Management of Nocturnal Enuresis in Adults
Initial Diagnostic Evaluation
Begin with a comprehensive history focusing on distinguishing between monosymptomatic nocturnal enuresis (bedwetting only) versus non-monosymptomatic enuresis (bedwetting plus daytime lower urinary tract symptoms), as this fundamentally determines your treatment pathway. 1, 2
Essential History Components
Document voiding patterns: Ask specifically about daytime urgency, frequency, holding maneuvers, interrupted stream, weak stream, and any daytime incontinence to distinguish monosymptomatic from non-monosymptomatic enuresis 2, 3
Assess fluid intake patterns: Quantify total daily fluid intake, evening fluid consumption, and caffeine/alcohol use to identify nocturnal polyuria (nighttime urine production >35% of 24-hour total) 1, 4
Review medications systematically: Diuretics, hypnotics, lithium, valproic acid, clozapine, and theophylline can all contribute to nocturnal enuresis 3, 4
Screen for comorbidities: Specifically ask about constipation, sleep apnea (snoring, witnessed apneas, daytime sleepiness), diabetes, heart failure, neurologic disease, and psychiatric conditions 1, 3, 5
Evaluate sleep patterns: Hypnotic use is frequently overlooked but can prevent awakening to bladder distension 4
Mandatory Physical Examination
- Abdominal exam: Palpate for bladder distension and fecal impaction 3
- Genitourinary exam: Assess for anatomical abnormalities, prostatic enlargement in men 1, 3
- Neurologic exam: Check for signs of autonomic dysfunction, spinal cord pathology 1, 3
- Assess for lower extremity edema: Suggests fluid redistribution contributing to nocturnal polyuria 1
Required Testing
Urinalysis is the only mandatory laboratory test to exclude urinary tract infection, diabetes mellitus, kidney disease, and hematuria 2, 3
Bladder diary for at least 2 days to objectively document voiding frequency, volumes, timing, and calculate nocturnal polyuria index 2, 6
Post-void residual measurement if there are obstructive symptoms, history of neurologic disease, or suspected urinary retention 1
Urodynamic studies are reserved for refractory cases or when non-monosymptomatic enuresis suggests underlying bladder dysfunction 6, 5
Treatment Algorithm
Step 1: Address Underlying Causes First
Before initiating generic enuresis treatments, you must identify and treat specific contributing factors, as adult nocturnal enuresis is typically multifactorial. 7, 4, 5
Discontinue or adjust hypnotics that prevent awakening to bladder signals 4
Treat constipation aggressively with daily polyethylene glycol targeting soft daily bowel movements, as this is a paramount cause of treatment resistance 3, 8
Manage bladder outlet obstruction in men with alpha-blockers or surgical intervention if indicated 4
Optimize heart failure management and consider afternoon diuretic dosing (rather than evening) to reduce nocturnal polyuria 1, 4
Treat sleep apnea if identified, as this commonly contributes to nocturnal enuresis 3
Step 2: Behavioral Modifications (All Patients)
Fluid management: Restrict evening fluids to ≤200 mL (6 ounces) after dinner, with liberal water intake during morning and early afternoon 8, 6
Establish regular voiding schedule: Void every 2-3 hours during the day, always immediately before bedtime and upon awakening 8
Minimize caffeine and alcohol, especially in the evening 1
Elevate legs in the afternoon if edema is present to promote daytime diuresis 1
Step 3: First-Line Pharmacotherapy
For monosymptomatic nocturnal enuresis in adults, desmopressin is the primary evidence-based pharmacologic option, particularly when nocturnal polyuria is documented. 8, 6, 4
Desmopressin Therapy
Dosing: 0.2-0.4 mg orally taken at least 1 hour before sleep 8
Critical safety requirement: Fluid restriction is mandatory—limit evening intake to 200 mL or less with no drinking until morning to prevent hyponatremia and water intoxication 8
Contraindications: Polydipsia, heart failure, hyponatremia, renal insufficiency 8
Monitoring: Schedule regular drug holidays to assess ongoing need 8
Avoid nasal spray formulations due to higher hyponatremia risk 8
Step 4: Second-Line Pharmacotherapy
If desmopressin fails or is contraindicated, consider anticholinergics for patients with documented detrusor overactivity or reduced bladder capacity. 6, 4, 5
Anticholinergics (e.g., oxybutynin, tolterodine) are appropriate when urodynamics demonstrate detrusor overactivity or bladder diary shows reduced nocturnal voided volumes 1, 4, 5
Imipramine may be considered in select refractory cases, though evidence in adults is limited; FDA-approved dosing for enuresis is 25-75 mg at bedtime, not to exceed 2.5 mg/kg/day 9
Step 5: Combination Therapy
For refractory cases with multiple contributing factors, combine desmopressin with anticholinergics when both nocturnal polyuria and detrusor overactivity are present. 5
Critical Pitfalls to Avoid
Do not skip urinalysis—this is the only mandatory test and missing it could overlook treatable causes like UTI or diabetes 2, 3
Do not overlook hypnotic medications as a reversible cause of enuresis 4
Do not prescribe desmopressin without strict fluid restriction counseling—water intoxication with hyponatremia and seizures can occur 8
Do not ignore constipation—it must be treated aggressively before expecting success with other interventions 3, 8
Do not assume monosymptomatic enuresis without a bladder diary—many patients have subtle daytime symptoms that change the treatment approach 2, 5
Do not use anticholinergics as monotherapy if nocturnal polyuria is the primary problem—they will not address excessive nighttime urine production 4, 5
When to Refer to Urology
Non-monosymptomatic enuresis with daytime symptoms suggesting bladder dysfunction 1, 3
Continuous wetting or abnormal voiding patterns suggesting anatomical abnormality 2, 3
Hematuria not associated with infection 1
Failure of conservative management after 2-3 months of appropriate therapy 3
Suspected neurologic etiology requiring urodynamic evaluation 7, 5