Enuresis

Etiology

The etiology of enuresis is multifactorial, with a solid genetic component influenced by physiologic and environmental factors. Children with 1 affected parent face a 44% likelihood of developing enuresis, and those with 2 affected parents have a 77% likelihood.[3][4] Only 15% of children born to parents without a history experience enuresis. Twin studies reveal a 68% concordance rate in monozygotic twins with enuresis.[3][13][14][15] Additional studies also reveal an autosomal dominant form with approximately 90% penetrance in Danish families linked to chromosome 13q13-q14.3.[16][17] Additional loci are on chromosomes 12q13-q21, 13q22.3, 22q11, and 6q16.2.[18][19] The following list includes the potential causes of both primary and secondary enuresis:

Primary Enuresis

• Idiopathic
• Nocturnal polyuria
• Maturational delay
• Disorder of sleep arousal
• Small bladder capacity
• Detrusor overactivity
• Cystitis
• Fecal incontinence or constipation
• Neurogenic bladder
• Arginine vasopressin disorders
• Urethral obstruction
• Ectopic ureter
• Constipation
• Sickle cell disease
• Significant life stressors [3][20][21][22][23]

Causes Unique to Secondary Enuresis  

• Diabetes
• Seizure disorder
• Obstructive sleep apnea [24]
• Chronic kidney disease
• Pinworms
• Primary polydipsia

Children with NMNE typically have anatomic causes, including structural urinary tract abnormalities leading to impaired bladder function.[6][25]

Epidemiology

The prevalence of enuresis is similar across cultures and varies with age, with males affected twice as often as females.[3][26] By age 4, nearly 25% of children experience frequent bedwetting; by 5, the condition affects approximately 15% of children. Once children reach 8, the incidence is 4%.[27] However, due to the stigma associated with enuresis, many cases go unreported, making the true prevalence challenging to ascertain. Primary MNE resolves at a rate of approximately 15% per year. However, some individuals, estimated between 1% and 2%, remain symptomatic as adults but often hesitate to report the condition due to fear of stigmatization.[26][28] 

The longer enuresis persists, the less likely it will resolve. When combined, secondary enuresis accounts for approximately 25% of cases, with the prevalence of secondary enuresis increasing with age. Nearly 9% of patients with sickle cell anemia have enuresis. A subset of children have associated bowel and bladder dysfunction. Nearly 20% of children with nocturnal symptoms have daytime symptoms, and 15% of children have fecal incontinence.

The International Children's Continence Society reports that 20% to 30% of children with enuresis have at least 1 mental health condition, approximately twice the rate of non-wetting children. The most frequently cited disorder accompanying enuresis is attention deficit hyperactivity disorder, but others include autism spectrum disorder, oppositional defiant disorder, and mood disorders. This link is an association, not proof of causation since enuresis can result in feelings of shame, embarrassment, and frustration, which then lead to anxiety and depression.[4][29] 

Pathophysiology

To understand the pathophysiology of enuresis, clinicians must first understand normal bladder maturation. At birth, voiding is uncontrolled. Bladder control during this time is via the lower spinal cord and primitive brain centers. Bladder filling, feeding, bathing, and tickling cause uninhibited detrusor contractions. As the child grows, bladder capacity increases. To gain bladder control, children mature through a stepwise process. They first become aware of the bladder filling. This, in turn, allows them to develop the ability to suppress detrusor contractions voluntarily. Finally, they coordinate urethral sphincter activity and detrusor contractions. This level of maturity develops typically during the day by age 4. However, nocturnal bladder control lags behind daytime control by months to years. 

Delayed Bladder Maturation

The majority of children with MNE will have spontaneous resolution of their symptoms, indicating a delay in normal bladder maturation. Study results reveal that children with enuresis have delayed central nervous system maturation, language, and gross motor development.[30][31][32][33]

Nocturnal Polyuria

Children with nocturnal enuresis have increased nighttime urine output when compared to their peers without enuresis. This may be due to increased fluid intake before bedtime, reduced anti-diuretic hormone (ΑDH) response, or decreased secretion of ΑDΗ. Most unaffected individuals produce 50% less urine at night than during the day. However, children with enuresis may exhibit an abnormal circadian rhythm with decreased nocturnal ADH secretion, resulting in larger quantities of dilute urine during sleep.[3][20][25] However, reduced ADH secretion or response does not explain why children do not wake to void. 

