What is the most effective treatment for nocturnal enuresis?

Begin by encouraging your child to drink one or two extra glasses of water in the morning or at lunchtime. Then in the evening, your child should only drink to quench thirst. Try to prevent drinking two hours before bed. Also, limit or stop your child from drinking caffeinated and carbonated drinks like soda.

Creating a schedule for bathroom use (changing toilet habits)

Bladder training is a way to set a bathroom schedule with your child. For example, have your child sit on the toilet five to six times each day and twice before bed, even if they say they don’t have to go.

Constipation management

Work with your doctor to determine if your child struggles with constipation. This is often seen by infrequent, hard to pass bowel movements, but can also be seen as small, frequent bowel movements, incomplete emptying of bowel movements or stool accidents. Your child may need increased fluid intake during the day, increased fiber and assistance with a medical bowel regimen. This can take some time to regulate but is of great value in helping with bedwetting.

Bedwetting (enuresis) alarms

Bedwetting alarms have a special sensor that detects moisture in a child's undergarments. It triggers a bell or buzzer to go off with wetness. The child wakes with the alarm and tries to get up to go to the bathroom before having an accident. An adult will need to help, since most children who wet the bed do not wake up by themselves at first. The alarm works by "conditioning" a child to wake when it is time to pass urine. This is a behavioral-type therapy known to be very successful.

Bedwetting alarms work with a sensor in the child's pajamas or underwear that links to an electronic alarm. The alarm is either attached to the child's clothing near the shoulder or clipped to the waist. The alarm unit may also be wireless and placed on the counter. When the sensor becomes moist, the alarm is triggered. Some alarms also have a vibration mode that shakes the device. The alarm wakes the child so they can get to the bathroom to pass urine or finish passing urine.

Success for alarm therapy depends on parents understanding that this is a learning process. There are stages a child and parents must go through for best results. Without patience, parent and child frustration will lead to quitting. Please try not to give up.

In the first and second stage of therapy, parents must wake up with the alarm and then wake the child from bed. The child then gets up, goes to the toilet and tries to pass urine for a couple of minutes. They should then clean themselves in the shower, change their bed sheet or put on a new Pull-up. The parent should be supportive and help. Then the child will turn the alarm back on, and go back to bed. You will start to see the child wake up on their own more and more over time.

In the third stage of therapy, the child should be able to wake on their own when their bladder feels full. Once the child successfully reaches this stage, parents should ask the child to use the device for two to three more weeks to reinforce this behavior. Everyone at this stage should feel proud and relieved.

Tips for success:

• Choose three to four months when a simple home routine can be made for treatment.
• Agree with the child on a date when therapy will begin.
• Perform a few drills with the alarm during the day so the child knows what to expect and what to do. 
• Keep a calendar in the child's room to monitor progress.
• Do not punish your child for accidents. Punishment is counterproductive. Instead, offer rewards for cooperating with therapy and completing tasks.

Advantages:

• Not a prescription medication, so there are no side effects.
• Low rate of recurrence after device is stopped upon successful treatment.
• If used the right way, the chances of success are about 75% with consistent use for at least one to two months.

Disadvantages:

• Alarms require hard work and commitment from parents
• May not be appropriate for children with sensory processing issues or other sleep disturbances. Talk about it with your child's pediatrician.
• They are not good for sleepovers.
• They disturb siblings who share a bedroom.
• Many health plans do not pay for these devices.

Prescription Drugs

Desmopressin is a synthetic form of the hormone "ADH or vasopressin."

In normal conditions, ADH is produced by the brain and causes the kidneys to conserve water. For example, athletes secrete more ADH when they are active and sweating. Most people have naturally higher levels of ADH during sleep. That is part of the reason why we can sleep through the night without needing to pass urine. In many children with enuresis, this hormone surge is absent.

DDAVP is available as a pill. It can be given an hour before going to bed for a period of three to six months, with a one week break. Because it works to decrease the volume of urine made, it is used with a schedule of drinking less fluid in the evening and stopping fluid intake two hours before bed.

