Enuresis

Straight to the point of care

Last updated: Nov 24, 2022

 Table of Contents
Overview 3
Summary 3
Definition 3

Theory 4
Epidemiology 4
Aetiology 4
Pathophysiology 5
Classification 5
Case history 6

Diagnosis 7
Approach 7
History and exam 8
Risk factors 9
Investigations 10
Differentials 11
Criteria 12
Screening 12

Management 13
Approach 13
Treatment algorithm overview 16
Treatment algorithm 18
Emerging 26
Patient discussions 26

Follow up 27
Monitoring 27
Complications 27
Prognosis 27

Guidelines 28
Diagnostic guidelines 28
Treatment guidelines 28

Online resources 30

References 31

Disclaimer 36
Enuresis Overview

Summary
Enuresis has primarily nocturnal symptoms in children older than 5 years of age.

Differentials include diabetes, medications, emotional problems, urinary tract infection, spina bifida, seizure

OVERVIEW
disorder, and neurogenic bladder.

Treatment is commonly involves behavioural changes, alarm therapy, or desmopressin.

Emotional support and encouragement is vital to management.

Definition
Enuresis is defined as normal micturition that occurs at an inappropriate or socially unacceptable time or
place. As recommended by International Children's Continence Society, in this topic 'enuresis' is reserved for
micturition during sleep, or bedwetting. Daytime wetting is called 'incontinence'.

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 Enuresis Theory

Epidemiology
The prevalence of incontinence varies depending on age and whether the enuresis occurs during the day
or at night. Daytime incontinence ranges from 3.2% to 9.0% in children aged 7 years, from 1.1% to 4.2%
THEORY

in those aged 11-13 years, and from 1.2% to 3.0% in adolescents aged 15–17 years. Nocturnal enuresis
in the community decreases with age; in several geographical settings, including the United States, the
Netherlands, and Hong Kong, the range is around 5% to 10% among 5-year-olds, 3% to 5% among 10-year-
olds, and around 1% among individuals 15 years or older.[1]

It is more common in boys, with a 2:1 male to female ratio reported.[3] [4] The disorder may also have higher
prevalence in youth with learning disabilities or attention-deficit/hyperactivity disorder.[1]

The natural history of urine control is that most children are dry during the day before they are dry at night.
The average age of toilet training has been rising for the last 50 years. In a prospective cohort study, median
age of dryness during the day was 3.5 years, and median age of dryness at night was 4 years.[5]

In otherwise healthy adults aged 18 to 64 years, studies show a 0.5% prevalence of enuresis.[6] A report
from the UK states that between 2% and 3% of 12- to 14-year-olds and 1% to 2% of people aged 15 years
and older wet the bed twice a week on average.[7] European guidelines report that 7 out of 100 children
wetting the bed at age 7 years will continue to have nocturnal enuresis into adulthood, emphasising the need
for early treatment.[3] Given this substantial percentage of patients still affected into adulthood, vigilance is
important in the treatment of children, because it is known that enuresis may have secondary implications,
both for psychological health and future voiding health.[1]

Aetiology
Investigation shows that enuresis is a heterogeneous disorder composed of many different subgroups.[8]
The common principle is a mismatch between nocturnal urine production and night-time functional bladder
capacity compounded by an inability to wake, resulting in bedwetting. In some children, sleep-disordered
breathing may compound the problem due to arousal thresholds while sleeping.

Disorders of sleep arousal

• In the case of a child who seems to have normally concentrated urine and an unremarkable bladder
capacity, a baseline disorder in arousal is a reasonable assumption.
Decreased functional bladder capacity

• There tends to be normal urine concentration (measured by laboratory urine testing) and there may
be a history of daytime frequency - a subconsciously learnt coping behaviour - only elucidated in the
voiding diary.
Nocturnal polyuria

• For patients who complain of nocturnal polyuria or of having their largest void of the day during the
night, it is reasonable to assume that the aetiology of their enuresis is related to nocturnal polyuria.
Poorly concentrated urine as assessed by urinalysis can also be indicative of nocturnal polyuria.
Nocturnal overactive bladder

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Enuresis Theory

• Children who do not respond to interventions with alarm therapy or desmopressin may suffer from
overactive bladder. Often daytime symptoms are masked by moderating fluid intake to minimise
daytime urination.
During daytime enuresis it is typical that the child defers voiding until incontinence occurs. This may be due

THEORY
to a reluctance to use the toilet as a result of social anxiety or a preoccupation with school or play activity.
The events most commonly occur in the early afternoon on school days or after returning from school.[1]

Pathophysiology
Typically, a circadian rhythm of urine production develops early in childhood, resulting in a reduced nocturnal
diuresis.[9] This is regulated by an increase in nocturnal release of arginine vasopressin (AVP) or antidiuretic
hormone (ADH), or solute excretion.[10] A significant portion of children affected with enuresis have
increased nocturnal urine volume and, specifically, the urine volume is larger on nights when the patient
has a wet episode.[11] This has led to various hypotheses on the mechanism of the increased nocturnal
diuresis. The most historically studied theory revolves around a decrease in secretion of AVP, which leads
to increased free-water excretion. In addition, some children have increased night-time fluid consumption,
which physiologically leads to increased nocturnal diuresis. The sum total is that increased nocturnal urine
production means that avoiding enuresis depends on the functional capacity of the bladder and ultimately on
the ability of the child to wake in time.

