Alarm Therapy is the Next Step
For this 6-year-old with primary monosymptomatic nocturnal enuresis and a positive family history, alarm therapy should be initiated as the first-line treatment, as it provides approximately 66% success rates and the highest long-term cure rates compared to all other interventions. 1
Why Alarm Therapy Over Other Options
Reassurance alone (Option A) is insufficient at age 6, as active treatment is now indicated given the psychological impact of enuresis on self-esteem and personality development, making treatment not only justified but mandatory 2, 1
Desmopressin (Option B) is second-line therapy and should be reserved for cases where alarm therapy has failed or is unlikely to be successful, as it provides only 30% full response and 40% partial response rates, which are inferior to alarm therapy's long-term success 1, 3
Toilet training (Option C) is not applicable since this child has primary nocturnal enuresis (never been dry at night), not a daytime voiding issue—the pathophysiology involves nocturnal polyuria, detrusor overactivity, and increased arousal threshold during sleep, not lack of toilet training 2
The family history is a positive prognostic indicator for alarm therapy success, as primary monosymptomatic enuresis has a strong familial component with complex inheritance patterns 4
Essential Pre-Treatment Steps Before Starting the Alarm
Before initiating alarm therapy, several critical evaluations must be completed:
Perform urinalysis to exclude diabetes mellitus (glycosuria) and kidney disease (proteinuria), as these medical conditions must be detected and ruled out 2, 1
Complete a frequency-volume chart or bladder diary for at least 1 week to confirm the monosymptomatic pattern and establish baseline voiding patterns 1, 3
Screen for and treat constipation by asking about bowel movement frequency (every second day or less) and stool consistency, as concomitant constipation must be treated first or it may be difficult to achieve dryness 2, 1
Ask specifically about daytime symptoms including urgency, holding maneuvers, interrupted micturition, weak stream, or any daytime incontinence—if present, this would indicate non-monosymptomatic enuresis requiring referral to a specialized center 2
Implementation Strategy for Alarm Success
The alarm therapy must be implemented with specific behavioral components:
Educate the child that bedwetting is not their fault and is common, avoiding any punishment, shaming, or control struggles that worsen the situation and create psychological distress 1
Implement a reward system such as a sticker chart for dry nights to increase motivation and awareness, which has an independent therapeutic effect 1, 3
Establish a regular daytime voiding schedule (morning, twice during school, after school, at dinner, and before bedtime) and minimize evening fluid intake while ensuring adequate daytime hydration 1
Involve the child in changing wet bedding to raise awareness, not as punishment 1
Critical Follow-Up Requirements
Schedule monthly follow-up appointments to sustain motivation and assess treatment progress, as frequent monitoring is necessary for success 1
Continue treatment for at least 2-3 months before attempting to wean, and ensure the child's active involvement in the treatment process 1
Expect approximately 66% success rate with alarm therapy, which is superior to the 30% full response rate with desmopressin 1
When to Consider Alternative or Combination Therapy
If alarm therapy fails after 2-3 months of consistent use with good adherence, then desmopressin can be added as combination therapy or used as second-line monotherapy 1, 5
Desmopressin may be considered earlier only for specific short-term situations (school camps, sleepovers) but not as first-line treatment for long-term cure 4
Referral to pediatric urology is indicated only for refractory cases after standard and combination therapies have failed, or if severe/continuous incontinence, weak urinary stream, or non-monosymptomatic features are present 3, 6