There is a DDAVP nasal spray but the pill form is preferred.

Advantages:

• When it works, it works very well.
• Can boost confidence on sleepovers.
• Can be used privately.
• The cost is usually covered by most health plans.

Disadvantages:

• This does not cure bedwetting but if it works, it can help decrease wetting while the child develops and matures. 
• This drug works best in children with normal capacity bladders and older children.
• The child's body can adapt with time and stop responding to the drug.

These prescription drugs stop the bladder from having spasms with overactive bladder symptoms. It is helpful when a child has small bladder capacity, often seen in children with daytime urinary frequency, urgency and daytime wetting.

Advantages:

• The drug is safe and well tolerated by children.
• The drug can be combined with desmopressin to increase bladder capacity, while decreasing the amount of urine made, which can be more successful in some children.

Disadvantages:

• The drug doesn't work for everyone.
• Common side effects include dry mouth, constipation and facial flush. If constipation becomes a problem, be aware that this can make bedwetting worse.

Imipramine is an anti-depressant medication that has been used for many years to treat children with bedwetting but is not commonly prescribed. It does not mean that depression is a cause for bedwetting. It is not clear how imipramine helps in this case, but it is believed to improve the child's sleep patterns and bladder capacity.

Due to the severity of some side effects, this is not commonly used or recommended. Side effects can include irritability, insomnia, drowsiness, reduced appetite and personality changes. Other side effects include severe cardiac (heart) issues. Overdose can be deadly. Heart tests should be performed by your doctor prior to prescribing. This drug must be used and stored safely.

Treatments That Are Not Recommended

Many parents think that if their child stops eating and drinking many hours before bed, it will help reduce or get rid of bedwetting. But this rarely helps. It is a good idea to stop drinks two hours before bed and to always limit caffeinated and carbonated sodas. If a child is hungry or thirsty, it is okay to provide small amounts of food and water. (Note: Limiting drinks is needed for treatment with DDAVP.)

Before seeking medical care, many parents try waking a child during the night to take them to the bathroom. Some families try this more than once during the night. While it can be helpful in the short term, it is hard to continue over time. It is hard on family members and does not always work.

Adults with bladder control problems may find help with pelvic muscle exercises, like the Kegel. During these exercises, adults are asked to hold a full bladder and try to stop their urine stream. This effort has not been proven to help children with bedwetting.

Homeopathy, herbal cures and chiropractic practices have not been found to help with children's bedwetting.

• Desmopressin Acetate (DDAVP)
• Imipramine
• Anticholinergics
• Summary

DDAVP is a drug to treat children with bed-wetting. Although DDAVP does not cure the condition, it does help treat the symptoms while the child is on the drug. Numerous studies report reduction in the number of wet nights.

DDAVP is a man-made copy of a normal body chemical that controls urine production. The therapeutic benefit of DDAVP might be due to a reduction in the overnight production of urine or possibly to an effect on arousal.

Many studies have attempted to identify those childrens most likely to respond to DDAVP. Older children are more responsive. Children with a normal bladder capacity are more likely to respond than those with a small bladder size.

The drug can be taken as a nasal spray or tablet. However, the tablet has several advantages. If your child has no problems swallowing pills, the tablet is more discreet for sleepovers and other special occasions. Additionally, the tablet has reported a better response rate. The nasal spray can be affected by a stuffy nose from colds or allergy. DDAVP should be given at bedtime. Because it works right away, it does not need to be given everyday to be effective.

DDAVP has few side effects. The most common side effects with the nasal spray are nasal discomfort, nosebleeds, tummy pain, and headache. The only serious side effect noted in children treated with DDAVP is seizure due to water intoxication. This serious problem is preventable with care not to overdo fluids on any evening that DDAVP is taken. Children should take only one eight once cup of fluid at supper, no more than 8 ounces between supper and bedtime, and nothing to drink in the two hours before bedtime. Early symptoms of water intoxication include headache, nausea, and vomiting. If these symptoms occur, the medication should be stopped and the child should be seen by a doctor immediately. Caution should be used in children with attention deficit hyperactivity disorder since they are often impulsive. These children might require especially close monitoring of their fluid intake.

