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 line – reassurance

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ACUTE
|
age <7 years
1st line – 

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 line – education, lifestyle changes, and behavioural measures

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ACUTE
|
age ≥7 years
1st line – 

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.[32] Bladder training as an initial measure for all enuretic children has yet to be studied rigorously and its wide use is still considered investigational.[33]

Consider – management of contributing medical conditions

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ACUTE
|
age ≥7 years
Consider – 

management of contributing medical conditions

Additional 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.[34] Any signs or symptoms of upper airway obstruction should be evaluated and referred to the ear, nose, and throat department or a sleep-disordered breathing specialist.

2nd line – alarm therapy

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ACUTE
|
age ≥7 years
2nd line – 

alarm therapy

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 literature shows a significant increase in bladder capacity after alarm treatment.[35][36]

The data for success on alarm therapy are strong, with multiple meta-analyses generally concluding that alarm therapy may be more effective than no treatment in reducing enuresis in children and probably has a lower risk of adverse events than desmopressin.[36] [ Cochrane Clinical Answers logo ] ​ 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.[48]

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.[37]

Plus – education, lifestyle changes, and behavioural measures

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ACUTE
|
age ≥7 years
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.[32] Bladder training as an initial measure for all enuretic children has yet to be studied rigorously and its wide use is still considered investigational.[33]

Consider – management of contributing medical conditions

Back
ACUTE
|
age ≥7 years
Consider – 

management of contributing medical conditions

Additional 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.[34] Any signs or symptoms of upper airway obstruction should be evaluated and referred to the ear, nose, and throat department or a sleep-disordered breathing specialist.

3rd line – desmopressin

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ACUTE
|
age ≥7 years
3rd line – 

desmopressin

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.[38][39]

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.

Primary options

desmopressin: 0.2 to 0.4 mg orally once daily at bedtime, dose may be increased up to 0.6 mg/day

Plus – education, lifestyle changes, and behavioural measures

Back
ACUTE
|
age ≥7 years
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.[32] Bladder training as an initial measure for all enuretic children has yet to be studied rigorously and its wide use is still considered investigational.[33]

Consider – management of contributing medical conditions

Back
ACUTE
|
age ≥7 years
Consider – 

management of contributing medical conditions

Additional 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.[34] Any signs or symptoms of upper airway obstruction should be evaluated and referred to the ear, nose, and throat department or a sleep-disordered breathing specialist.

Consider – detrusor-relaxing drugs

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ACUTE
|
age ≥7 years
Consider – 

detrusor-relaxing drugs

Additional treatment recommended for SOME patients in selected patient group

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.[43]

Primary options

oxybutynin: 5 mg orally (immediate-release) twice daily

OR

tolterodine: 1 mg orally (immediate-release) twice daily

4th line – combination therapy: alarm + desmopressin

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ACUTE
|
age ≥7 years
4th line – 

combination therapy: alarm + desmopressin

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.

Primary options

desmopressin: 0.2 to 0.4 mg orally once daily at bedtime, dose may be increased up to 0.6 mg/day

Plus – education, lifestyle changes, and behavioural measures

Back
ACUTE
|
age ≥7 years
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.[32] Bladder training as an initial measure for all enuretic children has yet to be studied rigorously and its wide use is still considered investigational.[33]

Consider – management of contributing medical conditions

Back
ACUTE
|
age ≥7 years
Consider – 

management of contributing medical conditions

Additional 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.[34] Any signs or symptoms of upper airway obstruction should be evaluated and referred to the ear, nose, and throat department or a sleep-disordered breathing specialist.

Consider – detrusor-relaxing drugs

Back
ACUTE
|
age ≥7 years
Consider – 

detrusor-relaxing drugs

Additional treatment recommended for SOME patients in selected patient group

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.[43]

Primary options

oxybutynin: 5 mg orally (immediate-release) twice daily

OR

tolterodine: 1 mg orally (immediate-release) twice daily

5th line – imipramine

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ACUTE
|
age ≥7 years
5th line – 

imipramine

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 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 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.[44][45][46]

Primary options

imipramine: children >6 years of age: 1 to 2.5 mg/kg orally once daily at bedtime

Plus – education, lifestyle changes, and behavioural measures

Back
ACUTE
|
age ≥7 years
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.[32] Bladder training as an initial measure for all enuretic children has yet to be studied rigorously and its wide use is still considered investigational.[33]

Consider – management of contributing medical conditions

Back
ACUTE
|
age ≥7 years
Consider – 

management of contributing medical conditions

Additional 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.[34] Any signs or symptoms of upper airway obstruction should be evaluated and referred to the ear, nose, and throat department or a sleep-disordered breathing specialist.

6th line – fluoxetine

Back
ACUTE
|
age ≥7 years
6th line – 

fluoxetine

One randomised placebo-controlled trial studied the short-term efficacy of a small dose of fluoxetine to treat children aged 8 to 18 years with no other urinary symptoms, constipation, or neuropsychiatric diagnosis.[47]​

It found that the group treated with fluoxetine had fewer wet nights when compared with the placebo group at the 4-, 8-, and 12-week marks of treatment. However, efficacy decreased after the 4-week mark and the study was limited to 12 weeks.

This intriguing data supports the use of fluoxetine in the treatment of primary monosymptomatic nocturnal enuresis. Further studies may be needed to investigate long-term effects of fluoxetine, if increasing the fluoxetine dosage changes outcome, and if fluoxetine would be beneficial in patients with a neuropsychiatric diagnosis. It would also be worthwhile to see a multi-varied analysis that investigates if there is a change in stooling patterns in patients on fluoxetine as it does have a side effect of diarrhoea.

Fluoxetine comes with a warning of suicidality in children, which needs to be considered when trialling with this medication.

Primary options

fluoxetine: consult specialist for guidance for dose

Plus – education, lifestyle changes, and behavioural measures

Back
ACUTE
|
age ≥7 years
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.[32] Bladder training as an initial measure for all enuretic children has yet to be studied rigorously and its wide use is still considered investigational.[33]

Consider – management of contributing medical conditions

Back
ACUTE
|
age ≥7 years
Consider – 

management of contributing medical conditions

Additional 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.[34] Any signs or symptoms of upper airway obstruction should be evaluated and referred to the ear, nose, and throat department or a sleep-disordered breathing specialist.

ONGOING

recurrence

1st line – reinstate treatment

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ONGOING
|
recurrence
1st line – 

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.

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Choose a patient group to see our recommendations

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

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