Management of Childhood Enuresis

Initial Evaluation

The American Academy of Child and Adolescent Psychiatry recommends distinguishing monosymptomatic from non-monosymptomatic enuresis by asking about daytime urgency, holding maneuvers, interrupted micturition, weak stream, and daytime incontinence in children with enuresis 3
Assessing frequency and pattern of enuresis, including whether it occurs every night or sporadically, and whether it is primary or secondary, is essential for determining the appropriate treatment approach 3
Screening for comorbidities such as constipation, sleep apnea, ADHD, and diabetes is crucial, as these conditions can contribute to treatment resistance 3, 4
Obtaining a family history of enuresis is important, as having one or both parents affected increases the risk of enuresis in the child 4
Reviewing medications that may contribute to secondary enuresis, such as lithium, valproic acid, clozapine, and theophylline, is necessary 5

A physical examination should include an abdominal examination to palpate for bladder distention and fecal impaction 6
A genitalia examination should be performed to examine for meatal abnormalities, epispadias, and phimosis 6
A back examination should be conducted to inspect for sacral dimple or vertebral anomalies suggesting spinal cord issues 6
A complete neurologic exam is necessary to rule out subtle dysfunction 6

Urinalysis and urine culture are recommended for all patients to exclude infection, diabetes, and kidney disease 5, 6, 7
No routine imaging is needed unless the history reveals continuous wetting, abnormal voiding pattern, recurrent UTIs, or positive urinalysis 6

The American Academy of Child and Adolescent Psychiatry recommends enuresis alarm therapy as the first-line treatment for children over 7 years old with primary monosymptomatic nocturnal enuresis, with a success rate of 66% initial response and over 50% long-term cure 1, 2
Implementing regular daytime voiding schedule, restricting evening fluids, voiding immediately before sleep, and treating constipation aggressively are essential behavioral modifications for all patients 1, 7, 4
Desmopressin may be used for rapid or short-term response, especially when alarm therapy is inappropriate or undesirable, with a response rate of 30% full response and 40% partial response 7, 4

Non-monosymptomatic enuresis requires a different approach, treating underlying bladder dysfunction first, and urgent specialty referral is needed if the child has weak stream, uses abdominal pressure to void, or has continuous incontinence 3
Secondary enuresis requires investigating psychological stressors, treating underlying causes such as UTI, diabetes, or sleep apnea, and considering surgical correction if obstructive sleep apnea is identified 5, 4

Failing to screen for constipation, which is a paramount cause of treatment resistance, and must be aggressively treated 3, 7
Inadequate treatment duration before declaring failure, with a minimum of 2-3 months required 7
Excessive fluid intake on desmopressin, which increases the risk of hyponatremia 7
Punitive parental response, which reinforces that bedwetting is involuntary, not behavioral 1
Insufficient alarm monitoring, which requires frequent follow-up and parental commitment 1
Missing sleep apnea, which requires specifically asking about snoring, witnessed apneas, and daytime sleepiness 4