What is the best approach to managing primary nocturnal enuresis in a pediatric patient?

Managing Primary Nocturnal Enuresis

For children under 6 years old, start with education, behavioral interventions (reward systems, fluid restriction, regular voiding schedules), and treatment of constipation if present; for children 6 years and older who fail behavioral measures, enuresis alarm therapy is first-line treatment, with desmopressin as second-line for nocturnal polyuria or when alarms fail. 1, 2

Initial Assessment

Essential Diagnostic Steps

• 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 identify monosymptomatic versus non-monosymptomatic enuresis 1, 2
• Screen for constipation by assessing bowel movement frequency and stool consistency, as treating constipation can resolve urinary symptoms in up to 63% of cases 1
• Assess early-morning urine specific gravity (less than 1.015 may indicate ADH deficiency) 3

When to Avoid Further Testing

• Renal ultrasound and voiding cystourethrogram are pursued only with specific red flags: continuous wetting, abnormal voiding pattern, recurrent urinary tract infections, weak urinary stream, or abnormal physical examination findings 3, 4

Family Education and Counseling

Educate parents that 15-20% of 5-year-olds have enuresis with a 14% spontaneous remission rate per year, emphasizing the nonvolitional nature to prevent punitive responses and control struggles. 1, 2

• Avoid punishment, shaming, or creating control struggles, as these worsen the condition and create psychological distress 1, 2
• Reassure families that not all children require active treatment; many parents choose watchful waiting after ruling out underlying conditions 3

Treatment Algorithm by Age

For Children Under 6 Years Old

Begin with behavioral interventions only, as more intensive treatments (alarms and medications) should be reserved for children 6 years and older. 2

First-Line Behavioral Interventions

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

Optional Supportive Measures (Unproven but Low-Risk)

• Waking the child to void during the night may help for that specific night but does not provide long-term benefit 3, 2
• Keep a dry bed journal to raise consciousness 3

For Children 6 Years and Older

First-Line Treatment: Enuresis Alarm Therapy

Alarm therapy achieves approximately 66% initial success rate with more than half experiencing long-term success, making it superior to pharmacologic treatments. 3, 1

Keys to Alarm Success

• Provide written instructions and establish a contract with the child and family 1
• Schedule frequent monitoring appointments (monthly) to sustain motivation 1, 2
• Continue treatment for at least 2-3 months before attempting to wean 1
• Present the alarm with confidence and enthusiasm, as casual introduction reduces success rates 3

Common pitfall: Alarm therapy requires significant commitment from families; a casual or unenthusiastic introduction does not promote the commitment needed for success. 3

Second-Line Treatment: Desmopressin

Consider desmopressin for children with documented nocturnal polyuria when alarm therapy has failed or is unlikely to be successful. 1

Dosing and Administration

• Typical oral dose: 0.2 to 0.4 mg tablets or 120 to 240 mg melt formulation, taken 1 hour before bedtime 1
• A linear dose-response relationship exists from 0.2 to 0.6 mg 5
• Expect immediate anti-enuretic effect with approximately 30% full response and 40% partial response rates 1, 5

Critical Safety Measure

• Limit fluid intake to 200 ml (6 ounces) or less in the evening with no drinking until morning to prevent hyponatremia 1

Common pitfall: Failure to restrict fluids adequately increases the risk of hyponatremia, a potentially serious adverse effect. 1

Third-Line Treatment: Anticholinergics

Consider anticholinergics (oxybutynin, tolterodine, or propiverine) as second-line therapy only for children with suspected detrusor overactivity when standard treatments have failed. 1

• Typical dosing: 2 mg tolterodine, 5 mg oxybutynin, or 0.4 mg/kg propiverine at bedtime 1
• Monitor for constipation and post-void residual urine that may cause urinary tract infections 1

Fourth-Line Treatment: Imipramine

Reserve imipramine only as third-line therapy at tertiary care facilities due to safety concerns, despite approximately 50% response rates in therapy-resistant cases. 1

Dosing per FDA Label

• Initial dose: 25 mg/day for children aged 6 and older, given one hour before bedtime 6
• If no response within one week: increase to 50 mg nightly in children under 12 years; children over 12 may receive up to 75 mg nightly 6
• Maximum dose: 2.5 mg/kg/day should not be exceeded; ECG changes of unknown significance have been reported at twice this amount 6
• For early night bedwetters: 25 mg in mid-afternoon, repeated at bedtime may be more effective 6

Important Safety Considerations

• Taper gradually rather than discontinue abruptly to reduce relapse tendency 6
• Children who relapse when the drug is discontinued do not always respond to subsequent treatment courses 6
• Close supervision required due to cardiac and CNS effects 6

Combination Therapy for Resistant Cases

Combine alarm therapy with desmopressin for children not responding to single modalities. 1

• Combining behavioral therapy and medication may be necessary in cases with mixed disorders 1
• Always prioritize treating constipation first before escalating urinary treatments if both conditions coexist 1

Follow-Up and Monitoring

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

When to Refer to Specialist

Refer immediately to a pediatric urologist for: 4

• Severe or continuous incontinence
• Weak urinary stream
• Non-monosymptomatic enuresis (daytime symptoms present)
• Recurrent urinary tract infections
• Suspected urinary tract malformations
• Neurologic disorders
• Primary enuresis refractory to standard and combination therapies 7