Enuresis refers to involuntary urination.
Nocturnal enuresis refers to bedwetting at night.
Diurnal enuresis refers to daytime wetting.
Most children have daytime control by 3 years and nighttime control by 4 years.
Primary Nocturnal Enuresis
Primary nocturnal enuresis is where the child has never managed to be consistently dry at night.
Primary nocturnal enuresis can be a variation of normal development, particularly under 5 years. There may be a family history of delayed dry nights. Reassurance is important.
Other causes of primary nocturnal enuresis include:
- Overactive bladder
- Reduced bladder capacity
- Fluid intake before bedtime (fizzy drinks, juice and caffeine can have a diuretic effect)
- Failure to wake due to particularly deep sleep and underdeveloped bladder signals
- Psychological distress (e.g., low self-esteem, too much pressure or stress at home or school)
- Secondary causes, such as chronic constipation, urinary tract infection, learning disability or cerebral palsy
A history and examination help identify and exclude any physical or psychological causes.
A bladder diary (recording fluid intake, urine output, and wetting episodes) can help establish patterns and determine the cause (e.g., too much fluid before bed).
Management of primary nocturnal enuresis involves:
- Reassurance if under 5 years (it is likely to resolve without any treatment)
- Lifestyle changes (reduced fluid intake in the evenings, passing urine before bed and ensuring easy toilet access)
- Encouragement and positive reinforcement (avoid blame, shame or punishment)
- Treat underlying causes (e.g., constipation)
- Enuresis alarms
- Pharmacological treatment
Secondary Nocturnal Enuresis
Secondary nocturnal enuresis is where bedwetting occurs after being consistently dry at night for at least 6 months. It is more suggestive of an underlying cause than primary enuresis. Causes include:
- New psychosocial problems (e.g., stress in family or school life)
- Urinary tract infection
- Constipation
- Diabetes
- Maltreatment
Consider maltreatment and safeguarding, particularly with deliberate bedwetting, punishment (despite parental education) or unexplained secondary nocturnal enuresis.
Management of secondary nocturnal enuresis involves treating the underlying cause. Urinary tract infections and constipation are common and easily treatable. Other problems may require referral for further management.
Diurnal Enuresis
Diurnal enuresis refers to involuntary urination during waking hours. Most children have daytime control by 3 years. Diurnal enuresis is more common in girls. Common causes include:
- Variation of normal development
- Overactive bladder
- Reduced bladder capacity
- Behavioural factors (e.g., prolonged holding)
- Psychosocial problems
- Constipation
- Urinary tract infection
Urge incontinence is an overactive bladder that gives little warning before emptying. They experience a sudden need to pass urine and do not make it to the toilet in time.
Stress incontinence describes leakage of urine during physical exertion, coughing or laughing.
Enuresis Alarms
An enuresis alarm is a device that makes a noise at the first sign of bedwetting, waking the child and stopping them from urinating. It requires training and commitment and needs to be used consistently for a prolonged period (e.g., at least 3 months). Some families may find them very helpful, whereas others may find they add to the burden and frustration and are counterproductive.
Pharmacological Treatment
Desmopressin is an analogue of vasopressin (anti-diuretic hormone). It reduces the volume of urine produced by the kidneys. It is taken at bedtime to reduce nocturnal enuresis.
Oxybutynin and tolterodine are anticholinergic drugs that reduce the bladder’s contractility. They can be helpful in cases of overactive bladder.
Imipramine is a tricyclic antidepressant. It is unclear how it works, but it may relax the bladder and lighten sleep.
Last updated March 2025
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