What are the treatment approaches for mono-symptomatic vs non-mono-symptomatic enuresis in patients?

Treatment Approaches for Mono-symptomatic vs Non-Mono-symptomatic Enuresis

The critical distinction is that monosymptomatic nocturnal enuresis (MNE) responds to alarm therapy and desmopressin as first-line treatments, while non-monosymptomatic enuresis (NMNE) requires addressing daytime bladder symptoms with urotherapy and anticholinergics before or alongside nocturnal interventions. 1, 2

Distinguishing Between MNE and NMNE

The differentiation between these two entities fundamentally determines treatment strategy:

• MNE is defined as bedwetting only at night with no daytime urinary symptoms (no urgency, holding maneuvers, interrupted micturition, weak stream, or daytime incontinence). 1
• NMNE includes any daytime bladder symptoms such as urgency, frequency abnormalities, holding maneuvers (standing on tiptoe, pressing heel into perineum), or daytime incontinence. 1
• Complete a frequency-volume chart for at least 1 week to reliably identify voiding patterns that distinguish MNE from NMNE, as family recollection is unreliable. 1, 3
• Specifically ask about urgency, holding maneuvers, interrupted micturition, weak stream, and any current or previous daytime incontinence, as these symptoms are often not volunteered spontaneously. 1

Important caveat: There is a large gray zone between MNE and NMNE, and many children initially assumed to have MNE are found to have NMNE after thorough evaluation. 1

Universal Initial Management (Both MNE and NMNE)

Before initiating specific therapies, these foundational interventions apply to all enuretic children:

• Perform urinalysis to exclude diabetes mellitus, urinary tract infection, or kidney disease. 1, 3
• Screen aggressively for constipation by assessing bowel movement frequency and stool consistency, as treating constipation alone resolves urinary symptoms in up to 63% of cases. 3
• Treat constipation with polyethylene glycol to achieve soft daily bowel movements, preferably after breakfast. 4, 3
• Educate parents that enuresis is nonvolitional and that punishment worsens the condition psychologically; emphasize the 14% annual spontaneous remission rate. 1, 3, 5
• Establish regular daytime voiding schedules (morning, twice during school, after school, at dinner, and before bedtime). 4, 5
• Implement fluid management: liberal water intake during morning and early afternoon, but minimize evening fluid and solute intake to 200 ml (6 ounces) or less. 4, 3, 5
• Encourage physical activity during the day. 4, 5

Treatment Algorithm for Monosymptomatic Nocturnal Enuresis (MNE)

For Children Under 6 Years Old with MNE

• Implement a reward system (sticker chart) for dry nights to increase motivation and awareness. 3, 5
• Continue behavioral interventions (regular voiding, fluid restriction, constipation management) as primary therapy. 3, 5
• Avoid alarm therapy or medications until age 6 or older, as these are typically reserved for older children. 3, 5

For Children 6 Years and Older with MNE

The treatment choice depends on the underlying pathophysiology:

First-Line Treatment Options:

Enuresis Alarm Therapy:

• Use alarm therapy as first-line treatment for MNE with reduced bladder capacity or normal nocturnal urine production. 1, 3, 6
• Alarm therapy achieves approximately 66% initial success rate, with more than half experiencing long-term success. 3, 5
• Ensure proper implementation: use modern portable battery-operated alarm with written contract, thorough instruction, frequent monitoring, overlearning, and intermittent reinforcement before discontinuation. 1
• Alarm therapy requires cooperative, motivated families to be effective. 1

Desmopressin:

• Use desmopressin as first-line treatment for MNE with documented nocturnal polyuria (nocturnal urine production >130% of expected bladder capacity for age). 4, 6
• Desmopressin is also appropriate when alarm therapy has failed or compliance is unlikely. 4
• Approximately 30% of children are full responders and 40% have partial response to desmopressin. 4
• Dosing: 0.2-0.4 mg oral tablets taken at least 1 hour before sleep, or 120-240 μg melt formulation taken 30-60 minutes before bedtime. 1, 4, 3

