Skip to Content
A home for paediatricians. A voice for children and youth.

Position statement

CPS

Evaluation and management of enuresis in the general paediatric setting

Posted: Aug 16, 2023

The Canadian Paediatric Society gives permission to print single copies of this document from our website. For permission to reprint or reproduce multiple copies, please see our copyright policy.

Principal author(s)

James Harris MD, Alisa Lipson MD, Joana Dos Santos MD, Community Paediatrics Committee

Paediatr Child Health 28(6):362-368.

Abstract

Assessing enuresis involves distinguishing monosymptomatic from non-monosymptomatic for this common paediatric problem, and identifying concomitant comorbidities. Addressing co-occurring factors concurrently ensures the best opportunity for a satisfactory outcome. Treatment begins with patient and family education on the natural history of enuresis and practical behavioural guidance. Evidence to support particular interventions is limited, and children and families should be involved when choosing appropriate therapy. Enuresis alarms and desmopressin are treatment options when more active intervention is desired. Clinical refinements and combined treatment modalities are emerging.

Keywords: Desmopressin; Enuresis alarms; Monosymptomatic enuresis (MSE); Non-monosymptomatic enuresis (NMSE); Primary enuresis; Secondary enuresis.

Background and definitions

Enuresis, or bedwetting, is defined as discrete episodes of urinary incontinence during sleep in children aged 5 and older, and is commonly encountered in paediatric practice. For related definitions, see Table 1. Enuresis represents delayed maturation in a normal developmental process that is typically achieved by age 5[1]-[4]). Specific contributing mechanisms include sleep arousal difficulties, with associated nocturnal polyuria, and relatively small bladder capacity[5]-[9]. The prevalence is 15% at age 5 years, 10% by age 7, and 5% by age 10[4]. Untreated enuresis has an estimated prevalence into adulthood of up to 2%. Family studies support strong genetic links[7][8][10][11]. Enuresis can have significant negative impacts on child health and family life[12]-[15].

This revised position statement is based on a literature review of PubMed, the Cochrane database, Ovid, and Google Scholar, with focus on articles published since 2010. Leading clinical practice guidelines were identified from the International Children’s Continence Society (ICCS)[1][3]-[5], the European consensus guideline[10], the UK’s NICE guideline[6], and the American Academy of Pediatrics guideline[8]. Meta-analyses and recent clinical trials were also integrated.

TABLE 1. Enuresis-related definitions

Incontinence

Involuntary wetting at an inappropriate time and place in a child ≥5 years old. Incontinence includes both enuresis and daytime incontinence. In this statement, the term ‘incontinence’ applies to intermittent (not continuous) incontinence.

 

Lower urinary tract symptoms (LUTS)

A heterogeneous group of voiding symptoms, including:

  • Increased (≥8 times/day)or decreased (≤3 times/day) voiding frequency
  • Voiding postponement, holding manoeuvres
  • Daytime incontinence
  • Urgency or dysuria (without urinary tract infection)
  • Interrupted flow
  • Sensation of incomplete emptying
Monosymptomatic enuresis (MSE) Enuresis without daytime LUTS

Non-monosymptomatic enuresis (NMSE)

Enuresis and any one indicator of LUTS

Primary enuresis

 Indicates a child who has never attained night-time bladder control

Secondary enuresis

Indicates a child who has experienced a dry period of >6 months before enuresis. Often associated with a psychological or physical comorbidity

Expected bladder capacity (EBC) (mL)

 

Volume formula: 30 + (age (years) × 30) up to age 12. Adult EBC is approximately 400 mL

 <65% of EBC is consistent with small bladder capacity

 >130% of EBC overnight is consistent with nocturnal polyuria

Based on references 1,3

Evaluating and diagnosing enuresis

1. Distinguish monosymptomatic from non-monosymptomatic enuresis, and ‘primary’ from ‘secondary’ enuresis

Distinguishing monosymptomatic from non-monosymptomatic enuresis requires active screening. Mild daytime lower urinary tract symptoms (LUTS) are common, affecting up to two-thirds of enuretic children. When present (i.e., in non-monosymptomatic enuresis), LUTS should be addressed first. Improvement in LUTS can improve enuresis secondarily. Conversely, enuresis treatment is less likely to succeed in the presence of unrecognized and untreated LUTS. Using a validated Canadian questionnaire can make screening more efficient[16].