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IMIPRAMINE

Imipramine has been used successfully for many years to treat children with bed-wetting. Complete dryness has been reported in 10-50% of patients. Some children who are not completely dry show significant improvement.

How this drug works is not well understood. Even though imipramine is a type of antidepressant, there is nor reason to suggest that depression plays a role in the cause of bed-wetting.

This type of drug is thought to work one of several ways:

• by changing the child's sleep and wakening pattern
• by affecting the time a child can hold urine in the bladder or
• by reducing the amount of urine produced.

Imipramine generally is not used to treat bed-wetting in children younger than 6 to 7 years of age. Success rates have been found to be higher in older children. As with all drugs used to treat bed-wetting if the drug is stopped, bed-wetting is likely to reoccur.

The usual dose of imipramine is taken 1 to 2 hours before bedtime for children 6 to 8 years old. A higher dose is needed for older children and adolescents. A child should be seen by a doctor after three to six months on the drug. If the child starts wetting again, then a repeat course of treatment may be restarted.

It is very important to take the drug in the amount prescribed by your doctor. Minor side effects of imipramine include irritability, insomnia, drowsiness, reduced appetite, and rarely, unpleasant personality changes. However, most children who take imipramine for bed-wetting do not experience these side effects. If they do occur, the side effects can be easily reversed by reducing or stopping the medication. Of more serious concern, imipramine can lead to death if an overdose is taken, therefore, it must be kept out of the reach of all children and sealed with a child proof cap. Accidental overdoses have been reported in children.

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ANTICHOLINERGICS

Anticholinergic drugs, such as oxybutynin (Ditropan) or hyosyamine (Levsinex), reduce or stop bladder contractions and increase bladder capacity. Anticholinergics may be helpful for children who have daytime wetting due to bladder contractions and/or small bladder capacity. A useful formula for estimating normal bladder volume in children is: age in years + 2 = ounces.

Anticholinergics alone are usually not helpful fo rchildren with isolated bed-wetting without any daytime voiding problems. However, some children with bedwetting who fail to respond to DDAVP alone will respond to a combination of DDAVP and an anticholinergic. This is often true for a child who has reduced functional bladder capacity. The reason behind this approach is that the DDAVP reduces night time urine output while the anticholinergic increases nighttime bladder colume. Together, these drugs may prevent bed-wetting by keeping the bladder from becoming full during the night.

For children older than 6 years, the dose of oxybutynin (Ditropan XL) is given once a day to children with daytime wetting symptoms. Another anticholinergic, hyoscamine, is also available in a long acting time capsule. The usual dosage is one hyosyamine twice daily. For children with isolated bed-wetting, only the bedtime dose of oxybutynin or hyosyamine is required. Common side effects are dry mouth and facial flushing. Occasionally, flushing may occur when the child is exposed to hot weather. An overdoes may result in blurring of vision and hallucinations. Fewer side effects have been reported with a newer anticholinergic, tolterodine (Detrol), which is more specific for its action on the bladder. However, this drug is not yet approved for use in children under twelve years.

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SUMMARY

Drug therapy of bedwetting is best thought of as a treatment, not a cure. Therefore, most children require long-term treatment to prevent a return of bed-wetting.

Reported response rates are similar for DDAVP and imipramine. DDAVP is more costly than imipramine, but it has fewer side effects and is less toxic. DDAVP plus an anticholinergic may be helpful in some children who have small bladder capacity. Anticholinergics may also help children who have small bladder capacity and daytime frequency, urgency and/or wetting. However, anticholinergics alone have not proved helpful for children with only night time wetting.