How should enuresis (bedwetting) be managed in children age five or older?

The Canadian Paediatric Society has issued a position statement on the evaluation and management of enuresis (bedwetting) in the general pediatric setting. The prevalence of enuresis is 15% at age five years, 10% by age seven, and 5% by age 10. Family studies support strong genetic links. Enuresis is defined as discrete episodes of urinary incontinence during sleep in children age five years or older. It is thought to involve delayed maturation in a normal developmental process that is typically achieved by age five years. Contributing factors include difficulty in sleep arousal, with associated nocturnal polyuria, and relatively small bladder capacity. Enuresis can have significant negative impact on child health and family life. An assessment for enuresis requires distinguishing monosymptomatic enuresis (enuresis without daytime lower urinary tract symptoms) from non-monosymptomatic enuresis (enuresis and any one indicator of lower urinary tract symptoms). Mild daytime lower urinary tract symptoms affect up to two-thirds of children with enuresis. When present (i.e., in non-monosymptomatic enuresis), lower urinary tract symptoms should be addressed first. Assessment also entails differentiating primary from secondary enuresis by asking whether bedwetting has followed a ‘dry’ period of at least six months. Children with secondary enuresis should be screened for common organic comorbidities, less common medical conditions and psychosocial stressors. Comorbidities that can affect bedwetting, such as unrecognized constipation, delayed development, untreated attention-deficit hyperactivity disorder and obstructive sleep apnea, should be identified and managed where possible. Less common medical conditions (e.g., diabetes mellitus, diabetes insipidus, renal disease, hyperthyroidism) and psychosocial stressors (e.g., bullying) should also be considered. The patient history should include details about enuresis frequency, severity and impact. Children with monosymptomatic enuresis often have one large void early in the night, while children with subtle lower urinary tract symptoms from overactive bladder may have a pattern of smaller frequent voids throughout the night. The quantity and timing of fluid intake should be recorded; some children have most of their liquids after school, which may contribute to nocturnal polyuria. Physical examination, possible lab investigations, a voiding diary and urine measurement are discussed in the position statement. Management The mainstay of management in primary monosymptomatic enuresis is education and reassurance that no treatment is necessary. Explain that virtually all children and adolescents will outgrow their bedwetting with time. Try to mitigate feelings of stigma or guilt. Monosymptomatic enuresis is common, unintentional and cannot be controlled either by positive incentives to ‘stay dry’ or negative consequences for bedwetting. For children and families experiencing ongoing distress after education and reassurance, behavioural and motivational counselling may help while awaiting natural resolution. Behavioural strategies include: Promoting optimal voiding practices (void first thing in the morning and immediately before bed) Recommend frequent voiding (aim for every 2 to 3 h, or 5–7 times/day) Optimize timing of fluid intake (some studies recommend 80% of total daily fluid intake before 4 pm) Avoid caffeinated drinks Address constipation (aim for 1 bowel movement/day; dietary management, including medication and nutritionist referral, may be needed) Give positive reinforcement (e.g., ‘rewards’ for agreed-upon behaviours within the child’s control, such as voiding before bedtime, liberal fluid intake during the day, and helping to clean wet sheets and garments. ‘Dry nights’ should not be incentivized as they are outside of the child’s control. Punishment is counterproductive. Active therapies include enuresis alarms and desmopressin, with anticholinergics, tricyclics, mirabegron and neuromodulation reserved for exceptional cases. Desmopressin, used intermittently, is recommended when families do not wish to use an alarm but want to help children control enuresis periodically or for special occasions (i.e., sleepovers, summer camp). Daily desmopressin use, with the aim of completely controlling enuresis, may be considered for select cases, but only after discussing the potential benefits and limitations with the child and family. For intermittent use, the usual dose of the desmopressin dissolvable (melt) dosage form is 120 µg administered 30–60 minutes before sleep. If dryness is not achieved, the dose can be doubled to 240 µg (maximum 360 µg.) Note that the melt is dosed on an µg basis, whereas the tablet is dosed on a mg basis (equivalent dose: melt 120 µg = tablet 0.2 mg). Side effects from desmopressin are uncommon. Water intoxication can be prevented by strictly restricting liquid intake to one sip with teeth-brushing, then limiting fluids to no more than 200 mL for at least 8 h (from 1 h before receiving medication until the next morning). Desmopressin should not be used on nights when a child’s evening sports activities necessitate rehydration after dinner. For continuous use, desmopressin can be used for three months at a time, with reassessment after a medication break to determine whether enuresis has resolved. Permanent cure rates may be improved by reducing to a half-dose for two weeks before discontinuation. If enuresis returns, use the effective dose again for three months, followed by the reduced dose. Monitor serum electrolytes (especially serum osmolality and sodium) about every three months during continuous desmopressin therapy. Combined alarm use and desmopressin has had favourable results in some studies, especially for children who do not respond to alarm therapy alone. Anticholinergic (antispasmodic) medications that target bladder overactivity are ineffective as monotherapy and have more side effects than desmopressin. They should only be used in rare cases under the supervision of a pediatric urologist and/or nephrologist. Oxybutynin is the most common anticholinergic prescribed in Canada, although tolterodine or solifenacin may have fewer side effects. Tricyclic antidepressants were historically used to treat children with enuresis, but should only be used in exceptional cases due to their serious cardiovascular and neurological adverse effects. Recommendations The position statement includes five recommendations: Education and reassurance are the mainstays of management for monosymptomatic or ‘simple’ enuresis. Emphasize that enuresis is common and unintentional; it cannot be improved through ‘consequences’ for bedwetting. Conduct a history and physical exam to determine that enuresis is the correct diagnosis, to distinguish monosymptomatic from non-monosymptomatic enuresis, and to rule out common comorbidities, especially constipation, developmental and psychiatric conditions, and upper airway obstruction. Lower urinary tract symptoms may not be evident unless clinicians specifically ask about them. When they are present, they should be addressed first or concurrently with treatment for enuresis. Referral to urology is appropriate when symptoms are severe, numerous or atypical. Work with patients and families to determine whether treatment is necessary or desired. Children who are not bothered by enuresis and whose self-esteem is intact, and families who are comfortable waiting for bedwetting to stop naturally, should be reassured that waiting is the recommended course of action. Patients experiencing distress related to their enuresis may respond well to active treatment, such as an enuresis alarm and/or the intermittent use of desmopressin. If these two active therapies fail, and further treatment is desired, refer to an expert in enuresis to consider further investigations and other active treatment options. References: 1. Canadian Paediatric Society. Position statement. Evaluation and management of enuresis in the general paediatric setting. Posted: August 16, 2023. (accessed September 5, 2023).

How should enuresis (bedwetting) be managed in children age five or older?

Register for free access or login.

Related Topics