What are the treatment options for an 8-year-old with nocturnal enuresis?

Management of Frequent Bedwetting in an 8-Year-Old

For an 8-year-old with frequent bedwetting, start with an enuresis alarm as first-line therapy, which achieves a 66% initial response rate and over 50% long-term cure rate, making it the most effective treatment for achieving permanent dryness. 1, 2

Initial Evaluation Steps

Before starting any treatment, complete these essential diagnostic steps:

• Perform a urine dipstick test immediately to exclude diabetes mellitus and kidney disease; if glycosuria is present, obtain urgent blood glucose testing 1, 2
• Assess and aggressively treat constipation first, as this is a paramount cause of treatment resistance—use polyethylene glycol as a stool softener to achieve a soft, comfortable bowel movement daily, preferably after breakfast 3, 1, 2
• Have the family complete a frequency-volume chart for at least 2 days of measured fluid intake and voided volumes, plus 1 week documenting wet/dry nights, daytime incontinence, and bowel movements—this objectively detects nocturnal polyuria and identifies polydipsia 1, 2
• Consider weighing nighttime diapers to assess nocturnal urine production, as nocturnal polyuria (>130% of expected bladder capacity) indicates desmopressin would likely be successful 1

Behavioral Modifications (Start Immediately)

Implement these evidence-based lifestyle changes for all children with bedwetting:

• Establish a regular daytime voiding schedule: the child should void in the morning, at least twice during school, after school, at dinner time, and just before turning out the lights—typically 6-7 times daily 3
• Restrict evening fluid and solute intake while allowing liberal water intake during morning and early afternoon hours to enable participation in social and sports activities 3, 1
• Keep a calendar of dry and wet nights, which provides a baseline to judge therapeutic interventions and has an independent therapeutic effect 3, 1
• Encourage physical activity 3
• Inform parents that waking the child at night to void is allowed but only helps for that specific night, if at all—it does not contribute to long-term cure 3, 1

First-Line Treatment: Enuresis Alarm Therapy

The enuresis alarm is the treatment of choice for monosymptomatic enuresis in children aged 6-7+ years because it has the highest long-term cure rate:

• Alarm therapy achieves a 66% initial response rate and greater than 50% long-term cure rate, making it superior to medication for permanent resolution 1, 2, 4
• The alarm should sound when the child begins to wet, training the child to wake to bladder fullness 4
• Treatment requires at least 2-3 months before declaring failure 2
• Schedule monthly follow-up appointments to sustain motivation and assess response—an individualized program with realistic goals between visits improves outcomes 3, 1, 2

Alternative Treatment: Desmopressin

Desmopressin is an alternative when rapid onset or short-term improvement is the priority, such as for sleepovers or camp:

• Desmopressin achieves a 30% full response and 40% partial response rate but has low curative potential 3, 1, 2
• Desmopressin is most efficient in children with nocturnal polyuria (nocturnal urine production >130% of expected bladder capacity) and normal bladder reservoir function (maximum voided volume >70% of expected bladder capacity) 3
• Dosing: 0.2-0.4 mg tablets taken 1 hour before sleep, or 120-240 µg melt formulation taken 30-60 minutes before bedtime—dose is not influenced by body weight or age 3, 1

Critical Safety Warning for Desmopressin

RESTRICT FLUID INTAKE FROM 1 HOUR BEFORE THE DOSE UNTIL 8 HOURS AFTER to avoid water intoxication, hyponatremia, and convulsions:

• Limit evening fluid intake to 200 ml (6 ounces) or less, then no drinking until morning 3
• Desmopressin is contraindicated in patients with polydipsia, hyponatremia, or excessive fluid intake 5
• Monitor serum sodium within 1 week and approximately 1 month of initiating desmopressin, and periodically thereafter 5
• The nasal spray formulation carries higher risk of water intoxication and should be avoided—use oral formulations only 3

Combination Therapy for Treatment-Resistant Cases

• For treatment-resistant enuresis, combine desmopressin and alarm therapy 2
• This approach may be considered after single-modality treatment has failed for at least 2-3 months 2

When to Refer to Specialist

Urgent referral to pediatric urology is needed if the child has:

• Weak urinary stream 2
• Continuous incontinence 2
• Recurrent urinary tract infections 2
• Abnormal neurological findings 2
• Non-monosymptomatic enuresis (daytime symptoms) that doesn't respond to initial management 2

Critical Pitfalls to Avoid

• Never use punitive parental responses—reassure the family that bedwetting is not the child's fault and has a strong genetic basis (44% risk if one parent had enuresis, 77% if both parents were affected) 1, 2
• Never fail to screen for and treat constipation first, as it is the most common cause of treatment resistance 1, 2
• Never prescribe desmopressin without strict fluid restriction counseling, as water intoxication can cause seizures, coma, and death 3, 5
• Never declare treatment failure before 2-3 months of consistent therapy 2
• Never miss non-monosymptomatic enuresis (daytime symptoms), which requires treating underlying bladder dysfunction first 1

Reassurance and Expectations

• The spontaneous cure rate is 14-16% annually without treatment, but many children will remain bedwetters for life if left untreated 3, 6, 7
• Bedwetting can significantly impair self-esteem and lead to social problems, justifying active treatment at this age 3, 7
• Promise the child that you will not give up until they are dry, and encourage them to lead a normal life despite the condition 3