Enuresis

Enuresis

Definitions

• Monosymptomatic: Nocturnal bedwetting only, without daytime lower urinary tract symptoms

• Non-monosymptomatic: Enuresis accompanied by daytime incontinence, urgency, or other bladder symptoms

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Differentials

• Constipation: Rectal distension impacting bladder emptying

• Urinary tract infection: Dysuria, frequency, fever

• Obstructive sleep apnoea: Snoring, daytime somnolence, poor growth

• Overactive bladder: Urgency, frequent small-volume voids

• Diabetes mellitus: Polyuria, polydipsia, weight loss

• Psychological stressors or abuse: Family dysfunction, trauma history

• Attention deficit hyperactivity disorder: Impulsivity, inattentiveness

• Spinal dysraphism: Neurological bladder, abnormal gait, possible cutaneous spine markers

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History

• Onset of bedwetting: Whether acute, gradual, or occurring after a dry period of more than 6 months

• Daytime symptoms: Urgency, frequency, incontinence

• Family history: High prevalence of enuresis in families

• Constipation: Signs such as straining, infrequent stools

• Systemic issues: Polyuria (diabetes), snoring (OSA), dysuria or fever (UTI)

• Psychosocial factors: Stress, NAI risk, recent changes in family dynamics

• Dietary factors: High evening fluid intake, caffeine consumption

• ADHD symptoms: Hyperactivity, inattention impacting toileting routines

• Previous interventions: Use of alarms, medications, or behavioural strategies

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Examination

• Growth parameters: Poor growth may suggest OSA or chronic illness

• Tonsillar hypertrophy: Potential indication of OSA

• Abdominal exam: Identify faecal mass or palpable bladder distension

• Genital exam: Rule out anatomical abnormalities or signs of abuse

• Spine inspection: Look for dimples or hair patches indicating spinal dysraphism

• Neurological screening: Assess lower limb reflexes, tone, and gait for neurogenic bladder clues

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Management

• Non-Pharmacological

  • Regular toileting and timed voids throughout the day

  • Limit evening fluids and caffeine

  • Address constipation early with adequate dietary fibre and hydration

  • Encourage positive reinforcement rather than punishment

  • Bedwetting alarms for children over 6 years, used consistently for at least 6–8 weeks

  • Consider urotherapy techniques such as bladder training and scheduled voiding

• Pharmacological

  • Desmopressin (for children 7 years and older), starting at 200 micrograms at bedtime and increasing to 400 micrograms if needed

  • Ensure daytime bladder dysfunction is managed before focusing on nocturnal enuresis

  • Combine medication with behavioural strategies in refractory cases

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Notes

• Red flags: Poor growth, abnormal neurological signs, or signs of abuse requiring prompt referral

• Obtain urine dipstick if diagnosis is uncertain to rule out glycosuria or proteinuria

• Parental involvement and consistent follow-up improve long-term success rates

• Many children outgrow enuresis spontaneously, but support and appropriate interventions can expedite dryness and reduce psychosocial impact