Treatment of nocturnal enuresis (mainly monosymptomatic, in children)

1. Assess first

• Take a history. Separate monosymptomatic enuresis (nighttime wetting only) from non-monosymptomatic enuresis (daytime urgency, frequency or incontinence). Ask about bowel habits, constipation, fluid intake and family history.
• Urinalysis is the only test recommended for every child. It screens for UTI, diabetes mellitus, diabetes insipidus and renal disease. Do further tests only if there is a specific indication (Swanson's Family Medicine Review).
• Treat constipation and daytime bladder-bowel dysfunction first. Look for sleep-disordered breathing and other secondary causes.

2. Start with education and behavior measures (all children)

• Reassure the child and family that this is common, not the child's fault, and often resolves on its own. Never punish the child. This worsens the problem.
• Void regularly during the day and just before bed, about 6 to 7 times a day.
• Avoid caffeine and sugary drinks, especially in the evening.
• Keep a diary or calendar of wet and dry nights, and use positive reinforcement.
• Start active treatment only when the child is motivated, usually not before about 6 years. Motivation should come from the child more than from the parents. (Campbell-Walsh Urology)

3. First-line active treatment (choose one)

• It is the most effective option for long-term cure. About two-thirds of children become dry during treatment, and nearly half stay dry afterward (Campbell-Walsh Urology).
• It suits motivated families and children without nocturnal polyuria.
• The child, not the parent, switches off the alarm, goes to the toilet, changes the bedding and resets the sensor. Parents wake the child at first if needed.
• Treatment may take up to 12 to 16 weeks. About 30% drop out, so follow-up matters.

• Dose: oral tablet or melt, taken at bedtime.
• It suits children with nocturnal polyuria and normal bladder capacity, those with infrequent wet nights, and those who fail or refuse the alarm. It also works well for short-term needs such as camps or sleepovers.
• Efficacy is roughly 70%. Relapse after stopping is common, so taper gradually rather than stopping abruptly. A meta-analysis found a higher relapse rate than with the alarm and similar efficacy (Campbell-Walsh Urology; Swanson's).
• Restrict fluids in the evening and at night, from about 1 hour before to 8 hours after the dose. This prevents water intoxication and hyponatremia. Do not use the nasal spray for this indication, because of the hyponatremia risk.

4. Second- and third-line options

• Combination of desmopressin and an anticholinergic (oxybutynin, tolterodine, solifenacin, propiverine). This helps when there is a small functional bladder capacity, nocturnal overactivity, or desmopressin failure. Oxybutynin alone is not effective for monosymptomatic enuresis.
• Alarm plus desmopressin. This combination can help in refractory cases.
• Imipramine. Response is similar to desmopressin but side effects are worse, including cardiotoxicity in overdose. Use it as a last resort.
• For non-monosymptomatic enuresis, treat the daytime bladder dysfunction first with timed voiding, anticholinergics and bowel management.

5. Recent evidence

6. Adults