Indian Academy of Pediatrics (IAP)

STANDARD
TREATMENT
GUIDELINES 2022

Enuresis:
What to Know
and How to Treat?
Lead Author
Pankaj Deshpande
Co-Authors
Fagun Shah, Rajiv Sinha

Under the Auspices of the IAP Action Plan 2022

Remesh Kumar R
IAP President 2022
Upendra Kinjawadekar Piyush Gupta
IAP President-Elect 2022 IAP President 2021
Vineet Saxena
IAP HSG 2022–2023
© Indian Academy of Pediatrics

IAP Standard Treatment Guidelines Committee

Chairperson
Remesh Kumar R
IAP Coordinator
Vineet Saxena
National Coordinators
SS Kamath, Vinod H Ratageri
Member Secretaries
Krishna Mohan R, Vishnu Mohan PT
Members
Santanu Deb, Surender Singh Bisht, Prashant Kariya,
Narmada Ashok, Pawan Kalyan
 Enuresis: What to Know
116
and How to Treat?
Introduction

The word “enuresis” has become synonymous with bedwetting. There can be nothing further
from the truth and we need to erase this kind of thinking.

Enuresis is defined as involuntary passage of urine beyond the age at which bladder control
is deemed to be achieved. Mainly can be divided as:
;; Daytime enuresis: Often missed and the one that every pediatrician should be aware of to
be able to diagnose and treat appropriately. Most children in this group get treated for
the “nonexistent”’ urinary tract infections (UTIs)!

Definition
;; Nocturnal enuresis: The enuresis occurs predominantly at night when the child is fast
asleep (including wetting when asleep in the day).
Enuresis can be clinically considered as follows:
;; Predominantly daytime (overactive bladder)
;; Both daytime and nocturnal (posterior urethral valves, tubular problems, and neurogenic
bladder)
;; Predominantly nocturnal (primary nocturnal enuresis)
Different causes of enuresis and their management is given in Table 1.
 Enuresis: What to Know and How to Treat?

TABLE 1:  Conditions presenting as enuresis and treatment.

Overactive bladder Posterior urethral valves Juvenile
nephronophthisis
Symptoms Frequency, urgency, dysuria, and Can present as day-time Can present as daytime
daytime wetting wetting and wetting at polyuria/wetting and
night in older boys nocturnal enuresis
Differential Urinary tract infections (UTI), local Mistaken for UTI, other Overactive bladder,
diagnosis problems such as vulval redness enuresis causes diabetes insipidus,
diabetes mellitus, and
chronic kidney failure
Clinical clues Prevoid wetting, small volumes of ;; May be using abdominal ;; Nocturnal enuresis
urine, wetting by a few drops of pressure to void may start late
urine, not waking to drink water at ;; Urinary stream may ;; Drinks large amounts
night, usually not wetting at night, not be good of water
and parents complain “waits till last ;; Pre- and postvoid ;; Family history
minute to void” wetting (autosomal recessive)
Diagnostic Ultrasound shows normal ;; Ultrasound may show ;; Ultrasound: Normal
clues kidneys and bladder with low dilated ureters and kidneys and bladder
prevoid volume and emptying to renal pelvis/pelves but Urine shows low-
Enuresis

;;
completion sometimes may not specific gravity (1.005),
;; High postvoid residue may be trace sugar,
(even after second minor hematuria and
void) proteinuria
Investigation Ultrasound scan of kidneys and Micturating cystogram Raised serum creatinine,
bladder (MCU) hyposthenuria, raised
urinary tubular protein, and
characteristic kidney biopsy
Maneuvers Vincent’s curtsy, crossing legs, and
holding perineum with hand or heel
Aggravating Constipation, stimulant drinks such
factors as tea and coffee, and fizzy drinks
Treatment ;; Treat constipation (lactulose Fulguration of posterior Need dialysis and
and lactitol) used for prolonged urethral valves (surgery) transplantation when end-
period (3–4 months) and long-term follow-up of stage kidney disease
;; Stop stimulant and fizzy drinks renal function
;; Voiding diary for noting
improvement
;; Anticholinergic medication
(oxybutynin 0.5–0.6 mg/kg/
day in two or three doses,
tolterodine 2 mg for a child
<35 kg once a day)

4
 Enuresis: What to Know and How to Treat?

TABLE 2:  Conditions presenting as enuresis and treatment (Continued).

Neurogenic bladder Ectopic ureter Diabetes mellitus Primary nocturnal
insertion below the (D)/diabetes enuresis
bladder sphincter insipidus (DI)
Symptoms ;; Wetting throughout ;; Continuous ;; Increased thirst ;; Wetting at night
;; Dribbling of urine urinary leakage ;; Frequent voiding persistent above 5
;; Recurrent UTIs and wetting nocturnal enuresis years of age when
;; Severe constipation ;; Never dry when weight loss, asleep
awake or asleep irritability, and ;; No daytime symptoms
behavior changes
Differential ;; Enuresis ;; Enuresis Tubular disorders UTI, May be confused with
diagnosis ;; Posterior urethral valves ;; Bladder and chronic kidney overactive bladder,
;; Other causes of recurrent dysfunction disease diabetes mellitus, and
UTIs diabetes Insipidus
Clinical clues ;; History of repair of ;; Never dry ;; DM: Enuresis, Wetting at least 5 nights
meningomyelocele/spinal ;; Continuous weight loss despite per week, no daytime
tumor/trauma leaking of polyphagia, and symptoms, positive family
;; Any lump or tuft of hair in urine often family history history in parents, no
the back seen on vulval ;; DI: Polydipsia and polyuria or failure to thrive
;; Delayed walking/ examination polyuria, waking
abnormal gait at night for water
;; Lower limb weakness and voiding urine
;; Severe constipation ;; Central DI: CNS
insult history
Diagnostic ;; USG KUB: Thick ;; Ultrasound ;; DM: Glycosuria, Normal USG KUB, normal