Some LUTS, including urgency, frequency (≥8 times/day) and incontinence, suggest an overactive bladder, typically a functional condition[1]. Other LUTS, including dysuria (without urinary tract infection (UTI)), interrupted micturition, hesitation, holding manoeuvres, urinary infrequency (≤3 times/day), and the sensation of incomplete emptying, suggest dysfunctional voiding (the inability to relax pelvic floor muscles during micturition) or a lower urinary tract obstruction. When LUTS are severe, numerous, or atypical, urology consultation is appropriate[1][3][17].

To distinguish primary from secondary enuresis, inquire whether bedwetting has followed a ‘dry’ period of at least 6 months. Children with secondary enuresis should be screened for common organic comorbidities, less common medical conditions, and psychosocial stressors. When no clear precipitant is found, treatment recommendations for primary enuresis can be followed[1][10].

2. Identify common comorbidities

Constipation: Unrecognized constipation can cause both LUTS and enuresis and, if untreated, is associated with enuresis treatment failure. Constipation is often missed in school-aged children because parents are less aware of abnormal or infrequent bowel movements than in younger children. One recent study found that 82% of primary, simple enuretic children had constipation[18]. Treating constipation alone resolved enuresis in more than half the children affected[19], confirming the interplay between bladder and bowel function. Constipation management can be framed as “bladder-friendly bowel health”[20][21]. Family-friendly information on healthy bowel habits can found at the CPS Caring for Kids website.

Developmental and psychiatric conditions: Children with delayed development may not have the maturation to remain dry at night. If enuresis symptoms are distressing for the child experiencing them and the family desires active therapy, treatment can be offered and tailored for the child’s developmental age and stage. If a child has unrecognized and untreated attention-deficit hyperactivity disorder (ADHD), enuresis treatment is less likely to be successful[6].

Upper airway obstruction: Numerous studies have underlined the connections between obstructive sleep apnea (OSA) and enuresis, possibly related to sleep arousal. Treatment for OSA can help resolve enuresis[18].

3. Consider less common medical conditions and psychosocial stressors

Serious medical conditions do not usually present as primary or secondary enuresis. Rarely, however, incontinence during sleep can be a sign of diabetes mellitus or diabetes insipidus, renal disease, hyperthyroidism, spinal dysraphism, infections, seizure disorders, and cardiac arrhythmias[22]. Child maltreatment, trauma, and psychosocial stressors, including bullying, may also precipitate enuresis and should be considered.

4. Confirm enuresis details

Frequency, severity, and impact of enuresis are key elements of the history. Children with monosymptomatic enuresis often have one large void early in the night. Children with subtle LUTS from overactive bladder may have a pattern of smaller, frequent voids through the night. Large quantities voided through the night suggest nocturnal polyuria, which has treatment implications. Enuresis that occurs every night is less likely to resolve spontaneously or respond to treatment than intermittent enuresis[6].

5. Ask about fluid intake

Inquire about the quantity and timing of fluid intake. Some children drink little during the day and have most of their liquids after school, which may contribute to nocturnal polyuria[23].

6. Perform a complete physical examination

Include growth parameters and examine for enlarged tonsils and signs of motor or sensory abnormality by inspecting the child’s lumbosacral spine, lower limbs, and gait. Abdominal examination may suggest constipation. Genital examination and rectal palpation are optional and should be guided by patient comfort and history. Inspecting underwear may reveal urine or fecal incontinence. In most cases, the physical exam is normal.

7. Consider lab investigations, a voiding diary, and urine measurement

Investigations are seldom necessary and should be limited to a urinalysis. Urinalysis is not needed when the clinician is confident diagnosing monosymptomatic primary enuresis[6]. Other studies (e.g., ultrasound) are rarely indicated[1][5][10].

A daily written voiding diary (see reference 10) or voiding diary app can be a useful tool for eliciting or clarifying symptoms (e.g., daytime LUTS) and monitoring response to treatment.

Urine volume measurements can help inform treatment choices when assessing for:

  • Small bladder capacity. To measure maximum voided volume in 24 to 48 h (i.e., the largest volume in one void per day), the child voids into a measured container as many times as they wish throughout the day. The container is emptied after each measure. Compare the maximum voided volume with the child’s expected bladder capacity (EBC) as per the formula in Table 1. Maximum voided volume <65% of EBC suggests small bladder capacity.
  • Nocturnal polyuria. Measure night-time volumes using diaper weight or by combining urine volumes collected through the night and during the first morning void. An amount >130% of EBC indicates nocturnal polyuria.

