What is the most appropriate next step for a 6-year-old with primary nocturnal enuresis, a family history of the same, and no other urinary symptoms?

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

The most appropriate next step is to offer either an enuresis alarm (Option D) or desmopressin (Option B) as first-line treatment after completing a frequency-volume chart to guide the choice between these two evidence-based therapies. 1, 2

Why Reassurance Alone Is Insufficient

At age 6 years with primary monosymptomatic nocturnal enuresis and a positive family history, active treatment is warranted rather than simple reassurance. 2 While spontaneous remission occurs at approximately 14% per year, the psychosocial impact on the child's self-esteem and quality of life justifies intervention at this age. 2, 3 The International Children's Continence Society explicitly states that treatment should usually be started at age 6 years, making reassurance alone (Option A) inadequate. 1, 2

Why Toilet Training Is Not the Answer

Primary nocturnal enuresis is not a toilet-training problem. 2 By age 6, daytime toilet training should already be established, and nocturnal bladder control requires specific interventions targeting the underlying pathophysiology—altered antidiuretic hormone profiles, arousal failure, or reduced functional bladder capacity. 4 Option C (toilet training) fundamentally misunderstands the condition.

The Critical First Step: Frequency-Volume Chart

Before initiating treatment, complete a frequency-volume chart for at least 1 week (ideally measuring intake and output for 2 days) to differentiate nocturnal polyuria from reduced bladder capacity. 1, 2 This simple tool is mandatory because it determines which first-line therapy will be most effective. 2 Also perform urinalysis to exclude diabetes mellitus, urinary tract infection, or kidney disease. 1, 2

Choosing Between First-Line Options

The International Children's Continence Society guidelines provide two valid first-line therapies with equivalent efficacy but different indications: 1

Enuresis Alarm (Option D)

• Best for: Well-motivated families and children without nocturnal polyuria but with low voided volumes 1, 2
• Success rate: Approximately 66% with sustained dryness in over half of treated children 5
• Advantages: Superior long-term cure rates compared to medications, with lower relapse rates 5, 6
• Requirements: Written instructions, treatment contract, frequent monitoring visits (every 3 weeks), and parental commitment to help awaken the child initially 2, 5
• Duration: Expect 2-3 months of treatment before attempting to wean 2, 5

Desmopressin (Option B)

• Best for: Children with documented nocturnal polyuria and normal bladder reservoir function 1, 2
• Dosing: 0.2-0.4 mg tablets or 120-240 mg melt formulation, taken 1 hour before bedtime 2
• Response rates: 30% full response and 40% partial response 2, 5
• Critical safety requirement: Limit fluid intake to ≤200 ml (6 ounces) in the evening with no drinking until morning to prevent hyponatremia 2, 5
• Limitation: Higher relapse rates (up to 50%) compared to alarm therapy 5

Practical Algorithm for This Case

1. Order urinalysis to exclude medical causes 1, 2
2. Provide frequency-volume chart for 1-2 weeks 1, 2
3. Review chart results:
   • If nocturnal polyuria with normal voided volume → prescribe desmopressin 1, 2
   • If low voided volume without polyuria → prescribe enuresis alarm 1, 2
   • If family motivation is uncertain or they prefer medication → offer desmopressin 1
   • If family is highly motivated and prefers non-pharmacologic approach → offer alarm 1

When First-Line Therapy Fails

If one modality fails after consistent use for 2-3 months, switch to the alternative first-line option. 1, 2 For therapy-resistant cases, consider combination therapy (alarm plus desmopressin), which may be more effective than monotherapy. 1, 2, 3 Anticholinergics are reserved as second-line therapy only if detrusor overactivity is suspected. 1, 2

Common Pitfalls to Avoid

• Never punish or shame the child—this worsens outcomes and creates psychological distress 2, 5
• Don't skip the frequency-volume chart—it is essential for individualizing therapy and predicting response 1, 2
• Don't forget to screen for constipation—treating it can resolve enuresis in up to 63% of cases 2
• Don't prescribe desmopressin without strict fluid restriction counseling—hyponatremia is a serious risk 2, 5
• Don't discontinue alarm therapy prematurely—success requires several weeks to months 5