Enuresis (bed wetting)

Involuntary urination during sleep ≥2 times/week for ≥3 months in children >5 years old.

Developmental Norm:
- Night-time continence is a normal developmental milestone with wide variability.
- Daytime bladder control by ~4 years; night-time control expected by 5–7 years.
Prevalence:
- ~30% of 4-year-olds wet the bed.
- ~10% of 6-year-olds continue to experience enuresis.
Natural Course:
- High rate of spontaneous resolution.
- Treatment usually not initiated before 6 years due to this.
Psychosocial Impact:
- Generally no underlying physical/emotional pathology.
- Can cause embarrassment, shame, reduced self-esteem, especially with age.
- Problematic mainly when it interferes with social activities (e.g., sleepovers, school camps).
Treatment Indications:
- Not required if enuresis is infrequent or not distressing to child/parents.
- Consider treatment if it impacts psychosocial functioning.
Key Take-Home Messages
- Enuresis is developmental, common, and seldom signifies organic disease.
- Classify (primary vs secondary, MNE vs non-MNE) to guide work-up.
- Start with bowel management and education; alarm therapy is the most effective evidence-based first-line treatment in motivated families.
- Desmopressin offers rapid but often temporary control; tailor dose per ETG/PBS recommendations.
- Always consider and treat constipation and sleep-disordered breathing—both major modifiable contributors in Australian cohorts.

Classification

Type	Definition	Key points
Enuresis	Intermittent, involuntary voiding of urine during sleep at a frequency ≥ 2 episodes/week for ≥ 3 months.
Primary	Child has never maintained ≥ 6 consecutive months of night time dryness	Represents delayed maturation of the normal continence mechanisms
Secondary	Recurrence after ≥ 6 months of dryness	Often precipitated by = new stressors = constipation = UTI = diabetes = sleep-disordered breathing
Monosymptomatic (MNE)	Night-time wetting without daytime lower-urinary-tract symptoms (LUTS)	Most common evaluation focuses on nocturnal mechanisms
Non-monosymptomatic	Bed-wetting plus one or more LUTS (urgency, daytime incontinence, dysuria, abnormal stream, constipation, etc.).	Treat underlying bladder/bowel dysfunction first

Epidemiology:

Prevalence similar across cultures, varies with age:
- 15% at age 7
- 10% at age 10
- 2% in adolescents
- 0.5 to 1% of adults
More common in boys (3:1 ratio), but ratio decreases with age
Additionally, 20 to 30% of patients with enuresis also suffer from at least one psychological, behavioural, or psychiatric disorder, a rate twice as high as that of the general population.
The most common of these comorbidities is attention deficit and hyperactivity disorder
Other comorbid conditions in this category include autism spectrum disorder, oppositional defiant disorder, and mood disorders

Risk Factors & Common Contributing Conditions

Category	Examples / evidence
Genetic	Bed-wetting in ≥ 1 parent (risk 40 % if one, 70 % if both)
Sleep disordered breathing / OSA	Snoring witnessed apnoeas (↑ arousal threshold & natriuretic peptides)
Constipation / faecal retention	Rectal distension reduces bladder capacity treat before enuresis therapy
Neuro-behavioural	ADHD, ASD → impaired arousal / delayed bladder maturation
Urological / renal	Recurrent UTI posterior urethral valves neurogenic bladder (red flags)
Endocrine / metabolic	Type 1 diabetes diabetes insipidus (polyuria) sickle-cell disease
Psychosocial stress	Divorce bullying school change – common trigger for secondary enuresis

Pathophysiology:

genetic component
- studies suggest that inheritance of the condition is in an autosomal dominant pattern with 90% penetrance
Nocturnal Polyuria:
- Associated with vasopressin deficiency or circadian release alterations.
- Leads to increased urine production at night.
Bladder Dysfunction:
- More common in patients with daytime incontinence.
- Manifests as:
  - Diminished bladder capacities.
  - Abnormal urodynamics.
  - Nocturnal detrusor hyperactivity.
- Can be linked to constipation, causing bladder distortion.
High Arousal Thresholds:
- Difficulty waking up due to:
  - Disturbed sleep (e.g., obstructed airway).
  - Contractions in the bladder.
- Can be a cause or result of enuresis.
Maturational Delay Hypothesis:
- Supported by:
  - Higher prevalence of motor clumsiness.
  - Perceptual dysfunction.
  - Speech disturbances in children with enuresis.