Disturbed Sleep

The contribution of disturbed and excessively deep sleep to enuresis must be clarified. Sleep disturbances, such as obstructive sleep apnea, periodic limb movements, and increased cortical awakenings, are also associated with enuresis.[34] These conditions disrupt typical sleep patterns and contribute to the failure to awaken in response to a full bladder.[24] Children with enuresis have a higher arousal threshold during sleep and difficulty awakening.

Long-term repeats of apneic episodes during sleep associated with obstructive sleep apnea lead to repeated arousals during sleep, increasing a child's arousal threshold. Children with an increased arousal threshold have a decreased sensitivity to bladder filling or detrusor contraction, which normally signals the urge to void. Children with obstructive sleep apnea are unable to wake in time to void, causing enuresis.[24][25] Brain natriuretic peptide, secreted by myocardial cells, promotes sodium excretion, inhibiting the renal-angiotensin-aldosterone system, reducing the release of ADH, and promoting urination.

After an apnea event, the negative pressure within the chest intensifies, causing an increase in systemic venous return and a heightened load on both the left and right ventricles. This acute ventricular strain and atrial wall dilation due to the elevated intrathoracic negative pressure stimulate brain natriuretic peptide release from ventricular myocytes, ultimately contributing to enuresis.[35] Enuresis often improves or resolves after tonsillectomy and adenoidectomy in these patients.[3][5][36] 

Small Bladder Capacity

At birth, the normal bladder volume is approximately 60 mL and increases in size by 30 mL yearly until age 10. Children with nocturnal enuresis have a smaller functional bladder capacity than that of their peers.[24][25][37][38] 

Detrusor Overactivity

Detrusor overactivity is most commonly associated with daytime incontinence. However, clinicians should also consider detrusor overactivity in children with persistent nocturnal enuresis, as this may indicate an underlying issue with the circadian rhythm controlling detrusor inhibition or pelvic floor activity.[24][25]

Neurodevelopmental Concerns

Children with neurodevelopmental disorders, including intellectual disabilities, autism spectrum disorder, and attention-deficit/hyperactivity disorder (ADHD), experience enuresis more frequently. Psychological influences, environmental stressors, and coexisting medical conditions can exacerbate or contribute to enuresis. Children with bedwetting may experience psychosocial stress and impaired self-esteem, which further complicate the situation. Though experts suggest psychological causes may precipitate enuresis, evidence suggests that behavioral abnormalities are more likely a result of enuresis than a cause.[3][20] 

Structural Abnormalities

Posterior urethral valves (PUV), often associated with both daytime and nocturnal symptoms, obstruct membranous folds within the lumen of the posterior urethra, causing urinary tract obstruction. PUVs develop due to disruption during the normal development of the male urethra between gestational weeks 9 and 14. An ectopic ureter occurs when the ureteral orifice is caudal to the normal insertion on the trigone of the bladder. Because they bypass the external sphincter in nearly two-thirds of affected females, incontinence is the presenting feature in many females. In contrast, a urinary tract infection is the typical indicator in males. Ectopic ureters result from an abnormally high origin of the ureteral bud from the mesonephric duct, coupled with a delay or failure in separating the bud from the duct.

The distension of the rectum in a child with constipation puts direct pressure on the bladder wall, causing detrusor overactivity and impairing bladder emptying. In addition, detrusor-sphincter dyscoordination occurs due to prolonged anal sphincter contraction and inappropriate pelvic floor muscle contraction. Colonic and rectal distension may also increase parasympathetic activity, causing increased detrusor activity.

Infectious Causes

Pinworms can irritate the urethra, leading to enuresis. Lower urinary tract infections irritate the bladder, potentially causing enuresis. 