Another subgroup of nocturnal enuretics is composed of children who have normal nocturnal urine
production but have reduced bladder capacity or bladder dysfunction.[12] [13] These patients may either
have normal daytime bladder function and normal urodynamics and bladder capacity, or have daytime
abnormalities that remain occult.[14] The theory on why a child with normal daytime bladder function
would develop abnormal behaviour at night centres on a deficiency of inhibitory brainstem signalling,
which can result in bladder instability only at night.[15] Any pathology is concealed during the daytime by
subconsciously learned behaviour of frequent voiding or decreased fluid intake. These patients tend to have
severe symptoms and may need second- or third-line treatments or combination therapy.[12]

If a child has a normal, functioning bladder with adequate capacity holding an appropriate amount of urine,
but does not wake when the bladder is full, he or she will have enuresis. Thus, a failure to wake in time to
void is the base cause of enuresis. Anecdotally, many parents report that enuretic children are difficult to
rouse; and there are good data showing that enuretic children are more difficult to rouse than their age-
matched controls.[16] Some children with arousal disorders will have concurrent sleep-disordered breathing
or even obstructive sleep apnoea. In these children, correcting the breathing problem can improve or
eliminate the enuresis.[17]

During nocturnal enuresis, voiding may take place during rapid eye movement (REM) sleep, and the child
may recall a dream that involved the act of urinating.[1]

Classification

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 Enuresis Theory
Clinical classification
• Enuresis is socially inappropriate voiding: the voluntary or involuntary repeated discharge of urine into
clothes or bed after a developmental age when bladder control should be established. Most children
THEORY

with a mental age of 5 years have obtained such bladder control.[1]

• Primary nocturnal enuresis: nocturnal enuresis in which the child has never had a period of dryness
longer than 6 months.
• Secondary nocturnal enuresis: nocturnal enuresis recurring after a period of more than 6 months of
the child being dry at night.
There are subtypes of enuresis; nocturnal-only is the most common subtype and involves incontinence only
during night-time sleep, typically during the first one-third of the night. The diurnal-only subtype occurs in
the absence of nocturnal enuresis and may be referred to as urinary incontinence. Those with diurnal- only
subtype may have urge incontinence (i.e., have sudden urge symptoms and detrusor instability) or voiding
postponement (i.e., consciously defer micturition urges until incontinence results).

Case history
Case history #1
A 7-year-old boy is brought to the clinic by his parents, who complain that he continues to wet the bed
at night, 2 to 3 times a week. Further investigation determines that both the mother and the father had
nocturnal enuresis but report that they just grew out of it. The child and family are clearly distressed about
this and are willing to do whatever it takes to improve the situation.

Other presentations
The most common form of enuresis is monosymptomatic nocturnal enuresis, which is usually referred
to as bedwetting. Other types of enuresis are associated with baseline voiding dysfunction. All other
conditions in which voiding dysfunction manifests itself with the loss of urine are more appropriately
defined as incontinence. Monosymptomatic enuresis occurring only at night is dealt with separately from
incontinence, both diagnostically and therapeutically.

Parents of young children who have enuresis rarely bring them to a physician, as such behaviour is
socially appropriate. The age at which this becomes unacceptable varies from culture to culture. The
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and the
medical community generally recognise 5 years old as the cut-off.[1] Additionally, the consensus of the
International Children's Continence Society is that the number of acceptable wet nights is between 1 and
3 per month; more than this and the child and/or parents are typically concerned enough to bring it to
the attention of their physician.[2] Most of these children will present having never been consistently dry.
Secondary enuresis can be associated with a stressful life event or a new medical condition, and warrants
further investigation.

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Enuresis Diagnosis

Approach
When approaching a child for the first time who presents with enuresis, it is vital to determine that both the
patient and the family are in agreement that there is a problem and they are all committed to a treatment
plan. If the child shows little interest or does not recognise it as a problem, then it is wise to delay treatment
until that time arrives. Likewise, parents must be educated that treatment will require their involvement and
patience. If the parents do not demonstrate a willingness to be involved, or are relying on shame to motivate
the child, the physician must do some groundwork with the parents to ensure their support through diagnosis
and treatment.

Clinical assessment
It is important to diagnose the appropriate pathophysiological subtype of enuresis, as management and
treatment differ accordingly. Review of systems should focus on the patient's sleeping habits, bowel
function, and enquiry about symptoms or signs of upper airway obstruction.

A thorough evaluation should be done, including a detailed neurological and genitourinary examination to
rule out neurological disorders or anatomical abnormalities leading to voiding dysfunction.

Voiding or elimination diary

The diary, with questionnaire and frequency-volume chart, should be sent to the family to record the
child's voiding, starting 2 weeks before the appointment.[26] All information such as records of wet
days and nights and timing of fluid intake and voiding is recorded. A frequency-volume chart details
functional bladder capacity, which is assumed as being the largest micturition recorded during this period.
Estimating bladder capacity can also be performed using the Koff formula of (age in years + 2) x 30
mL.[27] Night-time voided volume can be calculated by weighing the nappy. By recording stool frequency
and consistency, patients with unrecognised constipation may be identified. The physician or nurse
specialist should talk with the family to explain exactly how to complete the chart. The diary assists in
obtaining an accurate history and provides a baseline as the treatment progresses.

It should be determined whether the patient takes in large amounts of fluids, specifically caffeinated

DIAGNOSIS
beverages, late at night. By asking the child, family, and possibly school teachers, it is common to find
that the patient does not drink an adequate amount of fluids while at school in order to avoid trips to the
toilet. Thus, most of their fluid intake is in the evening, which leads to increased night-time voiding.[28]

Investigations
On the initial visit, urinalysis (U/A) should be done to help rule out infection or new-onset diabetes.
If the child complains of frequency both day and night and on occasion also suffers from enuresis,
it is important to rule out diabetes as the cause before embarking on any further investigation. One
study supports ultrasound to evaluate bladder wall thickness, as it correlates well with baseline voiding
dysfunction, which could be responsible for the enuresis.[29] In practice, renal ultrasound may be
reserved for children in whom treatment has failed, or where there are complaints of other symptoms or
signs of voiding dysfunction.

After completing a thorough history and physical examination, reviewing the voiding diary, and performing
the U/A, it should be possible to rule out other causes for enuresis and start empirical treatment.

Further urological evaluation is necessary in children who cannot reliably empty the bladder or must use
secondary manoeuvres to do so. These children, by definition, do not have primary monosymptomatic

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 Enuresis Diagnosis
nocturnal enuresis, and investigations are required to determine the presence of bladder-sphincter
dyssynergia, or an anatomical or neurological disorder in the lower urinary tract. A child with primary
monosymptomatic nocturnal enuresis should be able to void to completion in one attempt, whether that
void be at night or during the day.

