Evidence based management of nocturnal enuresis

This is the fourth in a series of five articles A 10 year old boy has been brought to see you because of bedwetting. He is dry during the day. The only treatment he has had ever is desmopressin once when he was away at a camp for two nights. He was dry both nights but he slept very little, and his parents are not sure whether the desmopressin was responsible for his dry nights. Normally he is wet most nights. His parents realise that the wetting is now beginning to upset the boy and both he and they are requesting help. Nothing of note is found on examination and on urine culture. #### Summary points Daytime urinary symptoms in a bedwetting child suggest an underlying bladder dysfunction rather than nocturnal enuresis Enuresis alarms are effective and safe treatment but require several months of continuous use and are therefore unsuitable for some families Desmopressin and imipramine both improve bedwetting but there is no good evidence of lasting benefit after treatment is stopped Imipramine has high frequency of serious adverse effects and should be used with great caution The parents and child should actively participate in the choice of treatment Bedwetting is a common symptom with many causes.1 Nocturnal enuresis is the most frequent cause; it is recognised by the absence of other urinary symptoms or signs of disease. Most children presenting with nocturnal enuresis have never been reliably dry, but in a minority enuresis has started after they had become dry, possibly triggered by stressful life events. If daytime wetting is present the child is most likely to have the urge syndrome, with or without urge incontinence as well, or dysfunctional voiding—functional bladder disturbances that result in incontinence. Rarely, incontinence may be due to structural abnormalities of the urinary tract, such as …