, 4
• Severe/continuous incontinence, weak urinary stream, or non-monosymptomatic enuresis (daytime symptoms of frequency and urgency) requires immediate referral to a specialized center without delay. 3

Treatment Algorithm by Age

Ages 5-6 years:

• Provide reassurance to parents that enuresis is common (affecting 15-20% of 5-year-olds) and not the child's fault. 3
• Perform urinalysis to rule out diabetes mellitus, urinary tract infection, or kidney disease. 3
• Screen for and treat constipation first, as this can resolve enuresis independently. 3
• Implement behavioral interventions: reward systems (sticker charts), regular daytime voiding schedules, minimizing evening fluid intake, and encouraging bedtime voiding. 3

Age 6 years and older:

• Enuresis alarm therapy becomes first-line treatment with approximately 66% success rates. 3
• Desmopressin is second-line therapy, particularly if nocturnal polyuria is documented, with 30% full response and 40% partial response rates. 3
• For children aged 6 years and older, imipramine may be used as temporary adjunctive therapy after organic causes have been excluded. 5

Critical Pitfalls to Avoid

• Do not delay treatment if psychological damage is occurring. The psychological and developmental consequences (chronic anxiety, impaired self-esteem, social isolation) may be more devastating than the symptom itself and can precipitate physical or emotional abuse from frustrated caregivers. 1
• Do not assume psychological causation. Identifiable psychological factors are contributory in only a minority of children with enuresis; most cases have biological underpinnings (genetic factors, arousal dysfunction, nocturnal polyuria, or bladder dysfunction). 1
• Do not overlook comorbid conditions. Constipation, obstructive sleep apnea, diabetes mellitus, urinary tract infections, and psychiatric disorders must be identified and treated, as they can perpetuate enuresis. 6, 2