History and exam

Key diagnostic factors
presence of risk factors (common)
• Key risk factors include genetic predisposition and upper airway obstruction/snoring.

increased fluid intake at night (common)

• It should be determined whether the patient takes in large amounts of fluids late at night.

urinary frequency (common)

• Is variable and can be too frequent (>8 voids per day) or too infrequent (<3 voids per day).
• Detrusor overactivity can lead to urinary frequency, and detrusor underactivity may lead to urinary
infrequency.
• It should be determined when the child tends to void.
• Acute onset of frequency and polyuria necessitates ruling out diabetes. If any of these symptoms
lead to enuresis, their aetiologies can be treated specifically with the goal of normalising the voiding
patterns and habits.

constipation (common)
• Impacted faeces are hypothesised to place more than the physiological amount of pressure on
the bladder and thus reduce its ability to store urine. In some children, aggressive treatment of
constipation alone has led to a resolution of enuresis.[30]
DIAGNOSIS

caffeine and other bladder irritants (common)

• Caffeine intake increases detrusor contractions, and can cause daytime incontinence, urinary urgency,
and enuresis. There is weak evidence that irritants such as food colouring may do the same.

urinary urgency (uncommon)

• Commonly seen in children who race to the toilet in order to avoid incontinent episodes. May be due
to a sudden detrusor contraction or more commonly because of voiding postponement. These can be
distinguished based on the presentation.
• If the patient continues to engage in activity and is preoccupied while giving physical signs that they
need to void (e.g., crossing the legs, wriggling), they are most likely delaying micturition and this leads
to the urgency.

Other diagnostic factors

abnormal voiding habits (uncommon)
• Incomplete bladder emptying or employing secondary manoeuvres to empty the bladder necessitates
further work up.

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Enuresis Diagnosis
abnormal breathing pat tern at night (uncommon)
• Upper airway obstruction causing disturbed sleep pattern has been associated with enuresis.

Risk factors
Strong
genetic predisposition
• The mode of inheritance is typically autosomal dominant with high penetrance (90%). The risk of
children born to parents who both had nocturnal enuresis is 77%. This risk is 45% if only 1 parent was
affected and decreases to 15% in children born to non-enuretic families.[18]
• While multiple genes have been implicated, no direct genotype to phenotype correlations have been
made.
• Linkage analyses and foci have been found on chromosomes 8, 12, 13, and 22 but, unfortunately,
these molecular genetic investigations have raised more questions than have been answered.

upper airway obstruction/sleep-disordered breathing

• One study showed a significant decrease in or complete resolution of enuresis in 84% of children
after surgical treatment for upper airway obstruction.[19] This suggests that the disturbances in sleep
pattern due to upper airway obstruction may be causing enuresis. A prospective study evaluating
patients with enuresis did not find an improvement after tonsillectomy for all causes, suggesting that
the benefit is minimal or less clear.[20] However, that study did not differentiate obstructive sleep
apnoea from enlarged tonsils, which clinically may be a different condition as far as it relates to
enuresis. Another prospective study looking only at children with obstructive sleep apnoea showed
that half had complete resolution of enuresis after surgical correction of their obstruction.[17] Snoring
has been associated with a higher incidence of nocturnal enuresis. The pathophysiology is uncertain
but may involve higher levels of brain natriuretic peptide, as well as disorders of arousal.[21] Ongoing
research will clarify the benefit of intervening in sleep-disordered breathing for enuresis.

DIAGNOSIS
Weak
constipation
• Impacted faeces are hypothesised to cause a disproportionately high amount of pressure on the
bladder and thus reduce its ability to store urine. Habitual holding of stool is also theorised to increase
pelvic floor tension, which may lead to incomplete bladder emptying.

at tention deficit hyperactivity disorder (ADHD)

• These children have a 2.7 times increased incidence of nocturnal enuresis compared with controls.[22]
They are also more likely to have concomitant daytime symptoms, and are harder to treat.

psychological disorders
• Enuresis causes feelings of shame and inferiority as well as a decrease in feelings of self-worth
and self-esteem.[23] Psychological improvement has been noted after successful treatment of
enuresis.[24] [25] Other voiding dysfunctions, including secondary enuresis, are commonly caused
by psychological factors. These children have most commonly experienced a stress event such as
trauma, parental divorce, admission to hospital, or sexual abuse. In these children, enuresis is a

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 Enuresis Diagnosis
regressive symptom. Therefore, when discussing enuresis it is important to discuss the psychological
issues, as they may help to determine the aetiology, change the diagnosis, or establish symptoms from
which to monitor for improvement.

male sex
• Enuresis is more common in boys, with a 2:1 male to female ratio reported.[3] [4]

Investigations
1st test to order

Test Result
urinalysis normal
• To exclude infection, signs of renal disease, poor urine
concentrating ability, or glycosuria indicative of diabetes mellitus. In
monosymptomatic nocturnal enuresis, urinalysis should be normal.

Other tests to consider

Test Result
urinary tract ultrasound normal
• Historically, no imaging was recommended in the evaluation of
enuresis. However, investigation shows that ultrasound can measure
bladder volume and wall thickness, which can predict underlying
bladder dysfunction and poor treatment response.[29]
• It is most reasonable to proceed to ultrasound if the child is initially
refractory to treatment or is complaining of any other symptoms
or signs of voiding dysfunction. In this setting it can be useful and
should precede a full neuro-urological investigation. A thick bladder
wall may correspond to detrusor hypertrophy and overactivity,
whereas a thin bladder wall indicates detrusor areflexia and urinary
DIAGNOSIS

retention.

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Enuresis Diagnosis

Differentials

Condition Differentiating signs / Differentiating tests

symptoms
Congenital abnormality • Urinary tract infections, • Renal and bladder
of the urinary tract continuous incontinence or ultrasound; voiding
(e.g., ectopic ureter, dampness, hydronephrosis, cystourethrogram.
ureterocele, and urethral and daytime voiding
valves) dysfunction are clinical
features differentiating from
enuresis.