History

Much of the history should focus on voiding habits

Onset of bedwetting
- if acute — last few days to weeks — consider whether this is a presentation of systemic illness
Has the child previously been dry at night without assistance for 6 months?
- If so, consider possible medical, emotional, or physical triggers
- The presence of unexplained persistent secondary enuresis despite adequate management should prompt specialist referral
Presence of day-time symptoms
- frequency, urgency, polyuria, dysuria/recurrent UTI, poor urinary stream/straining, leakage)
- If daytime symptoms predominate, consider treating before bedwetting
Bedwetting pattern and trend
- nights per week/month
- amount
- time of night
- arousal from sleep
Fluid intake
- High evening fluid/solute intake, caffeine, carbonated drinks.
- polydipsia
Bowel habit
- constipation/soiling
Sleeping arrangements and routine
- including own bed/bedroom
- snoring and disturbed sleep
Medical History:
- consider other co-morbid factors which may exacerbate or prolong nocturnal enuresis;
- developmental or behavioural problems
- diabetes mellitus
- sleep apnoea
Family history of bedwetting or renal problems
Social history;
- family capacity and motivation to engage in treatment
- social difficulties (vulnerable child/family)
Development history
- Patients should have screening for psychological or behavioral disturbances, including attention deficit and hyperactivity disorder and learning disabilities, and obtaining a developmental history is also necessary

Examination

Height, weight, BP — poor growth / loss of weight / hypertension
Abdomen — distended bladder, faecal mass
Inspection of external genitalia (and perianal area if constipation also present)
Lower Back/Spine – exclude occult spinal dysraphism or tethered cord (asymmetric/deviation of gluteal cleft)
Assessment of lower limb neurology

Evaluation:

AS PER RCH GUIDELINES:
- Dipstick urinalysis is not required in primary enuresis.
- Consider if red flags apparent.
- Further imaging or blood tests are not routinely recommended in enuresis
Urinalysis MAY SHOW:
- alterations in specific gravity in diabetes insipidus
- glycosuria in case of diabetes mellitus
- presence of nitrites leukocyte esterase, leukocytes, or bacteria in case of infection

General Advice

Treat constipation first if present – essential before enuresis management.
Educate on normal bladder physiology and the genetic nature of enuresis.
Reassure:
- Very common in peers.
- Not the child’s fault – no shame or embarrassment warranted.
Encourage:
- Regular fluid intake and scheduled toileting, especially during school breaks and before bed.
Avoid:
- Fluid restriction (not helpful).
- Caffeine or stimulant drinks in the evening.
Motivation:
- Both parent and child must be ready before starting behavioural treatment.

Bedwetting Alarms (Pad and Bell Alarms)

First-line treatment:
- Best long-term success; lower relapse than pharmacotherapy.
Requires:
- Supportive home environment.
- Clear communication that it can take 6–8 weeks to show benefit.
Age:
- Generally used in 6–7+ years (if mature, motivated, and physically able).
Considerations:
- Mild-moderate intellectual disability → not a contraindication.
- Hearing-impaired → use vibrating alarm.
Contraindications:
- Emotionally overwhelmed carers, anger/blame towards child, or inability to manage sleep disruption.
Child’s role:
- Must be actively involved.
- Ideally, child should wake and walk to toilet independently.
Rewards:
- Focus on behaviours (e.g. responding to alarm), not on dry nights.
Monitoring:
- Continue if early improvement by 4 weeks → continue until 14 consecutive dry nights.
- Stop if no early improvement after 4 weeks.
- If partial response after 3 months → review appropriateness or trial again in 3–6 months.

Overlearning Technique

Used after achieving dryness for 2+ weeks.
Purpose: reinforce bladder control to reduce relapse.
Method: Extra fluid intake in hour before bedtime to challenge continence.

Other Behavioural Strategies

Lifting (carrying child to toilet asleep):
- Not effective for long-term dryness.
Waking & walking child:
- Provides short-term control only.
- May be useful if self-initiated using phone/alarm clock.

Desmopressin (Minirin™ melt / tablet) f

1. Role in Treatment Pathway

Step	Preferred intervention	Key points
First-line	Bed-wetting alarm (6–8 wk trial)	Best long-term cure, lowest relapse.
Second-line / adjunct	Desmopressin	Use when alarm fails, is unsuitable, or rapid short-term dryness is required (camps, sleep-overs). rch.org.au

PBS listing (Authority-Required, streamlined code) limits supply to children > 6 y with primary nocturnal enuresis who are refractory to, or cannot use, an alarm. The contraindication must be documented. pbs.gov.au

2. Patient Selection & Readiness

Age: > 6 y generally; consider maturity in 5–7 y olds.
Enuresis type: Monosymptomatic; daytime symptoms must be treated first.
Motivation: Child and family able to comply with strict overnight fluid restriction.
Red flags / exclude: Polydipsia–polyuria syndromes, chronic constipation, UTI, sleep apnoea, spinal dysraphism.

