What is the best approach to treating enuresis in a child?

Treatment of Childhood Enuresis

Start with enuresis alarm therapy as first-line treatment for children 6 years and older with primary monosymptomatic nocturnal enuresis, as it achieves the highest long-term cure rate of approximately 66% initial success with over 50% experiencing sustained dryness. 1, 2, 3

Initial Assessment and Diagnosis

Before initiating treatment, distinguish between monosymptomatic and non-monosymptomatic enuresis by specifically asking about:

• Daytime urgency, holding maneuvers, interrupted urination, weak stream, and daytime incontinence 2
• Frequency and pattern (nightly vs. sporadic) 2
• Primary (never been dry) vs. secondary (previously dry for at least 6 months) 2

Perform urinalysis on all children to exclude urinary tract infection, diabetes mellitus, and kidney disease. 1, 2, 3 No routine imaging is needed unless the history reveals continuous wetting, abnormal voiding pattern, recurrent UTIs, or abnormal urinalysis. 1, 2

Screen aggressively for constipation by assessing bowel movement frequency and stool consistency, as this is a paramount cause of treatment resistance and treating it alone can resolve enuresis in up to 63% of cases. 2, 3

Complete a frequency-volume chart or bladder diary for at least 1 week to establish baseline patterns. 3

Treatment Algorithm by Age

Children Under 6 Years Old

For younger children, begin with behavioral interventions:

• Implement a reward system (sticker chart) for dry nights to increase motivation 3
• Establish regular daytime voiding schedules 3
• Minimize evening fluid intake to 200 ml (6 ounces) or less 3
• Treat constipation aggressively with dietary changes and polyethylene glycol if needed, as this alone may resolve enuresis 3

Children 6 Years and Older

First-line treatment: Enuresis alarm therapy 1, 2, 3

• Achieves 66% initial success rate with more than half experiencing long-term success 1, 3
• Superior to pharmacologic treatments in head-to-head comparisons 1
• Requires frequent monitoring (at least every 3 weeks) and parental commitment 2, 4
• Use modern, portable, battery-operated alarms with written instructions 4
• Allow minimum 2-3 months of consistent use before declaring treatment failure 2

Second-line treatment: Desmopressin 1, 2, 3

• Consider when alarm therapy has failed, is inappropriate, or for rapid/short-term response (e.g., sleepovers, camp) 1, 2
• Dosing: 0.2-0.4 mg tablets or 120-240 mg oral melt formulation 1
• Tablets taken 1 hour before bedtime; oral melt 30-60 minutes before bedtime 1
• Response rates: 30% full response, 40% partial response 2
• Critical safety measure: Limit fluid intake to 200 ml (6 ounces) or less in the evening with no drinking until morning to prevent hyponatremia 3, 4
• Schedule regular drug holidays to assess ongoing need 1, 4

Treatment-Resistant Cases

For children who fail both alarm therapy and desmopressin:

Third-line treatment: Anticholinergics 1

Before prescribing anticholinergics, complete these essential steps:

1. Institute sound, regular voiding habits first 1
2. Exclude or treat constipation 1
3. Complete frequency-volume chart 1
4. Perform uroflowmetry with ultrasound measurement of post-void residual urine 1

Anticholinergic dosing:

• Tolterodine 2 mg at bedtime 1
• Oxybutynin 5 mg at bedtime 1
• Propiverine 0.4 mg/kg at bedtime 1
• Dose may need to be doubled 1
• Often requires combination with desmopressin at standard dose 1
• Effective in approximately 40% of treatment-resistant children 1
• Anti-enuretic effect should appear within maximum 2 months 1

Monitor for constipation (most bothersome side effect) and post-void residual urine causing UTIs (greatest danger). 1 Families must watch for dysuria or unexplained fever. 1

Fourth-line treatment: Imipramine (tricyclic antidepressant) 1, 5

Due to safety concerns, imipramine is only appropriate as third-line therapy at tertiary care facilities or when alarm has failed and families cannot afford desmopressin. 1

Dosing and monitoring:

• 25-50 mg at bedtime (larger dose for children older than 9 years) 1
• Evaluate effect after 1 month 1
• May add desmopressin for partial response (with strict fluid restriction) 1
• Taper to lowest effective dose with regular 2-week drug holidays every 3 months to decrease tolerance risk 1
• Response rate approximately 50% 1

Critical safety precautions for imipramine:

• Potentially cardiotoxic; overdose may be fatal 1, 5
• Keep securely locked away from smaller siblings 1
• Exclude long QT syndrome by prolonged ECG recording if any history of palpitations, syncope, sudden cardiac death, or unstable arrhythmia in family 1
• Common side effects include mood changes, nausea, insomnia 1

Special Considerations

Non-Monosymptomatic Enuresis

Treat underlying bladder dysfunction first before addressing nocturnal enuresis. 2 Urgent specialty referral is needed if the child has weak stream, uses abdominal pressure to void, or has continuous incontinence. 2

Secondary Enuresis

Investigate psychological stressors and treat underlying causes such as UTI, diabetes, or sleep apnea. 2 Specifically ask about snoring, witnessed apneas, and daytime sleepiness to screen for obstructive sleep apnea. 2

Critical Pitfalls to Avoid

• Failing to screen for and aggressively treat constipation, which is paramount for treatment success 2, 3
• Inadequate treatment duration before declaring failure (minimum 2-3 months required) 2
• Excessive fluid intake on desmopressin, increasing hyponatremia risk 2
• Punitive parental response—reinforce that bedwetting is involuntary, not behavioral 1, 2, 4
• Insufficient alarm monitoring without frequent follow-up and parental commitment 2, 4
• Missing sleep apnea by not asking about snoring and witnessed apneas 2
• Relying on "lifting" or waking the child at night, which may be less successful than other interventions 4

When to Refer to Pediatric Urology

Refer immediately for:

• Severe or continuous incontinence 3
• Weak urinary stream 3
• Non-monosymptomatic enuresis 3
• Recurrent urinary tract infections 3
• Suspected urinary tract malformations 3
• Primary enuresis refractory to standard and combination therapies 6

Family Education

Educate parents that 15-20% of 5-year-olds have enuresis with 14% spontaneous remission rate per year. 1, 3 Emphasize the nonvolitional nature to prevent punitive responses and control struggles. 1, 3, 4 Reassure families that not all children require active treatment and many parents choose watchful waiting after ruling out underlying conditions. 1, 3