Enuresis
clues trabeculated bladder shows normal high fasting/ urine examination
wall with often bilateral kidneys and random blood
hydronephrosis bladder sugars, and raised
;; MCUG: Thick walled ;; Hydroureter may Hb1Ac
trabeculated bladder and be seen ;; DI: Urine
bilateral VUR and poor ;; Vesicoureteral osmolality
emptying reflux may be <300 mosm/L,
;; MRI for spinal defect present hypernatremia if
;; Associated urine infection inability to drink
Investigation ;; USG KUB ;; USG KUB ;; DM: Blood sugar Proper history is
;; MCUG ;; MR urography or and Hb1Ac diagnostic, investigations
;; Urodynamic study Contrast CT KUB ;; DI: Paired serum not required in majority
;; MRI lumbosacral spine ;; Cystoscopy and urine
osmolarity, water
deprivation test
Treatment ;; Anticholinergic treatment Surgical therapy: ;; DM: Dietary ;; Optimization of fluids
(oxybutynin, tolterodine Ureteric restrictions and ;; Avoid bladder irritants
as described above) reimplantation insulin therapy past evening
;; Treat constipation ;; Central DI: ;; Avoid constipation
;; Clean intermittent Vasopressin— ;; Star charts and night
catheterization (CIC) intranasal/oral bed alarms
;; Combined nephro- ;; Nephrogenic DI: ;; Primary Therapy:
urology long-term Reduce solute ;; Oral desmopressin for
management intake (salt/ 3 months and reassess
proteins) to (>50% reduction in
reduce obligatory wetting episodes
urine water losses considered success)
;; Thiazides/ ;; Enuresis alarm
amiloride/ ;; Combination therapy
indomethacin (if either monotherapy
fails)

5
(CNS: central nervous system; Hb1Ac: hemoglobin A1c; MCUG: micturating cystourethrogram; USG KUB: ultrasonography for
kidney, ureter, and urinary bladder; UTI: urinary tract infection)
 Enuresis: What to Know and How to Treat?
Conclusion

There is varied etiology for enuresis. After identifying whether daytime or nocturnal, treatment
should be directed at the cause of the enuresis.

TABLE 3:  Treatment of different conditions of enuresis.

Conditions Treatment (nonpharmacologic) Treatment (pharmacologic)
Detrusor ;; Avoid constipation ;; Lactulose/lactitol for prolonged periods
instability ;; Avoid caffeinated drink and (3–4 months)
carbonated drinks ;; Tablet oxybutynin (0.5–0.6 mg/kg/day in two
;; Ensure no vulval redness in to three doses or tablet tolterodine 2 mg
girls (weight < 35 kg)
PU valves Fulguration of valves
Juvenile Management of chronic kidney

Treatment (In Brief)

nephronophthisis disease
Neurogenic ;; Avoid constipation Lactulose/lactitol as above
bladder ;; Clean intermittent Oxybutynin/tolterodine as above
catheterization (CIC)
Ectopic ureter Surgery
Diabetes mellitus/ Specific therapy like insulin/ Central diabetes insipidus (DI):
insipidus antidiuretic hormone (ADH) ;; Oral desmopressin—0.05–0.2 mg/day BD/TDS
;; Intranasal 5–30 µg/day BD/TDS

Nephrogenic DI:
;; Thiazides—2–4 mg/kg/day in three divided doses
;; Amiloride—used along with thiazides, 0.3 mg/kg/
day in three divided doses
;; Indomethacin (use with caution, risk of renal injury)
—2–3 mg/kg day in two to three divided doses
Primary nocturnal ;; Treat constipation Oral desmopressin: 0.2–0.4 mg—1 hour before sleep for
enuresis ;; Ensure less fluid intake after months—taper and stop
7 PM
;; Ensure adequate fluid intake
in the day
;; Avoid caffeinated drinks and
fizzy drinks

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 Enuresis: What to Know and How to Treat?

;; Arda E, Cakiroglu B, Thomas DT. Primary nocturnal enuresis: A review. Nephrourol Mon.

Further Reading
2016;8(4):e35809.
;; Deshpande AV, Craig JC, Smith GH, Caldwell PH. Management of daytime urinary
incontinence and lower urinary tract symptoms in children. J Paediatr Child Health.
2012;48(2):E44-52.
;; Mahadik P, Vaddi SP, Godala CM, Sambar V, Kulkarni S, Gundala R. Posterior urethral valve:
Delayed presentation in adolescence. Int Neurourol J. 2012;16(3):149-52.
;; Nieuwhof-Leppink A, Schroeder RP, van de Putte EM, Jong TP, Schappin R. Daytime urinary
incontinence in children and adolescents. Lancet Child Adolesc Health. 2019;3(7):492-501.
;; Ramsay S, Bolduc S. Overactive bladder in children. Can Urol Asso J. 2017;11(1-2):S74-9.