#147: Urine Good Hands: Evidence-Based Approaches to Enuresis

July 30, 2025 | By Sydney Engel

Audio

Summary:

When it comes to enuresis, the answers aren’t always crystal clear. Join the Cribsiders and expert guest Carmen Tong, DO, as we flush out the nuances of nocturnal and daytime wetting. It’s time to streamline your approach with evidence-based insights.

Enuresis Pearls

1. Treatment of enuresis often requires multiple therapies, which may include medical, pharmacological, behavioral or dietary. These are best approached in a stepwise fashion. 
2. Urotherapy (a variety of behavioral modifications) is the first-line treatment in almost all cases of daytime incontinence. This includes things like voiding habits, dietary changes, timed and double voiding, and bowel management. 
3. Nocturnal enuresis is generally due to children’s inability to recognize bladder fullness overnight, which generally improves with age. Desmopressin and bedwetting alarms are both reasonable interventions in most cases, but should not be combined due to contradictory mechanisms.
4. For daytime enuresis, a sterile urine culture should be obtained in almost all cases. Renal ultrasound should be ordered in cases of recurrent urinary tract infections or in children with no history of consistent dryness. Post-void residual is helpful for determining appropriateness of medication use. 
5. Unfortunately, there is rarely a quick fix for enuresis! Approach these conversations with understanding and compassion for families, and emphasize that it is not the child’s fault. Consider follow up visits after 3 to 6 months to evaluate progress. 

Enuresis Notes 

Daytime Enuresis

Epidemiology

• Daytime urinary incontinence affects 7-10% of children over the age of five, with higher incidence in girls than boys.

Differential Diagnosis

• Urinary tract infection (UTI): Inflammation to the mucosa of the bladder can lead to detrusor overactivity, causing urine leakage. Dr. Tong describes this as the bladder “constantly spasming and trying to relax.” This can be a vicious cycle in girls, as damp underwear due to leakage can foster perineal bacterial overgrowth, creating risk for further UTIs. This worsens further when combined with constipation (see below)
• Bowel dysfunction: Retained stool in the rectum and colon can push on the bladder, making it more challenging for the bladder to both fill and empty appropriately. Diet-related
• Neurodevelopmental conditions
• Neurologic etiologies (e.g., issues with the spinal cord)
• Anatomic or structural problems with the urinary tract (e.g., reflux,  ectopic ureter)

History

• History of UTIs
• Dietary and voiding habits
• Lower extremity weakness/fatigue, not being able to participate fully in physical activity
• Prenatal history (e.g., hydronephrosis or urinary tract anomaly)
• Family history of vesico-urritoral reflux
• Medication use
• Social stressors or changes.

Physical Exam

• Lower abdomen
• Genitourinary (important!): In girls, check the labia for skin breakdown and inflammation (may be due to urine pooling) and vaginal opening for urine trapping  
• Back: Look for sacral dimples and gluteal cleft abnormalities that might suggest a neurologic deficit
• Gait: Monitor for lower extremity weakness

Testing

• Urinalysis and culture: Try to obtain a specimen that is as sterile as possible (i.e., avoid bagged specimen/hat if possible). Urine should be analyzed within an hour of collection. Note that a diagnosis of UTI requires both a positive culture and symptoms (including incontinence)
• Renal ultrasound: Generally recommended by the time a specialist is involved, consider in all patients, especially if the patient has never been fully toilet trained
• Post void residual – particularly important for pharmacologic management. Can estimate bladder capacity in mL based on the following rules of thumb:
  • Under 2 years old: Weight in kg  x 7 
  • Older than 2 years old: (Age + 2) x 30

First Line (Non-Pharmacologic) Management

Behavioral interventions (urotherapy) is considered first line in the vast majority of cases. This includes:

• Toileting habits: For girls this includes spreading legs fully and making sure that there is no urine trapping in the vagina
• Bowel management: In cases of clear constipation (e.g., visible on imaging), Dr. Tong often begins with a cleanout followed by maintenance therapy for a couple of months. 
• Timed voiding: Use of a watch that beeps every 2-3 hours to remind a child to go to the bathroom
• Double voiding: After the first void, the child counts to 20 or sings a short song and then tries again to empty all the way. Particularly helpful in the child that gets distracted easily. 
• School interventions: Ensure child has free access to the restroom (holding urine worsens incontinence) and to water during the day
• Voiding and stool diary 
• Dietary modifications: Caffeine, red and yellow dyes (limited evidence), spicy foods, and acidic foods can all be bladder irritants
• Pelvic floor therapy, biofeedback and neuromodulation also have some evidence of efficacy in children with enuresis – usually done via urology clinic

Emphasize to family that treatment often takes time – unfortunately there is no quick fix. Dr. Tong usually has families return after 3-6 months to reevaluate symptoms. 

Pharmacologic Management

• Oxybutynin: First-line medication for overactive bladder. Dr. Tong has used this in children as young as one year old. While generally safe, caution families about constipation (monitor stool diary), dry mouth, flushing. Titrate up from lowest dose based on symptoms. Note that anticholinergics can worsen urinary retention – obtaining a PVR that demonstrates full voiding is important to ensure appropriate use. 
• Antibiotic prophylaxis: Reasonable in cases of true recurrent UTI which is defined as 2-3 true UTIs (culture positive) with symptoms in a 6 month period. Dr. Tong’s “go to” is nitrofurantoin (can dump capsule in applesauce) 2-2.5 mcg/kg once daily (sulfamethoxazole-trimethoprim is her typical second line is not a lot of local resistance). She typically will continue prophylaxis for 3-6 months while the family also works on urotherapy interventions. 