3. Prescribing & Dosing

Formulation	Starting dose	Up-titration (after 1–2 wk)	Max	Notes
Sublingual “Melt”	120 microg SL at bedtime	240 microg if needed	240 microg	Preferred in younger children – no water needed.
Tablet	200 microg PO at bedtime	400 microg if needed	400 microg	Swallow with minimal water.
Intranasal	Not recommended – ↑ hyponatraemia risk.	—	—	Avoid.

Cessation strategy:

stop therapy for 7 days every 3 months to test for sustained dryness
taper rather than abrupt stop to lower relapse. rch.org.au continence.org.au

4. Administration Checklist

Dose timing: ~1 h before sleep, empty bladder first.
Fluid restriction:
- No drinks from 1 h pre-dose until ≥ 8 h post-dose.
- Discourage late salty/caffeinated foods.
Missed dose: skip; do not give later if the child has already slept.

“nightly fluid rule”

Aspect	Practical details	Rationale
Timing	Stop all drinks ≥ 1 h before the desmopressin dose and do not allow any fluid until the first morning void (≈ 8 h later).	Desmopressin concentrates urine; extra free water during this window raises the risk of water intoxication / hyponatraemia.
Allowed “wet-mouth” comforts	Damp sponge to lips, sugar-free gum or mouth spray (no swallowing).	Relieves thirst without adding meaningful fluid.
Evening diet tips	Avoid salty snacks or caffeine after dinner; encourage main fluid intake earlier in the day.	Reduces evening thirst drive.
Contra-indications to treatment	Child cannot reliably follow the rule (e.g. – sleep-walking to kitchen – polydipsia – intercurrent vomiting/diarrhoea – febrile illness – very hot weather without supervision).	Safety takes precedence; missed doses are safer than breaking the rule.
Parent script	“After your last drink and your medicine, the taps are closed until breakfast. If you feel thirsty, come and tell us—don’t get a drink yourself.”	Clear, positive framing helps adherence.

5. Monitoring & Follow-up

Parameter	When	Action threshold
Clinical response (wet-night diary)	After 2-4 wk	≥ 50 % reduction = continue; no benefit → stop.
Serum Na⁺ (optional, but prudent in high-risk)	Baseline and within first week	< 130 mmol/L → cease and reassess.
Safety review	Every 3 months	Reinforce fluid rules; repeat withdrawal trial.

6. Expected Outcomes

Response rate: ~70 % overall (30 % full, 40 % partial responders). continence.org.au
Relapse: 60–70 % relapse when stopped; gradual taper halves this risk. continence.org.au
Prognosis: Most children outgrow enuresis, but timely treatment improves self-esteem and social functioning.

7. Adverse Effects & Contraindications

Common	Rare / Serious	Contra-indications
Headache, nasal congestion (tablet), abdominal pain.	Hyponatraemia → seizures, water intoxication.	Non-adherence to fluid restriction, SIADH, habitual polydipsia, cystic fibrosis, craniofacial surgery, eGFR < 50 mL/min/1.73 m².

Advise parents to stop treatment and seek review if nausea, vomiting, headache, or confusion occur at night or next morning.

8. Practical Prescribing Tips (PBS)

Write “Streamlined authority 8662X / 8663Y – primary nocturnal enuresis, alarm failed/contraindicated” on script.
Pack sizes: 30 wafers (120 µg or 240 µg) or 30 × 200 µg tablets.
Max 3 packs / 5 repeats (total 6 months) per prescription; re-apply if longer therapy required.

