Summary
Background
Enuresis is an extremely common condition, which, although somatically benign, poses
long-term psychosocial risks if untreated. There are still many misconceptions regarding
the proper management of these children.
Aim
A cross-professional team of experts affiliated with the International Children's
Continence Society (ICCS) undertook to update the previous guidelines for the evaluation
and treatment of children with enuresis.
Methods
The document used the globally accepted ICCS terminology. Evidence-based literature
served as the basis, but in areas lacking in primary evidence, expert consensus was
used. Before submission, a full draft was made available to all ICCS members for additional
comments.
Results
The enuretic child does, in the absence of certain warning signs (i.e., voiding difficulties,
excessive thirst), not need blood tests, radiology or urodynamic assessment. Active
therapy is recommended from the age of 6 years. The most important comorbid conditions
to take into account are psychiatric disorders, constipation, urinary tract infections
and snoring or sleep apneas. Constipation and daytime incontinence, if present, should
be treated. In nonmonosymptomatic enuresis, it is recommended that basic advice regarding
voiding and drinking habits be provided. In monosymptomatic enuresis, or if the above
strategy did not make the child dry, the first-line treatment modalities are desmopressin
or the enuresis alarm. If both these therapies fail alone or in combination, anticholinergic
treatment is a possible next step. If the child is unresponsive to initial therapy,
antidepressant treatment may be considered by the expert. Children with concomitant
sleep disordered breathing may become dry if the airway obstruction is removed.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Pediatric UrologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Evaluation and treatment of monosymptomatic enuresis - a standardisation document from the International Children's Continence Society (ICCS).J Urol. 2010; 183: 441-447
- Evaluation and treatment of nonmonosymptomatic nocturnal enuresis: a standardization document from the International Children's Continence Society.J Pediatr Urol. 2012; 9: 234-243
- The standardization of terminology of lower urinary tract function in children and adolescents: update report from the standardization committee of the International Children's Continence Society.J Urol. 2014; 191: 1863-1865
- Micturition in infants and children with normal lower urinary tract.Scand J Urol Nephrol. 1976; : 1-106
- Enuresis in seven-year-old children.Acta Paediatr Scand. 1988; 77: 148-153
- The epidemiology of childhood enuresis in Australia.Br J Urol. 1996; 78: 602-606
- Enuresis and spontaneous cure rate: study of 1129 enuretics.Arch Dis Child. 1974; 49: 259-263
- Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study.BJU Int. 2006; 97: 1069-1073
- Family history of nocturnal enuresis and urinary incontinence: results from a large epidemiological study.J Urol. 2011; 185: 2303-2306
- Molecular genetics of nocturnal enuresis: clinical and genetic heterogeneity.Acta Paediatr. 1998; 87: 571-578
- Understanding of and misconceptions around monosymptomatic nocturnal enuresis: findings from patient and physician surveys.J Pediatr Urol. 2018; 15: e1-e37
- Abnormal diurnal rhythm of plasma Vasopressin and urinary output in patients with enuresis.Am J Physiol. 1989; 256: F664-F671
- Elevated sleep arousal thresholds in enuretic boys: clinical implications.Acta Pædiatrica. 1997; 86: 381-384
- The Pathogenesis of enuresis – towards a new understanding.Int J Urol. 2017; 24: 174-182
- Aberrant whole-brain functional connectivity and intelligence structure in children with primary nocturnal enuresis.PloS One. 2013; 8e51924
- Altered brain activation during response inhibition in children with primary nocturnal enuresis: an fMRI study.Hum Brain Mapp. 2011; 33: 2913-2919
- Central nervous system involvement in nocturnal enuresis: evidence of general neuromotor delay and specific brainstem dysfunction.J Urol. 2001; 166: 2448-2451