Management

In primary monosymptomatic enuresis, the mainstay of management is education and reassurance that no treatment is necessary. Explain the natural history of enuresis, including the fact that virtually all children and adolescents will outgrow their bedwetting with time. Try to mitigate feelings of stigma or guilt. Emphasize that monosymptomatic enuresis is common, unintentional, and cannot be controlled either by positive incentives to ‘stay dry’ or negative consequences for bedwetting. Children who are not bothered by enuresis and whose self-esteem is intact, and families who are comfortable waiting for bedwetting to stop naturally, should be reassured that waiting is the recommended course of action. For children who are bothered by enuresis, and whose self-esteem is affected, and for families who are distressed by their child’s bedwetting, education and reassurance is still the appropriate initial management. Many children and families, with appropriate counselling, can be reassured.

Behavioural and motivational counselling

For children and families experiencing ongoing distress after education and reassurance, behavioural and motivational counselling may help children and adolescents awaiting natural resolution[5][6][23][24].

Behavioural strategies include:

Optimal voiding practices

  • Void first thing in the morning and immediately before bed.
  • Frequent voiding (aim for every 2 to 3 h, or 5 to 7 times/day). Wearing a vibrating watch or timer may help decrease daytime LUTS[25][26].
  • Optimal posture for girls is to sit upright in the middle of the toilet with feet touching the ground or on a footstool[5].

Fluid intake

  • Drink liquids in the mornings and afternoons, and drink less after dinner. Some studies recommend 80% of total daily fluid intake before 4:00 pm.
  • Avoid caffeinated drinks[5].

Diet and nutrition

  • Address constipation. Active dietary management, including medication and nutritionist referral, may be needed, with one soft bowel movement per day being the goal[21].

Positive reinforcement

  • Plan ‘rewards’ for agreed-upon behaviours within the child’s control, such as voiding before bedtime, liberal fluid intake during the day, and helping to clean wet sheets and garments. “Dry nights”, which are outside of a child’s control, should not be incentivized[6].

Clinicians should help parents understand that when behavioural strategies do not work, it is neither their nor the child’s fault[24], and that punishment is counterproductive. 

Active therapies   

For children and families with persistent distress despite education and reassurance, shared decision-making with patients and families should inform the use of active therapies[5][6][8][10]. A transparent discussion of the risks, benefits, and likelihood of success associated with each active therapy is necessary, and spontaneous resolution should continue to be emphasized.

Many children who find enuresis stressful, unpleasant, and a source of unhappiness respond positively to treatment[13], so long as treatment is implemented without blame or judgement. As with all conditions, active treatment for enuresis should be addressed with seriousness, compassion and flexibility[12]-[14][18].  Recognizing that older adolescents often experience more psychological distress associated with their enuresis as compared to younger children and youth, health care providers should approach these patients and families with seriousness and sensitivity.  In addition to education and reassurance for these older adolescents, an earlier discussion of active therapies may be helpful.

 Importantly, for all children and youth, LUTS and identifiable comorbidities such as constipation need to be addressed before active intervention[5].

Alarm therapy

Used since the 1930s, the enuresis alarm wakes a sleeping child  with a moisture sensor at the initial stage of voiding. Nightly use trains a child to associate the alarm with a full bladder and, eventually, the child may wake before voiding. Along with improved arousal, the alarm may also inhibit the micturition reflex, improve reservoir function, and even improve nocturnal polyuria in some children[20].

Alarm studies have demonstrated varying success rates (success being defined as 14 consecutive dry nights), typically with an initial response of 60% to 80%, although up to one-half of children may relapse when alarm use is discontinued[27]-[30]. Both international guidelines and clinical studies support re-treatment using alarm therapy following relapse[5], and evidence indicates that alarm therapy can work as a permanent cure in up to 50% of cases[18][27][31]-[35], compared with a 15% spontaneous remission rate per year[36][37].

Nightly enuresis is more resistant to alarm therapy, while infrequent enuresis (less than once per week) does not allow sufficient opportunity for appropriate training. At least two episodes per week should be baseline for alarm use to be effective[5][24]. Alarm therapy may be more effective in children with a normal or small bladder capacity than in those with nocturnal polyuria[38]. Newer alarms are available in both wearable and wireless options, and may offer additional features and enhanced comfort compared with older models.