Prognosis

Spontaneous resolution common with age
However, may be associated with:
- Emotional or physical abuse
- Low self-esteem
- Poor academic performance

Complications of Untreated Enuresis

Quality of life significantly impacted
Psychological burden:
- Social withdrawal
- Low self-esteem
- Anxiety, stress, and mood disturbances
Effective management improves social functioning and mental health

Consider referral to a general paediatrician or continence service when

Red flags are present
Persistent enuresis with failure of an enuresis alarm
Day-time enuresis or combined day/night enuresis after exclusion or treatment of a UTI and constipation
History of recurrent urinary tract infections
Comorbidities such as type 1 diabetes, physical or neurological problems
Substantial psychological or behavioural problems (consider mental health referral, paediatrician and/or child protection services if significant concern exists)

Behavioural Interventions for Bedwetting (Enuresis)

from https://www.racgp.org.au/clinical-resources/clinical-guidelines/handi/a-z/b/behavioural-interventions-including-alarms-bedwett

1 | Indications for active therapy:

Child distressed or embarrassed.
Social limitation (sleep-overs, camps).
Parental burden.

Not required: Child unconcerned & no functional impact.

2 | Hierarchy of Behavioural Options

Level	Intervention	Core idea	Key tips
Simple, low effort	Lifting	Carry sleeping child to toilet without waking.	Useful for < 7 y; does not teach self-arousal.
	Waking	Wake child at set or random times to void.	Set alarm for parent; fade as control improves.
	Reward chart	Sticker/points for dry nights.	Combine with any other strategy; positive reinforcement only.
	Retention-control training	Once daily, delay voiding while awake to stretch functional bladder capacity.	Practice in daytime; stop if painful.
	Bed-wetting alarm	Moisture sensor triggers sound/light/vibration → teaches arousal & sphincter tightening.	See Section 3.
	Overlearning	After dry streak, give ~200 mL water before bed while alarm in place to “stress-test” control.	Initiate only once 3–4 consecutive dry weeks achieved.
Complex, high effort	Dry-bed training	Intensive nocturnal waking schedule over 7 nights.	Requires highly motivated family; see protocol in Sec 4.
	Full-spectrum home training	Combines dry-bed, bladder training, overlearning, & sheet-changing by child.	No proven benefit over alarm alone.

3 | Bed-Wetting Alarm – Practical Guide

Age to start: ≥ 7 y (younger if strongly motivated and neuro-typical).
Child ownership: Child turns on, tests, empties bladder pre-bed. Parents provide praise.
Parental role: Initially wake the child if alarm does not; ensure child walks fully awake to toilet (not sleepwalking).
Target outcome: 3–4 consecutive dry weeks.
- Typical duration: 3–4 months (range 5 weeks – 6 months).
- If relapse, simply restart programme.
Success rates: 60–70 % achieve sustained dryness; relapse 25–30 % (often respond to repeat course).
Troubleshooting: Persist > 6 months without progress → reconsider diagnosis, assess comorbid constipation/OSA, refer.

4 | Dry-Bed Training (Complex) – Seven-Night Protocol

Night 1: Wake child hourly until 01:00 h to toilet. Parent may stay bedside.
Nights 2 – 6: Wake once/night, 3 h after sleep onset, then progressively earlier each night until 1 h after bedtime on night 6.
Night 7: Child expected to self-wake.
Relapse rule: If wet on 3 nights, restart schedule.

Note: Evidence shows no additional benefit over alarm alone, with far greater sleep disruption. Reserve for specialised programmes or refractory cases.

5 | Readiness & Precautions

Exclude/treat contributors: constipation, UTI, diabetes, severe OSA.
Developmental readiness: Child can understand instructions, willing to cooperate; parents can commit nightly time.
Adverse effects: Sleep fragmentation, frustration, temporary behaviour issues. Mitigate with clear expectations and positive framing.

6 | Access & Cost (AU)

Purchase: Wireless/corded alarms ~$80–160 online.
Hire: State tertiary paediatric hospitals (e.g. RCH Melbourne) via paediatrician/continence clinic referral.

7 | When to Escalate Care

Persistent enuresis after:
- ≥ 6 months of well-run alarm therapy and
- Addressed constipation/daytime bladder dysfunction.
Associated daytime symptoms, recurrent UTIs, developmental delay, or parental/child distress.
Refer to multidisciplinary enuresis or continence service available in each state/territory.

8 | Key Take-Home Messages

Start simple: Reward charts ± lifting/waking; move to alarm once child ≥ 7 y or earlier if keen.
Alarm therapy remains the gold-standard behavioural cure; drugs (desmopressin) are for selected short-term use.
Motivation of both child and parents is the strongest predictor of success.
Address constipation and daytime bladder issues first; they sabotage any night-time strategy.
If in doubt, refer early to avoid prolonged distress and maintain family confidence.

(Level 1 evidence, NHMRC; Cochrane reviews 2013 & 2005)