In a 6-year-old with primary nocturnal enuresis since infancy and a brother with the same issue, what is the next step in management?

Management of Primary Nocturnal Enuresis in a 6-Year-Old

For this 6-year-old with primary monosymptomatic nocturnal enuresis and a positive family history, the next step is to offer either an enuresis alarm OR desmopressin as first-line therapy after completing a brief evaluation—reassurance alone is insufficient at this age. 1

Why Not Reassurance Alone?

While spontaneous remission occurs at approximately 14% per year, active treatment at age 6 is appropriate and recommended by multiple guidelines. 2, 3 The child is old enough to benefit from intervention, and the positive family history (brother with same problem) suggests a genetic component that may respond well to treatment. 1, 4

Essential Pre-Treatment Evaluation

Before initiating therapy, complete these steps:

• Perform urinalysis to exclude diabetes mellitus, urinary tract infection, or kidney disease 1, 2, 5
• Screen for constipation by asking about bowel movement frequency and stool consistency, as treating constipation can resolve enuresis in up to 63% of cases 2, 3
• Complete a frequency-volume chart for at least 1 week (ideally 2 days of measured intake/output) to detect nocturnal polyuria versus reduced bladder capacity 1, 5

First-Line Treatment Options

The International Children's Continence Society identifies two equally valid first-line therapies: 1

Option 1: Enuresis Alarm (Answer D)

• Best for: Well-motivated families and children without polyuria but with low voided volume 1
• Success rate: 66% initial response with >50% long-term cure rate 2, 5
• Duration: Expect 2-3 months of treatment before attempting to wean 2, 5
• Key to success: Written instructions, establishing a contract, frequent monitoring appointments, overlearning, and intermittent reinforcement before discontinuation 1, 2

Option 2: Desmopressin (Answer B)

• Best for: Children with nocturnal polyuria and normal bladder reservoir function 1
• Success rate: 30% full response and 40% partial response 2, 5
• Dosing: 0.2-0.4 mg tablets or 120-240 µg melt formulation, taken 1 hour before bedtime 2, 5
• Critical safety warning: Limit fluid intake to 200 ml (6 ounces) or less in the evening with no drinking until morning to prevent hyponatremia and water intoxication 2, 5
• Advantage: Immediate effect, useful when rapid response needed 5, 6
• Disadvantage: Lower curative potential compared to alarm therapy 5

Decision Algorithm

Two acceptable strategies: 1

1. Present both options (alarm and desmopressin) with their pros and cons, and let the family choose based on their motivation level and lifestyle
2. Use the frequency-volume chart to guide selection:
   • If nocturnal polyuria with normal voided volume → desmopressin
   • If low voided volume without polyuria → enuresis alarm

Why Toilet Training (Answer C) Is Incorrect

This child has primary nocturnal enuresis (never been dry at night), not a toilet training issue. 1 By age 6, daytime toilet training should already be established, and the problem is specifically nocturnal bladder control, which requires different interventions. 1

Important Behavioral Adjuncts

Regardless of which first-line therapy is chosen, implement these supportive measures:

• Educate the family that bedwetting is common (15-20% of 5-year-olds) and involuntary—avoid punishment 2, 3
• Implement a reward system (sticker chart) for dry nights to increase motivation 2, 3
• Establish regular daytime voiding schedules (morning, twice during school, after school, dinner time, bedtime) 2
• Minimize evening fluid intake while ensuring adequate hydration earlier in the day 2
• Involve the child in changing wet bedding to raise awareness (not as punishment) 2

If First-Line Therapy Fails

• Try the alternative first-line option: If alarm fails, try desmopressin, and vice versa 1
• Consider combination therapy: Alarm plus desmopressin for therapy-resistant cases 1, 5
• Re-evaluate for missed comorbidities: Constipation, sleep apnea, overactive bladder 1, 7
• Consider anticholinergics as second-line therapy only if detrusor overactivity is suspected 1, 2

Common Pitfalls to Avoid

• Never punish or shame the child—this worsens psychological distress without improving outcomes 2, 3
• Don't skip the frequency-volume chart—it's essential for individualizing therapy and predicting response 1, 5, 8
• Don't overlook constipation—treat it aggressively first with polyethylene glycol if present 2, 3
• Schedule monthly follow-up to sustain motivation and assess treatment response 2, 5