How should primary and secondary enuresis be evaluated and managed?

Evaluation and Management of Primary and Secondary Enuresis

Definitions and When to Treat

Enuresis should be evaluated and treated after age 5 years when bedwetting occurs at least twice weekly for three consecutive months, though treatment is warranted earlier if the child experiences distress, impaired self-esteem, or functional limitations regardless of frequency. 1

• Primary enuresis occurs in children who have never achieved consistent nighttime dryness 2
• Secondary enuresis is the resumption of wetting after at least 6 months of dryness and warrants prompt evaluation regardless of age, as it may indicate underlying medical conditions or psychological stressors 1
• Before age 4-5 years, bedwetting is a normal developmental variant with 30% annual spontaneous resolution, compared to 14-16% after age 4 1
• Boys are affected twice as often as girls until age 9 years 3

Initial Evaluation

History Taking

A thorough history is the cornerstone of evaluation and cannot be substituted by expensive testing. 2

Focus specifically on:

• Voiding patterns: Ask about urgency, holding maneuvers (standing on tiptoe, pressing heel into perineum), interrupted micturition, weak stream, or need for abdominal pressure to void 2
• Frequency of bedwetting: Every night versus sporadic, and whether nocturia is present (nocturia indicates the child can be aroused from sleep, which is a favorable prognostic sign) 2
• Daytime symptoms: Current or previous daytime incontinence must be specifically asked about—if present, this indicates nonmonosymptomatic enuresis requiring different management 2
• Bowel habits: Ask about stool frequency (every second day or less suggests constipation) and consistency, as constipation must be treated first or enuresis treatment will fail 2
• Recent stressors: For secondary enuresis, inquire about parental divorce, school trauma, abuse, hospitalization, or other life events 2
• Family history: 44% of children are enuretic when one parent was affected, 77% when both parents were affected 2

Physical Examination

Every child requires a thorough physical examination looking for specific findings. 2

Examine for:

• Enlarged adenoids or tonsils (may indicate sleep apnea) 2
• Bladder distention or fecal impaction 2
• Genital abnormalities 2
• Spinal cord anomalies (sacral dimple, hair tuft) 2
• Neurologic signs 2

Laboratory and Diagnostic Tests

• Urinalysis is mandatory in all cases 2
• Urine culture if infection is suspected 2
• First-morning specific gravity helps predict desmopressin response 2
• Two-week baseline record of wet and dry nights is useful 2
• Frequency-volume chart provides more reliable data than family recollection 2

Immediate Referral Criteria

Children with the following require immediate referral to a specialized center without delay: 2, 1

• Continuous incontinence
• Weak urinary stream requiring abdominal pressure to void
• Nonmonosymptomatic enuresis with severe daytime symptoms
• Genital abnormalities 2
• History of urinary tract infections 2
• Abnormal voiding patterns (unusual posturing, discomfort, straining) 2

Treatment Algorithm

Step 1: Address Underlying Conditions First

Treat constipation before addressing enuresis—disimpaction and establishing healthy bowel regimen often eliminates bedwetting. 2

• Aim for soft bowel movements daily, preferably after breakfast; polyethylene glycol can optimize bowel emptying 4
• Snoring and enlarged tonsils/adenoids: Surgical correction of upper airway obstruction has led to improvement or cure 2
• Secondary enuresis with identified stressor: Address the psychological factor or trauma directly 2

Step 2: Behavioral Interventions (All Ages)

Implement these foundational strategies before or alongside other treatments: 4

• Establish regular daytime voiding schedule—void at regular intervals, always at bedtime and upon awakening 4
• Fluid management: Liberal water intake during morning and early afternoon, minimize evening fluid and solute intake 4
• Encourage physical activity 4
• Implement reward systems for dry nights 1
• Critical: Reassure family that bedwetting is not the child's fault, as parental anger and family embarrassment can cause more psychological damage than the symptom itself 2

Step 3: First-Line Treatment Selection (Age 6+ Years)

For children aged 6 years and older, choose between enuresis alarm therapy (first-line) or desmopressin (second-line) based on specific clinical factors. 1

Enuresis Alarm Therapy

Enuresis alarm has approximately 66% success rate with more than half experiencing long-term success, making it the preferred first-line treatment. 1

• Requires several weeks to be effective and needs commitment from both child and caregivers 3
• Best for children over age 7 years 3
• More likely to produce long-term cure compared to medication 5

Desmopressin (Second-Line or Alternative First-Line)

Desmopressin is grade Ia evidence-based therapy with 30% full response and 40% partial response rates. 4

Use desmopressin as first-line when:

• Rapid onset or short-term improvement is the priority 3
• Alarm therapy is inappropriate, undesirable, or has failed 4, 3
• Nocturnal polyuria is documented (nocturnal urine production >130% of expected bladder capacity for age) 4
• Normal bladder reservoir function is present (maximum voided volume >70% of expected bladder capacity for age) 4

Dosing:

• 0.2-0.4 mg oral tablets taken at least 1 hour before sleep, OR
• 120-240 μg sublingual taken 30-60 minutes before bedtime 4

Critical Safety Requirements:

• Fluid restriction is mandatory: Evening intake limited to 200 ml (6 ounces) or less with no drinking until morning 4
• Polydipsia is an absolute contraindication 4
• Desmopressin combined with excessive fluid intake can cause water intoxication with hyponatremia and convulsions 4
• Avoid nasal spray formulations due to higher hyponatremia risk 4
• Schedule regular short drug holidays to assess whether medication is still needed 4

Step 4: Refractory Cases

For children not responding to standard therapy, perform thorough re-evaluation before escalating treatment: 6

• Re-examine for missed comorbidities (constipation, sleep apnea, ADHD, diabetes) 2, 6
• Consider combination therapy (alarm plus desmopressin) 6
• Refer to pediatric urology for suspected urinary tract malformations, recurrent UTIs, neurologic disorders, or failure of standard and combination therapies 7, 5

Key Pitfalls to Avoid

• Do not delay treatment if psychological damage is occurring—the psychological and developmental consequences (anxiety, impaired self-esteem, delayed developmental milestones, risk of abuse) can be more devastating than the symptom itself 2, 1
• Do not assume psychological causation—identifiable psychological factors are contributory in only a minority of children, and most cases have biological underpinnings involving nocturnal polyuria, detrusor overactivity, or increased arousal threshold 2, 1
• Do not prescribe desmopressin without strict fluid restriction counseling—this is the most dangerous treatment error 4
• Do not ignore constipation—it must be treated first or enuresis therapy will fail 2