Critical Safety Requirements for Desmopressin:

• Strictly limit evening fluid intake to 200 ml (6 ounces) or less with no drinking until morning to prevent water intoxication with hyponatremia and convulsions. 4, 3
• Polydipsia is an absolute contraindication to desmopressin. 4
• Avoid nasal spray formulations due to higher risk of hyponatremia. 4
• Monitor electrolytes if intercurrent illness occurs during treatment. 1
• Schedule regular short drug holidays to assess whether medication is still needed. 4

Second-Line Treatment for MNE:

Imipramine:

• Use imipramine only if alarm therapy and desmopressin have failed or are not feasible. 1
• Dosing: 1.0 to 2.5 mg/kg as single bedtime dose. 1
• Effectiveness is 40-60%, but relapse rate is as high as 50%. 1
• Consider pretreatment electrocardiogram to detect underlying rhythm disorder due to risk of cardiac arrhythmia with tricyclic antidepressants. 1

Combination Therapy for Refractory MNE:

• Combine desmopressin with alarm therapy for cases refractory to monotherapy, as this combination has positive effects. 6, 7
• Consider desmopressin combined with sustained-release anticholinergic agent if desmopressin alone is ineffective. 1
• Refractory cases likely result from multiple pathophysiological factors (both nocturnal polyuria and small bladder capacity). 6

Treatment Algorithm for Non-Monosymptomatic Enuresis (NMNE)

The presence of daytime symptoms fundamentally changes the treatment approach:

Primary Treatment Focus for NMNE:

• Address daytime bladder symptoms first with urotherapy before or alongside treating nocturnal enuresis. 2
• Urotherapy includes bladder training, timed voiding, and pelvic floor muscle training. 2, 7
• Anticholinergics (such as oxybutynin) play an additional role in NMNE when overactive bladder symptoms are present during the day. 2
• Oxybutynin is not indicated for MNE except for the very small subgroup with overactive bladder only during sleep. 6

Specific Conditions to Identify and Treat in NMNE:

• Exclude and treat urinary tract infections, as these commonly coexist with NMNE. 1, 2
• Identify dysfunctional voiding patterns (interrupted micturition, need to use abdominal pressure to void, weak stream) that require specific urotherapy. 1, 2
• Treat overactive bladder symptoms (urgency, holding maneuvers) with anticholinergics and behavioral interventions. 2

When Daytime Symptoms Are Controlled:

• Once daytime symptoms are resolved, treat residual nocturnal enuresis using the MNE algorithm (alarm therapy or desmopressin based on pathophysiology). 2
• Combined therapy (alarm, bladder training, motivational therapy, pelvic floor muscle training) is more effective than each component alone in NMNE. 7

Follow-Up and Monitoring (Both MNE and NMNE)

• Schedule monthly follow-up appointments to sustain motivation and assess treatment response. 3, 5
• Reassess the diagnosis and consider referral to pediatric urologist if no improvement occurs after 1-2 months of consistent therapy. 3

When to Refer to Pediatric Urologist

Immediate referral is indicated for:

• Severe or continuous incontinence 3
• Weak urinary stream 3
• Non-monosymptomatic enuresis refractory to initial urotherapy and anticholinergics 3
• Recurrent urinary tract infections 3, 8
• Suspected urinary tract malformations 3, 8
• Primary enuresis refractory to standard and combination therapies 8
• Neurologic disorders affecting bladder function 8

Common Pitfalls to Avoid

• Do not use bladder-stretching exercises, as there is no consistent evidence of effectiveness and the effort is unpleasant for child and family. 1
• Avoid hypnotherapy, dietary manipulation, and desensitization to allergens, as there is no empirical evidence of efficacy. 1
• Do not assume MNE without completing a frequency-volume chart, as many children have unrecognized daytime symptoms. 1
• Waking the child during the night to void only helps for that specific night and is not a treatment strategy. 5
• Basic bladder advice alone has limited efficacy (only 18% success after 3 months) and should not delay definitive therapy in unfavorable cases. 9