Constipation • Faecal incontinence, hard • Faecal markers (radio-

stools, and blood per rectum opaque markers that are
suggest primary constipation given on 3 consecutive days
as a possible cause for to evaluate constipation) and
urinary symptoms. kidney, ureter, bladder x-
ray, or ultrasound scan will
demonstrate constipation.

Diabetes • Glycosuria and polyuria. • Urinalysis; fasting serum

May also present with weight glucose; HbA1c.
loss and polydipsia, which
are distinguishable clinical
features.

Detrusor overactivity • Daytime urinary frequency, • Urodynamics; bladder

urgency, and possibly ultrasound may demonstrate
daytime incontinence. a thick bladder wall.

Detrusor areflexia • Daytime urinary infrequency • Urodynamics; bladder

and overflow incontinence. ultrasound may demonstrate
thin bladder wall, enlarged
bladder, or incomplete

DIAGNOSIS
emptying..

Emotional disturbance • Depression and/or defiant • Diagnosis is clinical.

activity may be overriding
features together with urinary
symptoms; not always easy
to distinguish as may occur
simultaneously.

Neurological disorder • Daytime voiding dysfunction • Tests depend on underlying

leading to voiding primarily, as opposed to condition, and diagnosis
dysfunction (i.e., spina nocturnal symptoms. In may be clinical. EEG may
bifida; epilepsy) spina bifida there is sacral show typical abnormalities in
deformity. Epilepsy is usually epilepsy. Spina bifida may be
defined by occurrence of at shown by x-ray, CT, or MRI
least 2 unprovoked seizures scan.
and may be associated
with incontinence. Consider
tethered cord in cases
of secondary nocturnal
enuresis with new lower
extremity weakness.

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 Enuresis Diagnosis

Condition Differentiating signs / Differentiating tests

symptoms
Urinary tract infection • Fever, dysuria, and • Urinalysis and urine culture
abdominal pain. will be positive for culprit
micro-organisms.

Criteria
DSM-5-TR diagnostic criteria for enuresis[1] [28]
• Repeated voiding of urine into bed or clothes:

1. Involuntary or intentional.
• Clinically significant criteria (1 of the following):

1. Twice weekly for at least 3 consecutive months

2. Clinically significant distress
3. Impaired social, academic (occupational), or other important areas of functioning.
• Developmental age 5 years or older.
• Secondary cause not present:

1. Medication (e.g. diuretics, or antipsychotic medication such as lithium)

2. Medical condition (e.g. diabetes mellitus, spina bifida, ectopic ureter in a female, posterior
urethral valves in a male, tethered cord, a seizure disorder)

Screening
DIAGNOSIS

Regular visits to the paediatrician

The paediatrician should routinely enquire about faecal and urinary continence. However, the issue of
treatment for nocturnal enuresis should only be pursued if the patient and the family are bothered by it
and wish to work towards its resolution. Otherwise, treating a patient or family who is not concerned about
nocturnal enuresis is rarely successful.

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Enuresis Management

Approach
Initial management includes educational, behavioural, and lifestyle measures. This may be followed by
additional treatments aimed at improving arousal thresholds, and/or matching nocturnal urine production to
bladder storage capacity.

Education, motivation, and lifestyle changes

Usually children under 7 years of age are not actively treated, and the family is reassured. Active
management is offered for children ≥7 years. It is very important that the family and patient are willing
participants in what is likely to be a long treatment course. Education on the natural history of the disease
is also important, emphasising that resolution occurs at a rate of 5% to 10% per year.[1] From this point
on, the patient must be supported emotionally and encouraged when positive progress is made, but
not embarrassed or punished for any set-backs. A star chart recording the patient's days and nights of
dryness with a star or reward can be useful.

Regular voiding habits must be developed for the daytime, as well as instructing the patient to limit the
amount of fluid intake, specifically caffeinated fluids, in the hours before sleep; this can be supplemented
by voiding immediately before bed. These educational, behavioural, and lifestyle measures continue, even
if other therapies are commenced.

Bladder training therapy (urotherapy) may be used as part of these initial behavioural measures. It
involves a combination of education, rigorous scheduling of diet and voiding habits, and psychological
support. It is most helpful in children who show signs and symptoms of daytime voiding dysfunction such
as urgency, frequency, or infrequent voiding. The child is shown that they can take control of their bladder
and that by doing this they can avoid the night-time accidents. This should be done under the supervision
of a trained urotherapist and has been shown to cure bedwetting in up to 90% of appropriately selected
patients.[31] With such a high success rate, some have proposed that all enuretic children start their
therapy with bladder training before any pharmacotherapy or alarm regimens. This has yet to be studied
rigorously and its wide use is still considered investigational.[32]

There have been historical recommendations for lifting or taking the child to the toilet during the night to
void to pre-empt enuresis; however, this has poor efficacy in resolving the underlying enuresis. It may
temporarily solve the problem and keep bedding dry until the child grows out of enuresis spontaneously.

Evaluation and treatment of other conditions

Many of these children will also have constipation, and by resolving this alone as many as 60% of
children will see their enuresis improve.[33] Any signs or symptoms of upper airway obstruction should be
evaluated, and if appropriate, the patient referred to the ENT department or a sleep-disordered breathing
specialist.

Treatments
Initial therapy (after educational, behavioural, and lifestyle measures have been employed) is alarm
therapy. An enuresis alarm is a device that makes a loud sound or vibrates as soon as a moisture sensor
MANAGEMENT

detects a small amount of urine. This rouses the sleeping child so that he or she can be walked to the
toilet to urinate. This treatment is the best studied of all therapies for nocturnal enuresis, and the literature
shows a significant increase in bladder capacity in these patients after alarm treatment.[11]

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 Enuresis Management
The data for success on alarm therapy are strong, with multiple meta-analyses that generally conclude
that around 60% of children are dry at the end of treatment with the alarm, and 40% to 50% are dry at
follow-up.[34]

Signs of successful treatment with alarm therapy may be slow to appear, especially when compared with
desmopressin.[35] It is vital that families are told at the outset that alarm therapy needs to be continuous
for up to 12 weeks before re-evaluation. Frustration over a lack of immediate success can lead to a high
percentage of patients dropping out, thus making analysis of the literature on alarm therapy difficult.[35]
The other downside of alarm therapy is that it is socially awkward, especially during overnight events; in
this case desmopressin therapy can be used as an adjunct.