- Periodic limb movements during sleep are associated with a lower quality of life in children with monosymptomatic nocturnal enuresis.Eur J Pediatr. 2015; 174: 897-902
- Sleep fragmentation and periodic limb movements in children with monosymptomatic nocturnal enuresis and polyuria.Pediatr Nephrol. 2015; 30: 1157-1162
- Outcome of a standardized approach to childhood urinary symptoms – long-term follow-up of 720 patients.Neurourol Urodyn. 2014; 33: 475-481
- Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence.Scand J Urol Nephrol. 1997; 31: 79-82
- The impact of bowel and bladder problems on children's quality of life and their parents: a scoping review.Child Care Health Dev. 2018; 45: 1-14
- Desmopressin (melt) therapy in children with monosymptomatic nocturnal enuresis and nocturnal polyuria results in improved neuropsychological functioning and sleep.Pediatr Nephrol. 2016; 31: 1477-1484
- Enuresis nocturna in adults.Scand J Urol Nephrol. 1997; 31: 533-536
- Comorbidity of ADHD and incontinence in children.Eur J Child Adolesc Psychiatr. 2015; 24: 127-140
- Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood.Pediatrics. 1997; 100: 228-232
- Urinary and faecal incontinence: a population-based study.Acta Paediatr. 2004; 93: 386-389
- Effect of rectal distention on lower urinary tract function in children.J Urol. 2010; 184: 1680-1685
- Management of functional constipation in children with lower urinary tract symptoms; Report from the Standardization Committee of the International Children's Continence Society.J Urol. 2013; 190: 29-36
- Management of functional nonretentive fecal incontinence in children: recommendations from the International Children's Continence Society.J Pediatr Urol. 2015; 12: 56-64
- Lower urinary tract dysfunction in girls with untreated asymptomatic or covert bacteriuria.J Urol. 1990; 143: 333-335
- Enuretic children with obstructive sleep apnea syndrome: should they see otolaryngology first?.J Pediatr Urol. 2013; 9: 145-150
- Sleep disordered breathing and nocturnal polyuria: nocturia and enuresis.Sleep Med Rev. 2003; 7: 403-411
- Childhood functional gastrointestinal disorders: neonate/toddler.Gastroenterology. 2016; ([ePub ahead of print])
- Early detection of psychological problems in a population of children with enuresis: construction and validation of the Short Screening Instrument for Psychological Problems in Enuresis.J Urol. 2007; 178: 2611-2615
- Enuresis: practical guidelines for primary care.Br J Gen Pract. 2017; 67: 328-329
- Use of pelvic ultrasound in the diagnosis of megarectum in children with constipation.J Pediatr Surg. 2005; 40
- Transabdominal ultrasound of rectum as a diagnostic tool in childhood constipation.J Urol. 2008; 179: 1997-2002
- Diagnostic evaluation of children with daytime incontinence.J Urol. 2010; 183: 693-703
- Treatment of daytime urinary incontinence: a standardization document from the International Children's Continence Society.Neurourol Urodyn. 2015; 36: 43-50
- Examining the effectiveness of parental strategies to overcome bedwetting: an observational cohort study.BMJ Open. 2017; 7e016749
- No effect of basic bladder advice in enuresis – a randomised controlled trial.J Pediatr Urol. 2015; 11: 153e1-153e5
- Psychological and psychiatric issues in urinary and fecal incontinence.J Urol. 2011; 185: 2303-2307
- Alarm interventions for nocturnal enuresis in children (Cochrane Review).The Cochrane Library, 2007 (Issue 1. Oxford: Update Software)
- The optimal duration of alarm therapy use in children with primary monosymptomatic nocturnal enuresis.J Pediatr Urol. 2018; 14 (447.e1-6)
- Efficacy of the bell and pad alarm therapy for nocturnal enuresis.J Paediatr Child Health. 2009; 45: 405-408
- Alarm treatment: analyses of response and relapse.Scand J Urol Nephrol. 1999; 33: 73-75
- Desmopressin for nocturnal enuresis.Cochrane Database Syst Rev. 2002; 3: CD002112
- Hyponatremia in patients with nocturnal enuresis treated with DDAVP.Eur J Pediatr. 1996; 155: 959-962