Treatment response can take time. Early signs of success include waking to the alarm without parental assistance, smaller volume enuretic voids, being able to urinate in the toilet after waking instead of emptying the bladder during sleep, and fewer enuresis episodes per night[23]. At the end of treatment, after consecutive dry nights and when the alarm is discontinued, higher evening fluid intake might help improve bladder conditioning[29][39][40].

However, caution is needed before considering such ‘overlearning’ as a therapeutic approach. In the presence of underlying overactive bladder or nocturnal polyuria, high fluid intake may cause increased urinary frequency and worsen bedwetting.   

The most common cause of failure is the child’s inability to wake up to the alarm. Set expectations accordingly. Initially, parents will need to supervise alarm use: first to ensure it is attached correctly, then to wake the child when the alarm sounds (if the child does not wake themselves), and help them to the toilet and back to bed. Involvement can disrupt family sleep patterns and should be discussed with parents before initiating therapy. Even children younger than 8 years can share responsibility by placing the alarm on themselves, getting out of bed to void what is left in the bladder after waking to an alarm, changing from wet sleepwear into dry, and resetting the alarm when returning to bed. Some experts suggest that children quietly ‘rehearse’ the sequence of steps they will go through if the alarm sounds in the night[55] before getting into bed. Other causes of alarm failure include non-compliance, technical difficulties (incorrect use or continuous use of diapers while using the alarm), or not giving alarm therapy sufficient time to work. 

Alarm therapy is not appropriate for all patients and families, and dropout rates in clinical trials are approximately 30%[18][27]. Many families find alarm use too demanding of time and energy, and too disruptive to sleep routines. Physician encouragement can strengthen commitment to a full trial, especially when early improvement has not occurred. However, if a family decides to forgo a full trial of alarm therapy, their decision should be supported.

Clinical follow-up should occur after the first 2 weeks of alarm therapy to provide support and identify early signs of success. Additional follow-up should depend on child and family needs. The usual treatment course is 12 to 16 weeks, though some children require longer[23]. Treatment should continue until the child has at least 14 consecutive days of dryness, and should be discontinued if there is no noticeable improvement after 6 weeks. Recent evidence suggests that relapse rates may be improved if the standard of 14 consecutive dry nights is extended[30].

Desmopressin

Desmopressin is a synthetic vasopressin analog that has been used for enuresis since the 1970s. Intermittent use of desmopressin is recommended when families do not wish to use an alarm but do wish to help children control enuresis periodically or for special occasions (i.e., sleepovers, summer camp). Daily desmopressin use, with the aim of completely controlling enuresis, may be considered for select cases, but only after discussing potential benefits and limitations with the child and family.

Desmopressin works by decreasing both urine volume and intravesical pressure at night. Desmopressin is effective for treating enuresis with a range of underlying mechanisms and may be especially useful for nocturnal polyuria with normal (rather than low) daytime bladder capacity (based on history, voiding diary use, and urine measurement)[42]. Daily use results in a full response in 30% of children, with another 40% experiencing a partial response[5][18][42]-[44]. The relapse rate when medication is discontinued is up to 70%[18][42].

Desmopressin is available in Canada in dissolvable (melt) and tablet forms. An intranasal form (upon which most Cochrane studies are based) has been discontinued in Canada due to unpredictable absorption and reports of rare but serious side effects. The melt has superior bioavailability and efficacy over the tablet, with an additional advantage of not requiring water to administer[45], but cost can be prohibitive. The tablet is available in generic form.

When desmopressin is used intermittently, the lowest effective dose should be used. The usual melt dose is 120 mcg administered 30 to 60 minutes before sleep. The anti-enuretic effect has been observed soon after medication initiation[7] but, if dryness is not achieved, the dose can be doubled to 240 mcg. The maximum dose for desmopressin is 360 mcg. A 60 mcg dose is available and may suffice for some children. Caution is advised when prescribing because the melt is dispensed on an mcg basis, whereas the tablet is dispensed on an mg basis. Equivalent dosing is as follows: Melt 60 mcg = tablet 0.1 mg; Melt 120 mcg = tablet 0.2 mg. 

Side effects from desmopressin are uncommon[27]. However, the risks associated with water intoxication should be disclosed to all families contemplating this therapy. Water intoxication can be prevented by strictly restricting liquid intake to one sip with teeth-brushing, then limiting fluids to no more than 200 mL for at least 8 h (i.e., from 1 h before receiving medication until the next morning). No medication should be used on nights when a child’s evening sports activities necessitate rehydration after dinner, or when the child has an illness affecting fluid balance[23].