Patients who are difficult to rouse may sleep through the alarm and will need a parent to come and wake
them and take them to the toilet. If a child does not get up to void every time the alarm sounds, they are
not likely to improve with alarm therapy. Alarm therapy is superior to all other therapies as about half of
children will have a durable response after therapy is completed.[34] All other therapies have much higher
relapse rates.

If alarm therapy is not improving the number of wet nights, desmopressin can be tried before instituting
combined therapy, although patients with decreased bladder capacity tend not to respond as well to
desmopressin therapy.[36] [37]

Desmopressin is the treatment of choice following failure of educational, behavioural, and lifestyle
measures alone and alarm therapy. Desmopressin is an analogue of arginine vasopressin (AVP) (also
known as anti-diuretic hormone [ADH]) and acts on the V2 receptors in the collecting ducts and distal
tubules to take up free water. Nocturnal diuresis in enuretic patients may be related to abnormalities in the
nocturnal rise of AVP. The evidence for desmopressin therapy is fairly good but is clouded by variations
in the definitions for cure and response throughout the literature.[38] [39] Desmopressin is not a panacea,
and in non-responders it is best to try other avenues of therapy to achieve a lasting cure. Intranasal
desmopressin is no longer recommended in some countries (including the US) due to post-marketing
reports of hyponatraemia-related seizures.

If treatment with desmopressin fails despite doubling of the dose, the recommended course of action
is to use alarm therapy in combination with desmopressin. The factors predicting a good response to
desmopressin are patients with decreased urine concentration, normal-capacity bladders, single episodes
of enuresis at night, and prior response to a small dose of desmopressin.[36] [40]

For children who have been shown to respond to desmopressin therapy (over the first 8 to 12 weeks of
therapy) but who are only concerned about the potential of night-time symptoms occurring while away
from home (e.g., while sleeping overnight at a friend's house), desmopressin may be used intermittently
for these short periods when the need to be dry at night is considered more important for the child.

In children not responding to alarm therapy, desmopressin, or combination therapy, it is appropriate to

investigate the possibility of a nocturnally overactive bladder. Detrusor-relaxing drugs such as oxybutynin
or tolterodine are instituted empirically. These should not be used alone but as adjuvant therapy.
Tolterodine is not yet approved for children in some countries but has been shown to be effective with few
MANAGEMENT

or no adverse effects.[41] Desmopressin plus oxybutynin have been used together in some children with
success when oxybutynin alone did not work.

Imipramine is the oldest of the pharmacological therapies for nocturnal enuresis. However, given its
adverse-effect profile and the development of better pharmacotherapy, it is not recommended except in

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Enuresis Management
specific instances. It is also used for the treatment of ADHD. In patients who are refractory to conventional
therapies and have concomitant ADHD, imipramine may be prescribed. The main concerns are suicidality
and cardiotoxicity. Because of this adverse-effect profile and its limited efficacy, it should be administered
with assistance from colleagues in psychiatry who have more experience with its use. The mechanism
of action is unclear but has been postulated to be related to reduction in detrusor activity and increased
bladder capacity due to anticholinergic and sympathomimetic activity. Although it is prescribed at lower
doses for enuresis than for psychiatric conditions, it can still pose a risk to both the patient and family
members who may accidentally come across it.[42] [43] [44]

Recurrence
With each treatment approach, recurrence is common, but spontaneous resolution does occur at a rate of
5% to 10% per year.[1] Management of recurrence is to reinstate therapy. Only alarm treatment has been
shown to have durable effects significantly greater than the background resolution rate of 15% per year
after treatment is withdrawn.

MANAGEMENT

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 Enuresis Management

Treatment algorithm overview

Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

Acute ( summary )
age <7 years

1st reassurance

age ≥7 years

1st education, lifestyle changes, and

behavioural measures

adjunct management of contributing medical

conditions

2nd alarm therapy

plus education, lifestyle changes, and

behavioural measures

adjunct management of contributing medical

conditions

3rd desmopressin

plus education, lifestyle changes, and

behavioural measures

adjunct management of contributing medical

conditions

adjunct detrusor-relaxing drugs

4th combination therapy: alarm +

desmopressin

plus education, lifestyle changes, and

behavioural measures

adjunct management of contributing medical

conditions

adjunct detrusor-relaxing drugs

5th imipramine

plus education, lifestyle changes, and

behavioural measures

adjunct management of contributing medical

conditions
MANAGEMENT

Ongoing ( summary )
recurrence

1st reinstate treatment

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Enuresis Management

MANAGEMENT

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 Enuresis Management

Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

Acute
age <7 years

1st reassurance

» Typically, specific treatment for enuresis is not

started until the child is ≥7 years old. Usually
children under this age are not actively treated,
and the family is reassured.
age ≥7 years

1st education, lifestyle changes, and

behavioural measures

» The patient must be supported emotionally

with positive reinforcement, and without being
punished or made to feel embarrassed. A star
or reward chart can be useful. Regular daytime
voiding habits must be developed, and advice
given to limit fluid intake before sleep.