Other Causes

Sickle cell disease may cause a urinary concentrating defect producing a low specific gravity. In addition, decreased functional bladder capacity, social and environmental factors, and decreased arousal during sleep all likely play a role. Arginine vasopressin resistance, previously called nephrogenic diabetes insipidus, contributes to enuresis by causing excessive urine production at night.[39][40]

History and Physical

Children with MNE present with individual episodes of nocturnal enuresis in the absence of lower urinary tract symptoms and no history of bladder dysfunction. Children with NMNE present with episodes of nocturnal enuresis and the following symptoms:

• Nocturia
• Urgency
• Daytime incontinence
• Hesitancy
• Weak stream
• Straining
• Post-void dribbling
• Maneuvers to avoid voiding
• Pain
• Sensation of incomplete bladder emptying [41]

Clinicians will often discover a family history of enuresis. Constipation is common with primary and secondary nocturnal enuresis, with a 33% to 56% prevalence.[42] Signs include recurrent abdominal pain, fecal incontinence, painful bowel movements, stool retention, large stool volume in the rectum, fewer than 2 weekly bowel movements, and stools that may clog the toilet. Some children may have bowel habits affecting bladder control without meeting the clinical definition of constipation, so clinicians should be aware of signs like missed bowel movements, the need to push, or hard-to-pass stools.[43] In addition, excessive late afternoon and evening fluid intake may be present due to inadequate hydration during the school day, resulting in them coming home thirsty. 

Straining to start urinating or a weak stream could signal urethral obstruction, while bowel issues combined with an abnormal gait may signify a neurogenic bladder. Nocturnal sounds or muscle movements during sleep may suggest a seizure disorder. Behavioral problems are rarely associated with primary enuresis. Children with enuresis are more likely to experience shame, low self-esteem, and social isolation. Depression, anxiety, conduct disorder, and ADHD are more common in children aged 9 to 12 with daytime incontinence or secondary enuresis.

Sleep issues, like restless sleep, snoring, and sleepwalking, may indicate a sleep disorder. Symptoms such as dysuria, cloudy urine, hematuria, or urgency may indicate cystitis. Persistent wetness in girls may be due to ectopic ureters. The symptoms of diabetes are polyuria, polydipsia, and weight loss with a normal or increased appetite. At the same time, arginine vasopressin disorders also present with polyuria and polydipsia, along with decreased specific gravity on the first morning urine. Children with chronic kidney disease present with poor growth, hypertension, weight loss, edema, anorexia, and fatigue, in addition to abnormalities like proteinuria and hematuria on urinalysis. 

Recent case reports of sudden death during sleep in adolescents and young adults preceded by isolated new onset episodes of enuresis raise the concern of possible long QT syndrome or other underlying cardiac abnormality. Clinicians who encounter secondary enuresis should consider performing an electrocardiogram and obtaining a family cardiac history to evaluate the possibility of a nocturnal cardiac event.[44][45] 

Evaluation

Primary MNE occurs when there is an imbalance between bladder capacity and nighttime urine production, combined with the child’s inability to wake up when the bladder is full. The affected child has never achieved 6 consecutive months of nocturnal dryness. Though less common, enuresis is sometimes linked to underlying medical, psychological, or behavioral conditions. A thorough history, detailed physical examination, and urinalysis can typically distinguish between MNE and NMNE, determining the need for further evaluation and supporting more effective treatment planning. Key features clinicians must obtain from the history are:

• Presence of daytime incontinence
• Voiding diary, including the timing and volume of daytime voids [3]
• Presence of lower urinary tract symptoms like urgency, holding maneuvers, interrupted or weak stream, and straining
• Number of wet nights per week or month
• Stooling history, including any history of fecal incontinence and constipation
• Family history of enuresis
• Psychosocial effects of enuresis
• Social history
• Developmental and behavioral history using developmental screening tools [29]
• Medical history
• Concurrent symptoms like snoring, abnormal gait, sleepwalking, night terrors, polyuria, or polydipsia [4] 
• What interventions have been tried to date
• Presence of 6 months or longer of dryness
• Fluid intake diary

Generally, the physical examination of the child with MNE is normal. Examination findings indicating an underlying cause are enlarged tonsils, stool palpated in the abdomen, and wet undergarments indicating daytime incontinence or ectopic urethral valves in girls. Vulvovaginitis or anal excoriations suggest pinworm infection, and abnormalities of the lower extremity neurological examination may be due to spinal cord abnormalities. Genital findings contributing to enuresis may include hypospadias, phimosis, labial adhesions, and signs of fecal soiling on the underwear.   