Guidelines for continuous use of desmopressin suggest treatment for 3 months at a time, then reassessment with a medication break to determine resolution of enuresis symptoms[5]-[7]. Recent strategies involving a structured withdrawal show promise in improving permanent cure rates[46][47], with a recommended half-dose given for 2 weeks before discontinuation. If enuresis returns, the effective dose can be used again for 3 months, when reducing titration can be repeated. It is important to monitor serum electrolytes in a child taking continuous desmopressin (especially serum osmolality and sodium) approximately every 3 months.

Evidence is emerging for the benefits of combining treatments for enuresis. Trials that have combined alarm use and desmopressin have reported some favourable results, especially for children with nocturnal polyuria who do not respond to alarm therapy alone[27][42][45][47].

Anticholinergics

Anticholinergic (antispasmodic) medications target bladder overactivity but have been shown to be ineffective when used as monotherapy for enuresis and have more side effects than desmopressin[48][49]. These medications should only be used in rare cases and require the supervision of an expert (a paediatric urologist and/or nephrologist) familiar with the risks and adverse events associated with anticholinergics. There may be a role for combination treatment in children with LUTS or an enuresis pattern characteristic of small bladder capacity or overactive bladder (small, frequent night-time voids), who have not responded to other therapies. Before starting an anticholinergic, use ultrasound or uroflowmetry to ensure that the child is emptying the bladder with zero or insignificant post-void residual volumes. Oxybutynin is the most common anticholinergic prescribed in Canada, although tolterodine or solifenacin may be associated with fewer side effects[49]-[51].

Tricyclics

Historically, tricyclic antidepressants were used to treat children with enuresis, but due to demonstrated serious cardiovascular and neurological adverse effects, they should only be used in exceptional cases and under the close supervision of a clinician expert in the use of these drugs[52][53].

Other treatments

Children who do not respond to education and reassurance, behavioural modifications, the bedwetting alarm, and/or desmopressin, and who are experiencing significant psychological distress should be referred to an expert in enuresis for consideration of further investigations and treatments. Families should be advised that the evidence base supporting these therapeutic options is limited, and research to determine their effectiveness is ongoing.

Mirabegron

Mirabegron is a selective agonist of the beta-3 adrenergic receptor present in the bladder wall. Mirabegron is used to treat overactive bladder (OAB) and acts by relaxing the detrusor muscle, similar to anticholinergic medications. Mirabegron does not cause constipation or other common anticholinergic-associated side effects and may be useful for children with NMSE and OAB who also have constipation or who experience negative side effects from anticholinergic medications[9][54]-[56]. Rare cases of hypertension have been reported[55][56]. If treatment with Mirabegron is considered, a referral to a paediatric urologist is recommended. Monitoring of blood pressure and post-void residual volumes is recommended before starting therapy and during follow-up.

Neuromodulation

In very rare circumstances, and only in cases of extreme psychological distress, neuromodulation can be considered for older children and adolescents with refractory primary MSE. Transcutaneous electrical neurostimulation (TENS) provides electrical stimulation to the sacral nerves responsible for bladder control. Early evidence suggests that this therapy can be safe and efficacious for treating refractory enuresis in children[57]-[59]. TENS is a non-invasive procedure that provides electrical stimulation to the lower back through leads connected to adhesive pads attached to the skin at the level of S2 to S4. Families can buy or rent the TENS machine from a physiotherapy clinic, and treatment is typically recommended for 8 to 12 weeks.  Other neurostimulation modalities are under study, and may be considered by specialists in refractory NMSE cases.   

Recommendations for clinicians

1. Education and reassurance are the mainstays of management for monosymptomatic or ‘simple’ enuresis (MSE). Talking with families about enuresis can help demystify the problem and alleviate guilt or stigma for children and parents. Emphasize that:

  • Enuresis is common and represents a delay in the process of normal night-time continence development.
  • Enuresis is unintentional and cannot be improved through ‘consequences’ for bedwetting.
  • Motivational strategies focused on behaviours within a child’s control can often improve enuresis, especially over time and with the involvement and support of a trusted clinician.