» Bladder training - a combination of education,

rigorous scheduling of diet and voiding habits,
and psychological support (supervision by a
trained urotherapist) - is most helpful in children
who show signs and symptoms of daytime
voiding dysfunction (e.g., urgency, frequency,
infrequent voiding). This has been shown to
cure bedwetting in up to 90% of appropriately
selected patients.[31] Bladder training as an
initial measure for all enuretic children has yet
to be studied rigorously and its wide use is still
considered investigational.[32]
adjunct management of contributing medical
conditions
Treatment recommended for SOME patients in
selected patient group
» Many of these children also have constipation.
By resolving this alone, up to 60% of children
will see their enuresis improve.[33] Any signs or
symptoms of upper airway obstruction should be
evaluated and referred to the ENT department or
a sleep-disordered breathing specialist.
2nd alarm therapy
MANAGEMENT

» Initial therapy (after educational, behavioural,

and lifestyle measures have been employed) is
alarm therapy. This treatment is the best studied
of all therapies for nocturnal enuresis, and the

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Enuresis Management

Acute
literature shows a significant increase in bladder
capacity after alarm treatment.[11] [34]

» The data for success on alarm therapy

are strong, with multiple meta-analyses that
generally conclude that around 60% of children
are dry at the end of treatment with the alarm,
and 40% to 50% are dry at follow-up.[34] It
can be considered in all patients with nocturnal
enuresis, but is noted to be especially beneficial
in patients with decreased bladder capacity,
more frequent wet nights, and with compliant
families.[8]

» It is slow to start showing signs of success,

so families need to be told that therapy will be
continued for up to 12 weeks before any re-
evaluation. This frustration can lead to a high
drop-out rate.[35]
plus education, lifestyle changes, and
behavioural measures
Treatment recommended for ALL patients in
selected patient group
» The patient must be supported emotionally
with positive reinforcement, and without being
punished or made to feel embarrassed. A star
or reward chart can be useful. Regular daytime
voiding habits must be developed, and advice
given to limit fluid intake before sleep.

» Bladder training - a combination of education,

rigorous scheduling of diet and voiding habits,
and psychological support (supervision by a
trained urotherapist) - is most helpful in children
who show signs and symptoms of daytime
voiding dysfunction (e.g., urgency, frequency,
infrequent voiding). This has been shown to
cure bedwetting in up to 90% of appropriately
selected patients.[31] Bladder training as an
initial measure for all enuretic children has yet
to be studied rigorously and its wide use is still
considered investigational.[32]
adjunct management of contributing medical
conditions
Treatment recommended for SOME patients in
selected patient group
» Many of these children also have constipation.
By resolving this alone, up to 60% of children
MANAGEMENT

will see their enuresis improve.[33] Any signs or

symptoms of upper airway obstruction should be
evaluated and referred to the ENT department or
a sleep-disordered breathing specialist.
3rd desmopressin

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 Enuresis Management

Acute
Primary options

» desmopressin: 0.2 to 0.4 mg orally once

daily at bedtime, dose may be increased up
to 0.6 mg/day

» If alarm therapy is not successful,

desmopressin may be considered, although
patients with decreased bladder capacity
tend not to respond as well to desmopressin
therapy.[36] [37]

» The advantage of desmopressin is its

immediate action. It is especially useful in short-
term treatment situations (e.g., overnight camps
or school trips).

» Desmopressin is generally safe and well

tolerated, but the patient and their family
should be warned about water intoxication and
hyponatraemia related to its administration.
This can be avoided by limiting the water intake
during and around the time of administration.

» Particular care to restrict fluids on the nights

desmopressin is given is required. Treatment
should be given for at least 8 to 12 weeks
before declaring it a failure. During that time,
if successful, 1 week of interruption should be
done periodically to evaluate for long-term cure.
In an attempt to achieve permanent cure, a
structured withdrawal programme should be
instituted. For children who have been shown
to respond to desmopressin therapy (over the
first 8 to 12 weeks of therapy) but who are only
concerned about the potential of night-time
symptoms occurring while away from home (e.g.,
while sleeping overnight at a friend's house),
desmopressin may be used intermittently for
these short periods when the need to be dry at
night is considered more important for the child.

» Intranasal desmopressin is no longer

recommended in some countries (including
the US) due to post-marketing reports of
hyponatraemia-related seizures.
plus education, lifestyle changes, and
behavioural measures
Treatment recommended for ALL patients in
selected patient group
MANAGEMENT

» The patient must be supported emotionally

with positive reinforcement, and without being
punished or made to feel embarrassed. A star
or reward chart can be useful. Regular daytime
voiding habits must be developed, and advice
given to limit fluid intake before sleep.

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Enuresis Management

Acute
» Bladder training - a combination of education,
rigorous scheduling of diet and voiding habits,
and psychological support (supervision by a
trained urotherapist) - is most helpful in children
who show signs and symptoms of daytime
voiding dysfunction (e.g., urgency, frequency,
infrequent voiding). This has been shown to
cure bedwetting in up to 90% of appropriately
selected patients.[31] Bladder training as an
initial measure for all enuretic children has yet
to be studied rigorously and its wide use is still
considered investigational.[32]
adjunct management of contributing medical
conditions
Treatment recommended for SOME patients in
selected patient group
» Many of these children also have constipation.
By resolving this alone, up to 60% of children
will see their enuresis improve.[33] Any signs or
symptoms of upper airway obstruction should be
evaluated and referred to the ENT department or
a sleep-disordered breathing specialist.
adjunct detrusor-relaxing drugs
Treatment recommended for SOME patients in
selected patient group
Primary options

» oxybutynin: 5 mg orally (immediate-release)

twice daily

OR

» tolterodine: 1 mg orally (immediate-release)

twice daily

» In children not responding to alarm therapy,

desmopressin, or combination therapy, it is
appropriate to investigate the possibility of a
nocturnally overactive bladder. Detrusor-relaxing
drugs such as oxybutynin or tolterodine are
instituted empirically. These should not be used
alone but as adjuvant therapy. Tolterodine is not
yet approved for children in some countries but
has been shown to be effective, with few or no
adverse effects at this dose.[41]
4th combination therapy: alarm +
desmopressin
MANAGEMENT

Primary options

» desmopressin: 0.2 to 0.4 mg orally once

daily at bedtime, dose may be increased up
to 0.6 mg/day
-and-

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 Enuresis Management

Acute
» alarm therapy

» If either alarm therapy or desmopressin

monotherapy is not working in isolation, it is
recommended that they be used in combination.

» One downside of alarm therapy is that it is

socially awkward, especially during overnight
events, and in this case desmopressin therapy
can be used as an adjunct.