A urinalysis is necessary for all children with enuresis—the urinalysis screens for diabetes, renal disease, arginine vasopressin disorders, water intoxication, and cystitis. A random or first-morning specific gravity greater than 1.020 excludes arginine vasopressin disorders. Clinicians reserve imaging like a renal sonogram and voiding cystourethrogram for patients with a history of urinary tract infections, daytime symptoms, or evidence of urologic abnormalities.[26] 

Lower extremity neurological abnormalities, gait abnormalities, and sacral findings such as dimples, hypertrichosis, nevi, hyper- and hypopigmentation, and hemangiomas prompt evaluation with MRI of the lumbosacral spine to exclude spinal cord abnormalities.[46] Children with evidence of snoring, mouth breathing, noisy breathing, pauses in breathing, coughing or choking, restless sleep, nighttime sweating, or other sleep disorders should undergo a sleep study.[47][48] The absence of snoring is not adequate to exclude obstructive sleep apnea. Children with sickle cell disease will have a family history and a urinary concentrating defect with a low specific gravity resulting in enuresis.[49]

Treatment / Management

The ideal time to treat primary MNE is when the child is motivated, able, and willing to adhere to a treatment program. Most children with MNE will have spontaneous resolution. If MNE is not distressing to the child, deferral of treatment is appropriate. Treatment of coexisting conditions, education, and motivational therapy are the mainstays of treatment for children younger than 6. Though the timing of treatment for enuresis varies among families, clinicians should routinely offer pubertal children advice and treatment options, keeping in mind that caregiver goals and expectations affect the treatment plan.

Understanding whether the child’s goal is to stay dry for specific events like sleepovers, reduce the overall frequency of wet nights, or minimize the impact of enuresis on the family is crucial for developing an effective treatment plan. Families and caregivers must be supportive and actively involved. Of particular importance is the understanding that the treatment of enuresis may be prolonged, involve multiple modalities, fail in the short term, and be prone to relapses. Children with daytime and nocturnal symptoms usually benefit from treating the daytime wetting first and obtaining an early urology consultation.

Patient and Caregiver Education

• Enuresis occurs in 15% of 5-year-olds and spontaneously resolves in most patients.
• Neither the child nor the caregiver is at fault, and punishment is not an acceptable way to prevent future enuresis episodes.
• Diapers or pull-on training pants, except for special occasions away from home, can hinder the child's motivation to get up and void in the middle of the night and avoid routine use.
• Using bed protection, room deodorizers, and emollients to prevent chafing helps minimize the effects of enuresis.
• The child should try to void 4 to 7 times daily. Attempts should be made every 2 hours, beginning when they first wake up, before they leave home or school, and the last attempt should be made before bed. If the child awakens at night, the caregiver should take the child to the bathroom.
• The school should have a note allowing unrestricted bathroom access. The child should not wait until scheduled breaks and avoid holding urine until the last minute.
• The child should avoid high-sugar and caffeinated drinks. 
• Some children find fluid restriction in the evening helpful. Families can attempt 40% of fluids in the morning and afternoon and 20% in the evening after 5 pm. Caretakers must ensure the child gets adequate fluid intake during the day before restricting evening fluids. Evening fluid restriction is only necessary if the family finds it successful.[50]
• Maintain a calendar of wet and dry nights to monitor the effectiveness of treatment.