Nocturnal Enuresis

Epidemiology

• The prevalence of nocturnal enuresis at about age five is 15% and decreases to about 5% for 10-year-olds, with the rate reducing by approximately 15% each year after age five. By teenage and young adult age, the prevalence drops to around 1%. 

History

• Prior dry period (secondary enuresis): If a child was previously dry overnight for more than 6 months consider psychological triggers, spinal cord/neurological injuries, diabetes, and sleep apnea
• Monosymptomatic (nocturnal symptoms only) vs non-monosymptomatic (with concurrent daytime symptoms): If daytime symptoms present, a more thorough workup is indicated (see above)
• Family history: Familial history of bedwetting is very common in children with nocturnal enuresis

Treatment: 

• Nocturnal enuresis is much easier to address when the child is motivated and ready to address it! Dr. Tong typically doesn’t recommend treatment prior to around age 6, although it depends on the child. 
• The primary treatments for nighttime incontinence are bedwetting alarms and desmopressin. The selection of a particular treatment depends greatly on family circumstance and social dynamics.
• Combining bedwetting alarms and desmopressin is generally not recommended as they may have contradictory mechanisms. However, desmopressin can be combined with anticholinergics like oxybutynin at nighttime for a synergistic effect in refractory cases.
• Behavioral modifications (important in all cases): Limiting fluids before bed, ensuring regular bowel movements, and double voiding before bed are important general recommendations. However, many parents have already tried these by the time they seek professional help. 
• Pull-ups vs. Underwear There is no strong evidence to suggest that using pull-ups versus underwear affects the physiological mechanism of bedwetting, which is related to the central nervous system’s recognition of bladder fullness.

Bedwetting alarms

The goal of a bedwetting alarm is to “retrain” the brain to recognize bladder fullness overnight. Dr. Carmen recommends starting this during a holiday break or summertime, as it is often very disruptive at first.

• The alarm goes off after the child begins to wet the bed.
• Requires the child to fully wake up, go to the bathroom to finish voiding, and participate in changing sheets to help the brain register the behavior. For a child that is deeply asleep, the parent often has to help physically wake up the child. 
• Can take months and requires a dedicated parent to ensure the child fully wakes up to the alarm.
• Most effective for children with frequent bedwetting episodes (most nights of the week).
• Treatment success is often defined as 14 consecutive dry nights.

Pharmacologic Treatment: Desmopressin

• Desmopressin works by reducing nighttime urine production.
• Effective for children who produce a lot of urine at night and have good bladder function.
• Dosage typically starts at 0.2 mg taken an hour before bed – can be titrated up to a maximum of 0.6 mg.
• Important Caveat: Requires strict fluid restriction a couple of hours before bedtime, voiding before bed, and only a small drink with the pill due to the risk of hyponatremia and potential seizures.
• Intranasal desmopressin is not recommended due to a higher risk of hyponatremic seizures.
• Can be used PRN for events like sleepovers or travel, but should be trialed at home first to determine the effective dose.
• Caution advised/hold the medication  if the child has a fever, vomiting, or diarrhea due to the risk of fluid/electrolyte imbalance (low threshold for ER)
• Taking “holidays” from desmopressin during periods like summer can help assess if the child has outgrown enuresis.

Social Disparities 

Health disparities can significantly impact families dealing with enuresis due to the cost of products like pull-ups and mattress pads, access to healthcare and specialists, and health literacy regarding the involuntary nature of bedwetting. Bedwetting alarms may not be feasible in crowded living situations, and medication costs can be a barrier. It’s important to consider realistic goals and provide support tailored to the family’s circumstances..

Resources 

• International Children’s Continence Society (including various parent resources)
• AAP Reference on Enuresis
• Pediatrics in Review: Nocturnal Enuresis 

Goal

Listeners will be able to explain the diagnosis and management of both daytime and nighttime enuresis, including behavioral strategies, medication options, and when to pursue further workup or referral.

Learning Objectives

After listening to this episode listeners will…  

1. Explain the differential diagnosis of daytime enuresis, including how urinary tract infections, constipation, neurodevelopmental, and anatomical factors contribute to incontinence.
2. Identify key elements of the history, physical exam, and initial workup necessary to evaluate a child with enuresis.
3. Describe first-line non-pharmacologic treatments for daytime enuresis, including behavioral strategies, bowel management, and school-based interventions.
4. Explain the clinical approach to nocturnal enuresis, including how to distinguish between monosymptomatic and non-monosymptomatic presentations and when further evaluation is warranted.
5. Describe evidence-based treatments for nocturnal enuresis, including the appropriate use of bedwetting alarms, desmopressin, and behavioral strategies, along with key counseling points for families.

Disclosures

Dr. Tong has served on an Advisory Committee for Novo Nordisk. The content provided is for educational purposes only and does not endorse any specific products or companies. All references to medications or treatments use generic names to maintain objectivity and avoid commercial bias.

 The Cribsiders report no relevant financial disclosures. 

Citation

Engel S, Tong C, Chiu C, Masur S.  “#147: Urine Good Hands: Evidence-Based Approaches to Enuresis”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ 30th July, 2025.