2. Conduct a history and physical exam to determine that enuresis is the correct diagnosis, to distinguish monosymptomatic from non-monosymptomatic enuresis, and to rule out common comorbidities, especially constipation, developmental and psychiatric conditions, and upper airway obstruction.

3. Lower urinary tract symptoms (LUTS) may not be evident unless clinicians specifically ask about them. When LUTS are present, they should be addressed first or concurrently with treatment for enuresis. Referral to urology is appropriate when symptoms are severe, numerous, or atypical.

4. Work with patients and families to determine whether treatment is necessary or desired. Consider the impact of enuresis on the child’s self-esteem, and family factors such as motivation, support, and available resources. Children who are not bothered by enuresis and whose self-esteem is intact, and families who are comfortable waiting for bedwetting to stop naturally, should be reassured that waiting is the recommended course of action.

5. Patients experiencing distress related to their enuresis may respond well to active treatment, such as an enuresis alarm and/or the intermittent use of desmopressin. If these two active therapies fail, and when further treatment is desired, refer to an expert in enuresis to consider further investigations and other active treatment options. 

Acknowledgements

The authors especially wish to thank Penny Miller, PhD, and Drs. Afshar Kourosh and Lane Robson for their contributions to this statement. Thanks also to Drs. Niraj Mistry and Michael Winters (Children’s and Women’s Health Centre, B.C.), for their expert review. The statement was also reviewed by the Mental Health and Developmental Disabilities Committee and the Drug Therapy and Hazardous Substances Committee of the Canadian Paediatric Society.

CANADIAN PAEDIATRIC SOCIETY COMMUNITY PAEDIATRICS COMMITTEE (October 2022)

Members: Peter Wong MD (Chair), Marianne McKenna MD (Board representative), Michael Hill MD, Audrey Lafontaine MD, Meta van den Heuvel MD, Alisa Lipson MD (2015-2021)

Liaison (s): Karen Cozens MD (Community Paediatrics Section)

