Treatment for Bedwetting (Nocturnal Enuresis)
The goals of treatment are to reduce the social and psychological impact of the condition and to eliminate the underlying cause. Treatments include the following:
- Behavior modification (e.g., positive reinforcement, periodic waking, restricted fluid intake, alarm therapy)
- Medication
- Surgery (in cases of obstructive sleep apnea, ectopic ureter, heart block)
Behavior Modification to Treat Bedwetting
It is important to manage nocturnal enuresis in a way that reduces the child's embarrassment and the anxiety within the family. Family members who have outgrown the condition can share their experience with the child to reduce feelings of isolation. Parents should use patience and caring while waiting for the child to outgrow bedwetting. Behavior modifications often improve nighttime dryness within 1 month.
Positive reinforcement (e.g., keeping a chart with gold stars awarded for dry nights) is sometimes beneficial, as is periodically waking the child at night to use the bathroom. An alarm clock set to go off a few hours after the child goes to bed can be used to wake the child or the parent can wake the child before retiring for the night.
Restricting the intake of fluids late in the day and encouraging voiding at regular intervals throughout the day may also be helpful. The child should be encouraged to use the bathroom every 1–2 hours during the day and immediately before bed. The restriction of fluids should not be demanded in a way that suggests punishment and should be implemented carefully in children who are physically active and in warm weather to reduce the risk for dehydration.
Alarm therapy has a success rate of approximately 70%, works best in older children who are well motivated, and requires commitment from all household members who may be awakened by the alarm. It takes from 2 weeks to several months to produce improvement, and if the child is not dry after 3 consecutive months of use, therapy should be discontinued until the child is older.
The alarm is positioned to sense wetness promptly and although most children sleep through the alarm, they stop voiding when it sounds. A parent then helps the child to the bathroom to finish voiding; changes wet sheets and pajamas; resets the alarm; and takes the child back to bed. Some children who achieve success with this type of therapy are able to sleep through the night without voiding, but others may continue to get up during the night to use the bathroom (nocturia).
Medications to Treat Bedwetting
Drug therapy usually is reserved for children who have had no success with nonpharmacological treatments. Medications used to treat nocturnal enuresis include the following:
- Desmopressin acetate (DDAVP®)
- Oxybutynin chloride (Ditropan®)
- Hyoscyamine sulphate (Levsin®)
- Imipramine (Tofranil®)
Desmopressin (DDAVP®) is an antidiuretic that is used to treat primary nocturnal enuresis. DDAVP® is available in a nasal spray (10–40 mcg, at bedtime) or oral form (0.2-0.6mg, at bedtime) and is up to 55% effective. It may also be combined with alarm therapy. Side effects of the nasal spray include nasal discomfort, nosebleed, abdominal pain, and headache. It is important to reduce fluid intake when taking DDAVP. If fluids are not restricted, water intoxication may occur. This condition requires immediate medical attention. Symptoms of water intoxication include headache, nausea, vomiting, and seizure.
Ditropan® and Levsin® are anticholinergic medications that reduce muscle contractions in the bladder. The usual dose is 2.5–5 mg taken at bedtime. Side effects include blurred vision, constipation, dizziness, dry mouth, facial flushing, and fluctuations in mood.
Tofranil® may be prescribed in doses of 25 mg in children 6 to 8 years old and 50–75 mg in older children, taken 1 to 2 hours before bed. This antidepressant effectively treats primary nocturnal enuresis without organic causes in as many as 40% of cases when used as a temporary adjuvant therapy.
Side effects include the following:
- Constipation
- Difficulty voiding
- Drowsiness
- Nervousness
- Mood changes
- Sleep disorders
Overdose can be fatal and the World Health Organization (WHO) does not recommend using this drug for nocturnal enuresis.
Oral antibiotics (e.g., Bactrim®, amoxicillan, Macrobid®, Levaquin®) are used to treat UTIs that cause bedwetting.
Surgery and Bedwetting
Structural abnormalities in the urinary system (e.g., ectopic ureter) and other conditions, such as obstructive sleep apnea and heart block, may require surgery. Surgery to correct these conditions often eliminates nocturnal enuresis.
Bedwetting Prognosis
The prognosis for children who experience nocturnal enuresis depends on the cause. Almost all children outgrow bedwetting, even without treatment.