» Desmopressin is generally safe and well

tolerated, but the patient and their family
should be warned about water intoxication and
hyponatraemia related to its administration.
This can be avoided by limiting the water intake
during and around the time of administration.

» Particular care to restrict fluids on the nights

desmopressin is given is required. Treatment
with desmopressin should be given for at least 8
to 12 weeks before declaring it a failure. During
that time, if successful, 1 week of interruption per
month should be done to evaluate for long-term
cure. In an attempt to achieve permanent cure,
a structured withdrawal programme should be
instituted.

» Intranasal desmopressin is no longer

recommended in some countries (including
the US) due to post-marketing reports of
hyponatraemia-related seizures.
plus education, lifestyle changes, and
behavioural measures
Treatment recommended for ALL patients in
selected patient group
» The patient must be supported emotionally
with positive reinforcement, and without being
punished or made to feel embarrassed. A star
or reward chart can be useful. Regular daytime
voiding habits must be developed, and advice
given to limit fluid intake before sleep.

» Bladder training - a combination of education,

rigorous scheduling of diet and voiding habits,
and psychological support (supervision by a
trained urotherapist) - is most helpful in children
who show signs and symptoms of daytime
voiding dysfunction (e.g., urgency, frequency,
infrequent voiding). This has been shown to
MANAGEMENT

cure bedwetting in up to 90% of appropriately

selected patients.[31] Bladder training as an
initial measure for all enuretic children has yet
to be studied rigorously and its wide use is still
considered investigational.[32]

22 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 24, 2022.
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Enuresis Management

Acute
adjunct management of contributing medical
conditions
Treatment recommended for SOME patients in
selected patient group
» Many of these children also have constipation.
By resolving this alone, up tp 60% of children
will see their enuresis improve.[33] Any signs or
symptoms of upper airway obstruction should be
evaluated and referred to the ENT department or
a sleep-disordered breathing specialist.
adjunct detrusor-relaxing drugs
Treatment recommended for SOME patients in
selected patient group
Primary options

» oxybutynin: 5 mg orally (immediate-release)

twice daily

OR

» tolterodine: 1 mg orally (immediate-release)

twice daily

» In children not responding to alarm therapy,

desmopressin, or combination therapy, it is
appropriate to investigate the possibility of a
nocturnally overactive bladder. Detrusor-relaxing
drugs such as oxybutynin or tolterodine are
instituted empirically. These should not be used
alone but as adjuvant therapy. Tolterodine is not
yet approved for children in some countries but
has been shown to be effective, with few or no
adverse effects at this dose.[41]
5th imipramine
Primary options

» imipramine: children >6 years of age: 1 to

2.5 mg/kg orally once daily at bedtime

» Imipramine is the oldest of the

pharmacological therapies for nocturnal
enuresis; however, given its adverse-
effect profile and the development of better
pharmacotherapy it is not recommended except
in specific instances.

» It may be considered in patients with

MANAGEMENT

concomitant ADHD who may also be prescribed

imipramine for symptoms of ADHD. The main
concerns are suicidality and cardiotoxicity.
Because of this adverse-effect profile and its
limited efficacy, it should be administered with

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 Enuresis Management

Acute
assistance from colleagues in psychiatry who
have more experience with its use.

» The mechanism of action is unclear but has

been postulated to be related to reduction in
detrusor activity and increased bladder capacity
due to anticholinergic and sympathomimetic
activity. Although it is prescribed at lower doses
than for psychiatric conditions it can still pose a
risk to both the patient and family members who
may accidentally come across it.[42] [43] [44]
plus education, lifestyle changes, and
behavioural measures
Treatment recommended for ALL patients in
selected patient group
» The patient must be supported emotionally
with positive reinforcement, and without being
punished or made to feel embarrassed. A star
or reward chart can be useful. Regular daytime
voiding habits must be developed, and advice
given to limit fluid intake before sleep.

» Bladder training - a combination of education,

rigorous scheduling of diet and voiding habits,
and psychological support (supervision by a
trained urotherapist) - is most helpful in children
who show signs and symptoms of daytime
voiding dysfunction (e.g., urgency, frequency,
infrequent voiding). This has been shown to
cure bedwetting in up to 90% of appropriately
selected patients.[31] Bladder training as an
initial measure for all enuretic children has yet
to be studied rigorously and its wide use is still
considered investigational.[32]
adjunct management of contributing medical
conditions
Treatment recommended for SOME patients in
selected patient group
» Many of these children also have constipation.
By resolving this alone, up to 60% of children
will see their enuresis improve.[33] Any signs or
symptoms of upper airway obstruction should be
evaluated and referred to the ENT department or
a sleep-disordered breathing specialist.
MANAGEMENT

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Enuresis Management

Ongoing
recurrence

1st reinstate treatment

» Based on the form of treatment, recurrence is

common, but spontaneous resolution does occur
at a rate of 5% to 10% per year.[1]

» Management of recurrence is to reinstate

therapy.

MANAGEMENT

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 Enuresis Management

Emerging
Alternative medicine
Alternative methods of treatment for enuresis exist, including acupuncture, chiropractic adjustments, and
hypnosis. A thorough review of the literature concludes there is weak evidence for hypnosis, psychotherapy,
acupuncture, chiropractic and medicinal herbs, but the evidence is of poor quality, provided by single, small
trials. Further, more robust evidence is required.[45]

Patient discussions
Useful resources are available. [American Academy of Pediatrics. Children's health topics: toilet training]
(http://www.healthychildren.org/English/ages-stages/toddler/toilet-training/Pages/default.aspx)

Basic advice for parents:

• Encourage children to empty their bladder before bed and not to drink large amounts in the
evening.
• Enable them to locate the toilet without difficulty; if the toilet is far from the bedroom, consider
placing a potty in your child's bedroom.
• Use a mattress protector and allow them to help clean up in the morning. Make sure they wash
every day to prevent the smell of stale urine from lingering.
• Be supportive; educate siblings and other people living in the home not to tease.
• Let children know that it's not their fault.
• Go back to see your child's physician if enuresis returns.

