Synopsis
Classify nocturnal and daytime wetting without blame, identify constipation, UTI, diabetes, neurological or safeguarding causes, use bladder and bowel retraining, and choose alarms or desmopressin according to the child's goals.
- Enuresis means intermittent wetting during sleep in a child aged at least 5 years. Daytime incontinence is involuntary urine leakage while awake after expected bladder control.
- Primary enuresis means the child has never achieved at least 6 months of sustained dryness; secondary enuresis returns after a dry interval and prompts assessment for new triggers.
- Monosymptomatic enuresis has no daytime lower-urinary-tract symptoms. Non-monosymptomatic disease includes urgency, frequency, infrequent voiding, daytime leakage, weak stream or straining.
- Ask how many nights, number and size of wet episodes, timing, waking, previous dry periods, daytime symptoms, stool pattern, fluids, sleep, development, family history and the child's priorities.
- First-line assessment is a supportive history and physical examination. Use a bladder, fluid and wetting diary when it will clarify capacity, frequency or response.
- Do not perform urinalysis routinely for uncomplicated longstanding monosymptomatic bedwetting. Test when onset is recent, daytime symptoms or illness is present, or UTI or diabetes is suspected.
- Treat constipation and daytime lower-urinary-tract symptoms before or alongside nocturnal therapy; a loaded rectum can reduce bladder capacity and impair emptying.
- First-line universal care is adequate daytime fluid, avoiding caffeine, relaxed regular toileting about 4–7 times daily including before sleep, and rewards for behaviours rather than dry nights.
- Offer an enuresis alarm after advice and an appropriate reward system when the family can sustain it. Review at 4 weeks and continue to at least 2 uninterrupted dry weeks when responding.
- Use desmopressin when rapid or short-term dryness is the priority or an alarm is unsuitable or unwanted: generally offer above age 7 and consider at ages 5–7.
- For oral lyophilisate, start 120 micrograms at bedtime and consider 240 micrograms after 1–2 weeks if not dry; reassess at 4 weeks and continue 3 months when responding.
- Fluid restriction is mandatory from 1 hour before until 8 hours after desmopressin. Withhold during vomiting, diarrhoea, fever with increased drinking, intense evening exercise or any inability to restrict fluid.
Key red flags
New polyuria, polydipsia, weight loss, fatigue, vomiting or deep breathing requires immediate glucose and ketone assessment.
Continuous dribbling from birth, never achieving dryness, weak stream or recurrent UTI suggests congenital urinary abnormality, ectopic ureter or outlet disease.
New leg weakness, gait change, saddle sensory loss, abnormal lower-limb reflexes or a concerning sacral lesion suggests neurogenic bladder.
Secondary wetting with marked distress, behavioural change, genital symptoms or an inconsistent history requires sensitive safeguarding and psychosocial assessment.
Daytime wetting with dysuria, fever, visible haematuria, loin pain or recurrent culture-proven infection requires UTI evaluation before continence treatment.
Severe constipation, faecal incontinence, abdominal mass or vomiting can impair bladder emptying and requires active bowel management.
Investigation priorities
Classify wetting, identify bowel and bladder patterns and select goal-concordant treatment.
Management branches
A child aged at least 5 years presents with wetting.
- Separate night from daytime symptoms and primary from secondary enuresis, then screen bowel, UTI, diabetes, sleep, neurology and stress.
- Use urinalysis only when recent onset, daytime symptoms, illness, UTI or diabetes is suspected.
- Agree an outcome with the child and family and begin adequate daytime drinks, caffeine avoidance, regular toileting and constipation care.