- The efficacy of DDAVP is related to the circadian rhythm of urine output in patients with persisting nocturnal enuresis.Clin Endocrinol. 1998; 49: 793-801
- Bladder capacity and renal concentrating ability in enuresis – pathogenic implications.J Urol. 2001; 165: 2022-2025
- A randomised comparison of oral desmopressin lyophilisate (MELT) and tablet formulations in children and adolescents with primary nocturnal enuresis.Int J Clin Pract. 2007; 61: 1454-1460
- Does structured withdrawal of desmopressin improve relapse rates in patients with monosymptomatic enuresis?.J Urol. 2014; 192: 530-534
- The gradual tapering of desmopressin leads to the better outcomes in nocturnal enuresis.Pediatr Int. 2015; 57: 656-658
- Oral desmopressin lyophilisate (MELT) for monosymptomatic enuresis: structured versus abrupt withdrawal.J Pediatr Urol. 2014; 10: 52-55
- Bladder dysfunction in children with refractory monosymptomatic primary nocturnal enuresis.J Urol. 1999; 162: 1049-1055
- Combination therapy with desmopressin and an anticholinergic medication for nonresponders to desmopressin for monosymptomatic nocturnal enuresis: randomized, double-blind, placebo-controlled trial.Pediatrics. 2008; 122: 1027-1032
- Frequency of wetting is predictive of response to anticholinergic treatment in children with overactive bladder.Urology. 2006; 67: 1049-1054
- Spectrum of central anticholinergic adverse effects associated with oxybutynin: comparison of pediatric and adult cases.J Pediatr. 2009; 155: 432-434
- The use of tolterodine in children after oxybutynin failure.BJU Int. 2003; 91: 398-401
- Comparison of tolterodine with standard treatment in pediatric patients with non-neurogenic dysfunctional voiding/over active bladder: a systematic review.Indian J Physiol Pharmacol. 2013; 57: 343-353
- Mirabegron: a review in overactive bladder syndrome.Drugs. 2018; 78: 833-844
- Prospective pilot study of mirabegron in pediatric patients with overactive bladder.Eur Urol. 2016; 70: 9-13
- Tricyclic and related drugs for nocturnal enuresis in children.Cochrane Database Syst Rev. 2000; 2000: CD002117
- Single dose imipramine reduces nocturnal urine output in patients with nocturnal enuresis and nocturnal polyuria.J Urol. 1997; 158: 830-836
- Imipramine for therapy resistant enuresis: a retrospective evaluation.J Urol. 2004; 171: 2607-2610
- The noradrenergic action in antidepressant treatments: pharmacological and clinical aspects.CNS Neurosci Ther. 2011; 17: 723-732
- Imipramine in the treatment of enuretic school children. A double-blind study.Am J Dis Child. 1968; 115: 17-20
- Treatment of nocturnal enuresis with imipramine and related preparations. A double blind trial with a placebo.Acta Paediatr Scand. 1971; 60: 244
- Nocturnal enuresis: a placebo controlled trial of two antidepressant drugs.Arch Dis Child. 1996; 75: 62-66
- The cardiotoxicity of the tricyclics.J Am Acad Child Adolesc Psychiatry. 1991; 30: 1991
- Sudden death of a child treated with imipramine. Case study.J Child Adolesc Psychopharmachol. 2000; 10: 321-325
- Imipramine for refractory daytime incontinence in the pediatric population.J Pediatr Urol. 2017; 14: 58.e1-58.e5
- Combination of the enuresis alarm and desmopressin. Second line treatment for enuresis nocturna.J Urol. 2008; 179: 1128-1131
- Prevention of relapse in full-spectrum home training for primary enuresis: a component analysis.Behav Ther. 1986; 17: 462-469
- Desmopressin resistant nocturnal polyuria may benefit from furosemide therapy administered in the morning.J Urol. 2007; 178: 2635-2639
- Combination treatment of nocturnal enuresis with desmopressin and indomethacin.Pediatr Nephrol. 2016; 32: 627-633
- Atomoxetine ameliorates nocturnal enuresis with subclinical attention-deficit/hyperactivity disorder (ADHD).Pediatr Int. 2017; 59: 181-184
- Reboxetine in therapy-resistant enuresis – a randomized, placebo-controlled study.J Pediatr Urol. 2016; 12 (397.e1-.e5)
Article info
Publication history
Published online: January 30, 2020
Accepted:
December 30,
2019
Received:
October 25,
2019
Identification
Copyright
© 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