Advice concerning specific therapies:

• There is a need to persevere with therapy in order to determine whether it will be effective.
Treatment with alarm therapy is often slow to start showing signs of success, so families need to be
told that therapy should be continued for at least 12 weeks before any re-evaluation is done.
• The patient and the family should be warned about possible water intoxication and hyponatraemia
related to desmopressin administration. This can be avoided by limiting the water intake during and
around the time of administration. It is important to shift drinking to earlier in the day.
• Oral desmopressin has a 1-hour onset of action, so a typical recommendation is for the child to
take the medication 2 hours before bed, and to stop drinking at that point. The child should be
encouraged to urinate just before going to bed.
• It is helpful for the patient and family to be informed of the typical natural course of enuresis.
Explain that recurrence is common, but in many patients spontaneous resolution does occur at a
rate of 5% to 10% per year.[1]
MANAGEMENT

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Enuresis Follow up

Monitoring
Monitoring

FOLLOW UP
Once the child and family are happy with the success of the treatment, no further monitoring is required.

Complications

Complications Timeframe Likelihood

psychological disorders long term low

Enuresis causes feelings of shame and inferiority as well as a decrease in feelings of self-worth and self-
esteem.[23] Psychological improvement has been noted after successful treatment of the enuresis.[24]
[46]

Prognosis

Prognosis
While short-term recurrence is the rule, especially with pharmacological interventions, long-term resolution is
almost inevitable as only 0.5% of adults have nocturnal enuresis.

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 Enuresis Guidelines

Diagnostic guidelines

International

Evaluation of and treatment for monosymptomatic enuresis: a

standardization document from the International Children’s Continence
Society (ht tp://www.jurology.com/article/S0022-5347%2809%2902682-2/fulltext)
Published by: International Children's Continence Society Last published: 2010

North America

Diagnosis and management of nocturia (ht tps://www.cua.org/guidelines)

Published by: Canadian Urological Association Last published: 2022
GUIDELINES

Treatment guidelines

United Kingdom

Bedwet ting in under 19s (ht tps://www.nice.org.uk/guidance/CG111)

Published by: National Institute for Health and Care Excellence Last published: 2010 (re-
affirmed 2018)

Europe

Guidelines on paediatric urology (ht tp://uroweb.org/individual-guidelines/

non-oncology-guidelines)
Published by: European Association of Urology; European Society for Last published: 2019
Paediatric Urology

International

Practical consensus guidelines for the management of enuresis (ht tps://

www.ncbi.nlm.nih.gov/pmc/articles/PMC3357467)
Published by: American Academy of Pediatrics; European Society Last published: 2012
for Paediatric Urology; European Society for Paediatric Nephrology;
International Children's Continence Society

Evaluation of and treatment for monosymptomatic enuresis: a

standardization document from the International Children’s Continence
Society (ht tp://www.jurology.com/article/S0022-5347%2809%2902682-2/fulltext)
Published by: International Children's Continence Society Last published: 2010

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Enuresis Guidelines

North America

Management of primary nocturnal enuresis (ht tp://www.cps.ca/documents/

position/primary-nocturnal-enuresis)
Published by: Canadian Paediatric Society Last published: 2013 (re-
affirmed 2016)

Diagnosis and management of nocturia (ht tps://www.cua.org/guidelines)

Published by: Canadian Urological Association Last published: 2022

Africa

The South African guidelines on enuresis (ht tps://www.sciencedirect.com/

science/article/pii/S1110570417300681)
Published by: South African Urology Association; Enuresis Academy of Last published: 2018

GUIDELINES
South Africa

Oceania

Nocturnal enuresis: "bedwet ting" (ht tps://www.paediatrics.org.nz/resources/

child-health-guidelines)
Published by: Paediatric Society of New Zealand Last published: 2005

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 Enuresis Online resources

Online resources
1. American Academy of Pediatrics. Children's health topics: toilet training (http://
www.healthychildren.org/English/ages-stages/toddler/toilet-training/Pages/default.aspx) (external link)
ONLINE RESOURCES

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Enuresis References

Key articles
• American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed. Text

REFERENCES
Revision, (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.

• European Association of Urology. Guidelines on paediatric urology. 2019 [internet publication]. Full
text (https://uroweb.org/guideline/paediatric-urology)

• Nevéus T, Eggert P, Evans J, et al. Evaluation of and treatment for monosymptomatic enuresis:
a standardization document from the International Children's Continence Society. J Urol.
2010;183:441-447. Full text (http://www.jurology.com/article/S0022-5347%2809%2902682-2/fulltext)
Abstract (http://www.ncbi.nlm.nih.gov/pubmed/20006865?tool=bestpractice.bmj.com)

• Glazener CM, Evans JH, Petro RE. Alarm interventions for nocturnal enuresis in children. Cochrane
Database Syst Rev. 2005;(2):CD002911. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/15846643?
tool=bestpractice.bmj.com)

• Longstaffe S, Moffat M, Whalen J. Behavioral and self-esteem changes after six months of
enuresis treatment: a randomized, controlled trial. Pediatrics. 2000;105:935-940. Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/10742350?tool=bestpractice.bmj.com)

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This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 24, 2022.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
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can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
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Contributors:

// Authors:

Erin C. Grantham, MD
Pediatric Urologist
Department of Urology, Billings Clinic, Billings, MT
DISCLOSURES: ECG declares that she has no competing interests.

// Acknowledgements:
Dr Erin C. Grantham would like to gratefully acknowledge Dr Duncan T. Wilcox and Dr Nicholas G. Cost, the
previous contributors to this topic. DTW and NGC declare that they have no competing interests.

// Peer Reviewers:

Prasad Godbole, FRCS, FRCS (Paed), FEAPU

Consultant Paediatric Urologist
Paediatric Surgical Unit, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, UK
DISCLOSURES: PG declares that he has no competing interests.

Elizabeth Jackson, MD
Associate Professor
Pediatric Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
DISCLOSURES: EJ declares that she has no competing interests.