What is the initial treatment approach for a pediatric patient experiencing nocturnal enuresis (bed wetting)?

Initial Treatment of Nocturnal Enuresis (Bed Wetting)

Start with education, behavioral interventions, and treating constipation before considering alarm therapy or medications.

First Steps: Assessment and Family Education

Begin by reassuring parents that bedwetting affects 15-20% of 5-year-olds with a 14% spontaneous remission rate annually, and emphasize this is not the child's fault 1, 2. This reduces parental guilt and prevents harmful punitive responses that worsen outcomes 1.

Essential Initial Workup

• Perform urinalysis to rule out diabetes mellitus, urinary tract infection, or kidney disease 1, 2
• Complete a frequency-volume chart or bladder diary for at least 1 week to establish baseline patterns and distinguish monosymptomatic from non-monosymptomatic enuresis 1, 2
• Screen aggressively for constipation by asking about bowel movement frequency and stool consistency, as treating constipation alone resolves urinary symptoms in up to 63% of cases with nocturnal enuresis 1

Initial Treatment: Behavioral Interventions (First-Line for All Ages)

These simple interventions should be implemented immediately and carry no risk:

• Implement a reward system (sticker chart) for dry nights to increase motivation and awareness, which has independent therapeutic effects 1, 2, 3
• Establish regular daytime voiding schedules: morning, at least twice during school, after school, dinner time, and bedtime 1, 2
• Minimize evening fluid intake (limit to 200 ml or 6 ounces), particularly caffeinated beverages, while ensuring adequate hydration earlier in the day 1, 2
• Treat constipation aggressively first with dietary changes and polyethylene glycol if needed before escalating urinary treatments 1, 4
• Involve the child in changing wet bedding to raise awareness (not as punishment) 1, 2
• Encourage physical activity during the day 1, 2

Critical Pitfall to Avoid

Never punish, shame, or create control struggles around bedwetting as this worsens the condition and creates psychological distress 1, 2. Penalties for wet beds are counter-productive 5.

Treatment Escalation After Age 6

If behavioral interventions fail after 1-2 months of consistent therapy in children 6 years and older:

Second-Line: Enuresis Alarm Therapy (Most Effective Long-Term)

• Alarm therapy is first-line treatment after age 6 with approximately 66% success rates 2, 4, 5
• About two-thirds of children become dry during alarm use, and nearly half who persist remain dry after treatment finishes 5
• Alarms are superior to desmopressin by the end of treatment (RR 0.71) and show greater long-term success 5
• Alarms are more effective than tricyclics both during treatment (RR 0.73) and afterwards (RR 0.58) 5
• Provide written instructions, establish a contract, and schedule frequent monitoring appointments to enhance success 1
• Continue treatment for at least 2-3 months before attempting to wean 1
• Add overlearning (giving extra fluids at bedtime after achieving dryness) to reduce relapse rates (RR 1.92) 5

Third-Line: Desmopressin (For Nocturnal Polyuria)

Consider desmopressin when alarm therapy has failed or is unlikely to be successful, particularly if nocturnal polyuria is documented 1, 2:

• Typical oral dose: 0.2 to 0.4 mg tablets or 120 to 240 mg melt formulation, taken 1 hour before bedtime 1
• Expect immediate anti-enuretic effect with approximately 30% full response and 40% partial response rates 1, 2
• Strictly limit fluid intake to 200 ml (6 ounces) or less in the evening and no drinking until morning to prevent hyponatremia 1
• Desmopressin may have more immediate effects than alarms but is less effective long-term 5

Fourth-Line: Anticholinergics (For Detrusor Overactivity)

Consider as second-line pharmacotherapy for children with suspected detrusor overactivity when standard treatments have failed 1:

• Options include oxybutynin (5 mg), tolterodine (2 mg), or propiverine (0.4 mg/kg) at bedtime 1
• Monitor for constipation and post-void residual urine that may cause UTIs 1

Fifth-Line: Imipramine (Tertiary Care Only)

Consider imipramine only as third-line therapy at tertiary care facilities due to safety concerns, though approximately 50% of therapy-resistant children respond 1.

Combination Therapy for Resistant Cases

• Combine alarm therapy with desmopressin for children not responding to single modalities 1
• Prioritize treating constipation first before escalating urinary treatments if both conditions coexist 1, 4

Follow-Up Strategy

Schedule monthly follow-up appointments to sustain motivation and assess treatment response 1, 2. Reassess the diagnosis and consider referral to a specialist if no improvement occurs after 1-2 months of consistent therapy 1.

When to Refer Immediately

Children with severe/continuous incontinence, weak urinary stream, or non-monosymptomatic enuresis must be sent to a specialized center without delay 4.