Authors: James Harris MD, Alisa Lipson MD, Joana Dos Santos MD

References

  1. Austin PF, Bauer SB, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children’s Continence Society. Neurourol Urodyn 2016;35(4):471–81.
  2. Wolfish NM. Enuresis: A maturational lag. Paediatr Child Health 2002;7(8):521–3.
  3. Austin PF, Bauer SB, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: Update Report from the standardization committee of the International Children’s Continence Society. J Urol 2014;191(6):1863-65.e13.
  4. Nevéus T, Fonseca E, Franco I, Kawauchi A, et al. Management and treatment of nocturnal enuresis—An updated standardization document from the International Children’s Continence Society. J Pediatr Urol 2020;16(1):10-9.
  5. 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(2):441-7.
  6. Nunes VD, O’Flynn N, Evans J, Sawyer L; Guideline Development Group. Management of bedwetting in children and young people: Summary of NICE guidance. BMJ 2010;341:c5399.
  7. Bayne AP, Skoog SJ. Nocturnal enuresis: An approach to assessment and treatment. Pediatr Rev 2014;35(8):327–34;quiz 335.
  8. Graham KM, Levy JB. Enuresis. Pediatr Rev 2009;30(5):165-72;quiz173.
  9. Nevéus T. Pathogenesis of enuresis: Towards a new understanding. Int J Urol 2017;24(3):174-82.
  10. Vande Walle J, Rittig S, Bauer S, et al. Practical consensus guidelines for the management of enuresis. Eur J Pediatr 2012;171(6):971-83.
  11. Jørgensen CS, Horsdal HT, Rajagopal VM, et al. Identification of genetic loci associated with nocturnal enuresis: A genome-wide association study. Lancet Child Adolesc Health 2021;5(3):201-9.
  12. Van Tijen NM, Messer AP, Namdar Z. Perceived stress of nocturnal enuresis in childhood. Br J Urol 1998;81(Suppl 3):98–99.
  13. Butler R, Heron J. An exploration of children’s views of bed-wetting at 9 years. Child Care Health Dev 2008;34(1):65–70.
  14. Longstaffe S, Moffatt ME, Whalen JC. Behavioral and self-concept changes after six months of enuresis treatment: A randomized, controlled trial. Pediatrics 2000;105(4 Pt 2):935–40.
  15. Butler RJ. Impact of nocturnal enuresis on children and young people. Scand J Urol Nephrol 2001;35(3):169–76.
  16. Afshar K, Mirbagheri A, Scott H, MacNeily AE. Development of a symptom score for dysfunctional elimination syndrome. J Urol 2009;182(4 Suppl):1939–43.
  17. Wang R, Kanani R, Mistry N, Rickard M, Dos Santos J. Practical tips for paediatricians: Assessment and management of bladder and bowel dysfunction in the office. Paediatr Child Health 2020;25(3):136-8.
  18. Fagundes SN, Surri Lebl A, Azevedo Soster L, et al. Monosymptomatic nocturnal enuresis in pediatric patients: Multidisciplinary assessment and effects of therapeutic intervention. Pediatr Nephrol 2017;32(5):843–51.
  19. Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics 1997;100(2 Pt 1):228–32.
  20. Robson L. How to Cure Bedwetting. Victoria, B.C: Friesen Press, 2016.
  21. Rowan-Legg A; Canadian Paediatric Society, Community Paediatrics Committee. Managing functional constipation in children. Pediatr Child Health 2011;16(10):661-70: www.cps.ca/documents/position/functional-constipation.
  22. Chorin E, Chorin O, Mann T, et al. Bedwetting from the heart: Time for a paradigm shift in the minimal diagnostic evaluation of enuresis. Heart Rhythm 2022;19(5):862-65.
  23. Lane W, Robson M. Evaluation and management of enuresis. N Engl J Med 2009;360(14):1429–36.
  24. Caldwell PHY, Nankivell G, Sureshkumar P. Simple behavioural interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2013;7:CD003637.
  25. Caldwell PH, Kerr M, Hamilton S, Teixeira-Pinto A, Craig JC. An alarm watch for daytime urinary incontinence: A randomized controlled trial. Pediatrics 2022;149(1):e2021053863.
  26. Hagstroem S, Rittig S, Kamperis K, Djurhuus JC. Timer watch assisted urotherapy in children: A randomized controlled trial. J Urol 2010;184(4):1482-8.
  27. Caldwell PH, Codarini M, Stewart F, Hahn D, Sureshkumar P. Alarm interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2020;5(5):CD002911.
  28. Arda E, Cakiroglu B, Thomas DT. Primary nocturnal enuresis: A review. Nephrourol Mon 2016;8(4):e35809.
  29. Caldwell PH. Tips for managing treatment-resistant enuresis. J Paediatr Child Health 2018;54(10):1060–4.
  30. Kosilov KV, Geltser BI, Loparev SA, et al. The optimal duration of alarm therapy use in children with primary monosymptomatic nocturnal enuresis. J Pediatr Urol 2018;14(5):447.e1-447.e6.
  31. Önol FF, Guzel R, Tahra A, Kaya C, Boylu U. Comparison of long-term efficacy of desmopressin lyophilisate and enuretic alarm for monosymptomatic enuresis and assessment of predictive factors for success: A randomized prospective trial. J Urol 2015;193(2):655–61.
  32. Hyuga T, Nakamura S, Kawai S, Nakai H. Evaluation of the effectiveness of a short-term treatment and repeat treatment of nocturnal enuresis using an enuresis alarm. Urology 2017;105:153–6.
