How should primary and secondary nocturnal enuresis be evaluated and managed across children, adolescents, and adults?

Evaluation and Management of Nocturnal Enuresis

Initial Evaluation

All children with nocturnal enuresis require a comprehensive assessment including detailed history from both parents and child, thorough physical examination focusing on genitourinary and neurologic systems, and urinalysis with possible urine culture. 1

History Components

• Distinguish primary vs. secondary enuresis: Primary means never consistently dry at night; secondary means resumption of wetting after ≥6 months of dryness 1
• Identify monosymptomatic vs. non-monosymptomatic patterns: Ask specifically about daytime wetting, abnormal voiding patterns (posturing, straining, poor stream), and urinary urgency 2, 3
• Screen for constipation: Document bowel movement frequency and stool consistency, as constipation directly decreases treatment success 2
• Assess for psychological stressors: In secondary enuresis, explore recent stressors including parental divorce, school trauma, sexual abuse, hospitalization, or family disorganization 1
• Obtain 1-2 week bladder diary: Record wet/dry nights and voiding patterns to establish baseline and detect nocturnal polyuria 1, 2

Physical Examination Red Flags

• Examine for: Enlarged tonsils/adenoids (sleep apnea), bladder distention, fecal impaction, genital abnormalities, spinal cord anomalies, neurologic signs including lower limb weakness, abnormal gait, speech disturbances 1, 2
• Urgent referral indicators: Severe/continuous incontinence, weak urinary stream, numbness, weakness, memory loss, autonomic symptoms, or any neurological abnormalities 4, 2

Laboratory Workup

• Routine testing: Urinalysis and urine culture only 1
• Additional testing if indicated: First-morning specific gravity (predicts desmopressin response), electrolytes/renal function, thyroid function, calcium, HbA1c if nocturnal polyuria documented or diabetes suspected 1, 2

Treatment Algorithm by Age and Type

Ages 5-6 Years

• Provide reassurance to parents that bedwetting is not the child's fault and has biological underpinnings 4
• Treat constipation first if present, as resolution may cure enuresis 2
• Implement behavioral interventions: Reward systems for dry nights, regular daytime voiding schedules, fluid restriction 2 hours before bedtime 4
• Consider treatment even if frequency criteria not met if there is distress, impaired self-esteem, or inability to attend sleepovers/camp 4

Ages 7 Years and Older (Primary Monosymptomatic Enuresis)

First-line treatment is enuresis alarm therapy, which achieves approximately 66% success rates and produces superior long-term outcomes compared to medications. 4, 5, 6

• Alarm therapy requirements: Takes several weeks to be effective, requires commitment from child and caregivers, appropriate for motivated families 5
• Second-line treatment is desmopressin: Use when rapid onset is priority, alarm is inappropriate/undesirable, or for short-term situations (camp, sleepovers) 4, 5
• Desmopressin dosing: Start with 120 µg MELT formula once daily 7
• Best response to desmopressin: Children with documented nocturnal polyuria on bladder diary 1, 8

Secondary Enuresis

Treat the underlying cause first, as secondary enuresis warrants prompt evaluation regardless of age. 4, 2

• Common triggers requiring separate treatment: Psychological stressors (divorce, abuse, trauma), urinary tract infections, diabetes mellitus, sleep apnea 1, 5
• If stress-related: Address the stressor through appropriate psychological intervention; enuresis is a regressive symptom 1

Non-Monosymptomatic Enuresis

• Refer to pediatric urology for daytime wetting, abnormal voiding, recurrent UTIs, or genital abnormalities 1, 3
• Treat constipation/encopresis: Disimpaction and healthy bowel regimen often eliminates enuresis 1
• Consider combination therapy: Antimuscarinic agents (propiverine) plus desmopressin for bladder dysfunction 7, 8

Adolescents and Adults

Approximately 0.5-3% of adolescents and adults continue wetting if untreated, and most cases have biological rather than psychological underpinnings. 1, 2

• Same evaluation principles apply: Rule out medical causes, obtain bladder diary, assess for sleep apnea 2, 5
• Treatment options: Alarm therapy remains effective; desmopressin for rapid control; combination therapy for refractory cases 7, 8

Combination Therapy for Refractory Cases

For treatment failures, combination therapy with desmopressin 120 µg plus propiverine 7.5 mg twice daily achieves 87% complete success rates with structured withdrawal protocols. 7

• Success rates: 92.7% in patients requiring only 120 µg desmopressin maintenance vs. 65% in those needing higher doses 7
• Duration: Requires structured withdrawal protocol over months with close follow-up 7

Critical Pitfalls to Avoid

• Never delay treatment if psychological damage is occurring: The impact on self-esteem, anxiety, and developmental milestones (attending camp, sleepovers) can be more devastating than the symptom itself 1, 4
• Do not assume psychological causation: Identifiable psychological factors are contributory in only a minority of children; most cases have genetic and biological underpinnings 1, 2
• Never pursue invasive testing without specific indications: Routine workup requires only urinalysis and possibly urine culture 1
• Do not overlook constipation: It is a paramount comorbid condition that directly decreases treatment success and must be treated first 2
• Avoid punitive approaches: Family embarrassment and parental anger can precipitate physical or emotional abuse in extreme cases 1

When to Refer

• Immediate urology referral: Severe/continuous incontinence, weak urinary stream, non-monosymptomatic enuresis, recurrent UTIs, genital abnormalities, neurologic signs 1, 4, 2
• Refractory cases: Primary enuresis unresponsive to standard and combination therapies after adequate trial 3, 6
• Urgent specialist referral: Any neurological symptoms including numbness, weakness, gait disturbance, speech problems, memory loss 2