OFFICIAL ABP TOPIC:

Manage a child with primary enuresis

BACKGROUND

Primary enuresis is involuntary nighttime bedwetting in children ≥5 years old who have never achieved a prolonged period of dryness (≥6 months). Though most cases of primary enuresis resolve on their own, it can cause significant psychosocial distress for the child and family. Cultural misconceptions and punitive parental responses can exacerbate this distress, so timely and appropriate management is important.

IDENTIFYING PRIMARY ENURESIS

Children with primary monosymptomatic enuresis have no other lower urinary tract symptoms (e.g., daytime incontinence, urgency, frequent urination, pain) and no history of bladder dysfunction. Primary enuresis should also be distinguished from secondary enuresis, which is enuresis that develops in a child who previously had a dry period of at least 6 months.

History should focus on voiding patterns, fluid intake, stooling habits, family history, as well as behavioral issues or stressors. Any neurological symptoms or exam findings should prompt workup for neurogenic causes of enuresis. Underlying medical conditions such as UTI, constipation, sleep apnea, and diabetes should be ruled out before diagnosing a child with primary enuresis.

INITIAL MANAGEMENT OF PRIMARY ENURESIS

Education and Counseling

• Normalize enuresis as common, with a high rate of spontaneous resolution.
• Discourage punishment; promote supportive, constructive responses.
• Minimize impact with mattress protectors, odor control.

Behavioral Modifications

• Schedule pre-bedtime voiding.
• Limit evening fluids to 6-8 oz; avoid caffeine and sugar.
• Distribute fluid intake earlier: 40% morning, 40% afternoon, 20% evening.
• Consider timed daytime voiding every 2-3 hours.

Motivational Therapy

For 5-7-year-olds with intermittent enuresis who can take some responsibility:

• Track progress with sticker charts or calendars.
• Reward positive behaviors (voiding before bed), not dry nights.
• Gradually increase rewards for longer dryness; avoid punishments.

ACTIVE THERAPY FOR PRIMARY ENURESIS

Consider active therapy for children with primary enuresis who have not improved after 3-6 months of behavioral management. First-line treatment is usually either enuresis alarms OR desmopressin, depending on family preference and frequency of enuresis.

Enuresis Alarms:

• First-line for enuresis >2 nights/week without urgent improvement needs.
• Require 3+ month commitment and motivated child/family.
• Work by training arousal to bladder fullness sensations.
• Child should turn off alarm, get up, and finish voiding in the toilet; at the beginning of therapy, caregivers may need to wake the child when the alarm is triggered.
• Child is responsible for using/resetting; train them on the process.
• Continue until 14 consecutive dry nights (often 3-4 months).
• If no response in 3 months, consider adding desmopressin or retrial in 6-12 months.

Desmopressin:

• First-line for enuresis ≤2 nights/week, short-term needs, or nocturnal polyuria with normal daytime voiding.
• Oral tablets (0.2-0.4 mg) or melts (120-240 mcg) 1 hour before bed.
• Titrate dose to effect; reassess in 1-2 weeks.
• More rapid effects than alarms but higher relapse risk.
• For daily use, consider weaning doses and planned interruptions.
• Limit fluids from 1 hour before to 8 hours after doses.
• If no response, suspect reduced bladder capacity or persistent polyuria.

Monitoring and Follow-up

• Continue treatment for 3 months if improving.
• Adapt plan based on progress:
  • Consider combination therapy if partial response.
  • Reevaluate if no improvement in 3 months.
• Manage relapses (≥2 wet nights/month) by restarting prior effective treatments.

Counseling and Support

• Prepare families for possible relapses given the chronic nature of enuresis.
• Educate about avoiding punishment and promoting self-esteem.
• Provide resources to help caregivers cope with stress and support the child.

REFRACTORY ENURESIS

Evaluation

• Abdominal/pelvic ultrasound: Assess for bladder wall thickening (overactivity) or rectal distension (constipation).
• Frequency/volume charts and bowel history.
• Consider screening for occult constipation or sleep apnea.

Management

• Repeat trials of alarms or desmopressin alone or combined.
• Consider a trial of imipramine, a tricyclic antidepressant that increases CNS arousal; second-line because of the risk of cardiac adverse events.
• Consider adding anticholinergics for reduced bladder capacity.

INDICATIONS FOR SPECIALIST REFERRAL

Refer to pediatric urology, developmental pediatrics, psychology, or psychiatry if:

• No response to 3+ months of alarms and desmopressin.
• Suspected anatomic abnormality.
• Daytime symptoms (non-monosymptomatic enuresis).
• Comorbid developmental, behavioral, or learning issues.
• Psychosocial factors or family difficulty coping.

REFERENCES

https://www.uptodate.com/contents/nocturnal-enuresis-in-children-management

https://publications.aap.org/pediatricsinreview/article/45/8/479/197999/Nocturnal-Enuresis