  33. Glazener CMA, Evans JHC. Simple behavioural and physical interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2004;(2)CD003637.
  34. Kroll P, Zachwieja J. A system for the treatment of nocturnal enuresis in children. Minerva Urol Nefrol 2017;69(3):293–9.
  35. Apos E, Schuster S, Reece J, et al. Enuresis management in children: Retrospective clinical audit of 2861 cases treated with practitioner-assisted bell-and-pad alarm. J Pediatr 2018;193:211–6.
  36. Forsythe WI, Redmond A. Enuresis and spontaneous cure rate. Study of 1129 enuretics. Arch Dis Child 1974;49(4):259–63.
  37. Monda JM, Husmann DA. Primary nocturnal enuresis: A comparison among observation, imipramine, desmopressin acetate and bed-wetting alarm systems. J Urol 1995;154(2 Pt 2):745–8.
  38. Van Heezle C, Evans J, Eggert P, Lottmann H, Norgaard JP, Vande Walle J. Predictive parameters of response to desmopressin in primary nocturnal enuresis. J Pediatr Urol 2015;11(4):200.e1-8.
  39. Robertson B, Yap K, Schuster S. Effectiveness of an alarm intervention with overlearning for primary nocturnal enuresis. J Pediatr Urol 2014;10(2):241-5.
  40. Kosilov KV, Loparev SA, Ivanovskaya M, Kosilova LV. Night diuresis stimulation increases efficiency of alarm intervention. J Pediatr Urol 2015;11(5):261.e1-5.
  41. Huang T, Shu X, Huang YS, Cheuk DKI. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2011;(12):CD005230.
  42. Glazener CM, Evans JH. Desmopressin for nocturnal enuresis in children. Cochrane Database Syst Rev 2002;(3):CD002112.
  43. Sinha R, Raut S. Management of nocturnal enuresis—Myths and facts. World J Nephrol 2016;5(6):328-38.
  44. Sharifiaghdas F, Sharifiaghdas S, Taheri M. Primary monosymptomatic nocturnal enuresis: Monotherapy vs combination therapy. Urology 2016;93:170–4.
  45. HealthLink B.C. Desmopresin 0.1 Mg/MI Spray – Nasal. July 2018. https://www.healthlinkbc.ca/medications/desmopressin-01-mgml-spray-nasal (Accessed May 18, 2022).
  46. Kamperis K, Van Herzeele C, Rittig S, Vande Walle J. Optimizing response to desmopressin in patients with monosymptomatic nocturnal enuresis. Pediatr Nephrol 2017;32(2):217-26.
  47. Chua ME, Silangcruz JM, Chang SJ, et al. Desmopressin withdrawal strategy for pediatric enuresis: A meta-analysis. Pediatrics 2016;138(1):e20160495.
  48. Vogt M, Lehnert T, Till H, Rolle U. Evaluation of different modes of combined therapy in children with monosymptomatic nocturnal enuresis. BJU Int 2010;105(10):1456–9.
  49. Montaldo P, Tafuro L, Rea M, Narciso V, Iossa AC, Del Gado R. Desmopressin and oxybutynin in monosymptomatic nocturnal enuresis: A randomized, double-blind, placebo-controlled trial and an assessment of predictive factors. BJU Int 2012;110(8 Pt B):E381-6.
  50. Yucel S, Akkaya E, Guntekin E, et al. Should we switch over to tolterodine in every child with non-neurogenic daytime urinary incontinence in whom oxybutynin failed? Urology 2005;65(2):369–73.
  51. Ghanavati PM, Khazaeli D, Amjadzadeh M. A comparison of the efficacy and tolerability of treating primary nocturnal enuresis with Solifenacin Plus Desmopressin, Tolterodine Plus Desmopressin, and Desmopressin alone: A randomized controlled clinical trial. Int Braz J Urol 2021;47(1):73-81.
  52. James LP, Kearns GL. Cyclic antidepressant toxicity in children and adolescents. J Clin Pharmacol 1995;35(4):343-50.
  53. Caldwell PHY, Sureshkumar P, Wong WCF. Tricyclic and related drugs for nocturnal enuresis in children. Cochrane Database Syst Rev 2016;(1):CD002117.
  54. Hsu FC, Weeks CE, Selph SS, Blazina I, Holmes RS, McDonagh MS. Updating the evidence on drugs to treat overactive bladder: A systematic review. Int Urogynecol J 2019;30(10):1603-17.
  55. Allison SJ, Gibson W. Mirabegron, alone and in combination, in the treatment of overactive bladder: Real-world evidence and experience. Ther Adv Urol 2018;10(12):411-9.
  56. Blais AS, Nadeau G, Moore K, Genois L, Bolduc S. Prospective pilot study of mirabegron in pediatric patients with overactive bladder. Eur Urol 2016;70(1):9-13.
  57. Chua ME, Fernandez N, Ming JM, et al. Neurostimulation therapy for pediatric primary enuresis: A meta-analysis. Urology 2017;106:183-87.
  58. Khedr EM, Elbeh KA, Abdel Baky A, Abo-Elfetoh N, El-Hammady DH, Korashy F. A double-blind randomized clinical trial on the efficacy of magnetic sacral root stimulation for the treatment of monosymptomatic nocturnal enuresis. Restor Neurol Neurosci 2015;33(4):435-45.
  59. Jørgensen CS, Kamperis K, Borch L, Borg B, Rittig S. Transcutaneous electrical nerve stimulation in children with monosymptomatic nocturnal enuresis: A randomized, double-blind, placebo controlled study. J Urol 2017;198(3):687-93.

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.

Last updated: Feb 9, 2024

In this section

Related information

statements and practice points

Paediatrics & Child Health