What is the appropriate evaluation and treatment plan for a 10‑year‑old girl with primary nocturnal enuresis and no daytime urinary symptoms?

Management of a 10-Year-Old Girl with Enuresis

Start with enuresis alarm therapy as first-line treatment for this 10-year-old with primary monosymptomatic nocturnal enuresis, as it offers the highest long-term cure rate (66% success) and lowest relapse rate (12%) compared to all other options. 1

Immediate Diagnostic Evaluation

Before initiating any treatment, complete these essential steps:

• Perform urinalysis (dipstick) to exclude diabetes mellitus, urinary tract infection, and kidney disease—this is the only mandatory laboratory test and takes approximately 2 minutes. 1, 2
• Screen for constipation by asking about bowel movement frequency; if movements occur less than every 2 days or stools are hard, this must be treated aggressively with polyethylene glycol before starting enuresis-specific therapy, as constipation can compress the bladder and perpetuate bedwetting. 1, 2
• Confirm this is monosymptomatic enuresis by verifying the child has no daytime urinary symptoms (urgency, frequency, holding maneuvers, weak stream, or daytime incontinence). 2

First-Line Treatment: Enuresis Alarm Therapy

The International Children's Continence Society explicitly endorses alarm therapy as the preferred initial intervention for motivated families with children over age 6. 1

Why Alarm Therapy is Superior

• Achieves 66% overall success rate with only 12% relapse after successful treatment. 1
• In contrast, desmopressin yields only 30% full response and 40% partial response during treatment, with 50-80% relapse after discontinuation—markedly inferior long-term outcomes. 1
• Alarm therapy provides durable conditioning that persists after treatment ends, unlike pharmacologic options. 1

Implementation Protocol

• Obtain a written contract with the child outlining expectations and responsibilities. 1
• Provide comprehensive instruction on proper alarm placement (worn on underwear or pajamas to detect first drops of urine). 1
• Schedule monthly follow-up visits to monitor progress and sustain motivation—this is critical for success. 1, 2
• Apply overlearning techniques before discontinuation (having child drink extra fluids before bed once achieving dryness) to consolidate the conditioned arousal response. 1
• Use intermittent reinforcement (variable-ratio reward schedule) to maintain adherence throughout the 12-week trial. 1

Essential Behavioral Modifications (Concurrent with Alarm)

These strategies independently improve outcomes and should be implemented alongside alarm therapy:

• Maintain a wet-night/dry-night calendar to track progress objectively. 1
• Implement a regular daytime voiding schedule: morning, twice at school, after school, at dinner, and immediately before bedtime. 1
• Limit evening fluid intake to ≤200 ml (6 oz) after dinner while encouraging liberal fluid consumption earlier in the day. 1
• Ensure the child voids at bedtime and immediately upon waking. 1
• Provide family education that bedwetting affects 5-10% of 7-year-olds, is not the child's fault, and has significant psychosocial impact (low self-esteem, social isolation) that warrants active treatment rather than waiting for spontaneous resolution. 1, 2

When to Transition to Second-Line Therapy

Do not use desmopressin as first-line therapy in this motivated 10-year-old, as this forfeits the superior long-term cure rates achieved with alarm conditioning. 1

Consider desmopressin only after:

• An adequate 12-week trial of alarm therapy fails to achieve sufficient dryness, or 1
• The family is unlikely to comply with alarm requirements (e.g., unable to wake to alarm, lack of motivation), or 1
• Short-term symptom control is needed for specific events (camp, sleepovers). 1

Desmopressin Dosing and Safety

• Prescribe oral desmopressin 0.2-0.4 mg taken 1 hour before sleep. 1, 2
• Enforce strict evening fluid restriction (≤200 ml) to prevent hyponatremic water intoxication and seizures. 1, 2
• Avoid nasal spray formulation due to higher risk of severe hyponatremia. 1
• Desmopressin is most appropriate for children with documented nocturnal polyuria (nighttime urine output >130% of expected bladder capacity). 1

Critical Pitfall to Avoid

Reassurance alone is insufficient for a 10-year-old; spontaneous remission occurs in only 14% of cases per year, while untreated enuresis causes significant psychosocial distress that may be more detrimental than the physical symptom itself. 1, 2

Red Flags Requiring Urgent Specialist Referral

Refer immediately to pediatric urology if any of these are present:

• Weak urinary stream, straining to void, or need to use abdominal pressure 3, 2
• Continuous incontinence or true daytime wetting 3, 2
• Recurrent urinary tract infections 3, 2
• Abnormal neurological findings on examination 3, 2
• Glycosuria on urinalysis (requires immediate blood glucose testing) 3