Families of children between 5 and 7 can implement motivational therapy. Initially, begin with a sticker for a predetermined behavior, like going to the bathroom before bed, with an agreed-upon reward for a set number of consecutive nights. As time progresses, give larger rewards for longer periods of success, eventually graduating to rewards for a specified number of dry nights. Clinicians should discourage penalties and remove previously earned rewards, which is counterproductive.[51] If the response to the abovementioned techniques for 3 months is insufficient, then active therapy with alarms or medications is warranted. 

Alarm Therapy

Alarm therapy increases nocturnal bladder capacity and nocturnal arousal by generating a conditioned response, where the child either learns to wake to void or stop bladder contractions. Clinicians must show the child and family how to use the alarm and clearly instruct that it must be used every night. Reinforce that the child is responsible for operating and cleaning the alarm and should test it before bed each night. Encourage the child to rehearse what to do when the alarm sounds mentally.

Alarm instructions

• The child must wear underwear, not an absorbent diaper, for the alarm to detect urine moisture.
• The child wakes up, turns off the alarm, and finishes voiding in the toilet. In the beginning, the caregivers may have to wake the child; however, having the child awake and aware of what is happening is crucial to the success of the alarm.[26] 
• The child returns to the bedroom and changes their bedding and clothing with adult supervision. Caregivers should remember to keep fresh linens and clothing close to the bed.
• The child cleans the sensor with a damp cloth and then dries it or disposes of the sensor if it is disposable.
• The child resets the alarm and goes back to sleep.
• The family maintains a diary of wet and dry nights using positive reinforcement for properly using the alarm, getting up to void, and dry nights.

Reevaluation occurs within 1 to 2 weeks. If the child has evidence of a positive response, then the family should continue alarm use for 3 months or until the child has 14 consecutive dry nights, which typically takes between 12 to 16 weeks. Clinicians continue alarm therapy beyond 3 months if the child has more dry nights than they did on initiation. If there is no early response to the alarm, clinicians can add desmopressin or discontinue the alarm and retry in 6 to 12 months. 

Medication

Desmopressin acetate, a synthetic analog of ADH, is the medication of choice for treating MNE and is available in tablet and orally disintegrating form. However, the oral disintegrating form is not approved for enuresis in the United States. Nasal desmopressin is no longer recommended due to the risk of severe hyponatremia, seizure, and death.[52][53][54] The starting dose for the tablet form is 0.2 mg 60 minutes before bed, and clinicians can titrate by 0.2 mg every 7 days to a maximum dose of 0.6 mg. The dose for the orally disintegrating tablet is 120 µg, with a maximum dose of 360 µg titrating by 120 µg every 7 days. At the correct dose, the effects are immediate. The full effects last approximately 8 hours.[3] Families may use desmopressin regularly or as needed for special events like sleepovers or camp. Families should try a test dose at home to ensure efficacy when used for special occasions. Test dosing should begin 6 weeks before events like overnight camp to ensure the proper titration.

Like enuresis alarms, clinicians should assess the response to desmopressin within 1 to 2 weeks of beginning therapy. Children with a positive response should continue for 3 months. If the family decides to use desmopressin nightly, they should attempt a 1-week trial without medication every 3 months to determine the need for continuation. To discontinue desmopressin, experts suggest decreasing the effective dose by half for 2 weeks and then discontinuing the medication. This strategy helps prevent relapse. 

Families may choose between desmopressin or an enuresis alarm, depending on their needs. Both are equally effective, with alarms providing 0.6 more dry nights than desmopressin. However, the risk of relapse is lower with alarms than with desmopressin.[3][55] Caregivers must understand that enuresis alarms require nightly use for 3 to 5 months to achieve the most effective results. (B2)

Relapse

An enuresis relapse is the recurrence of more than 1 symptom per month. If the child had initial success with either an enuresis alarm or desmopressin, reinitiating the successful modality is the treatment of choice. If a child relapses after successful treatment with desmopressin, then tapering the dose over 2 weeks before discontinuing the medication may help prevent relapse. Children who experience recurrent relapses after successful treatment with either desmopressin or an enuresis alarm may benefit from a combination of desmopressin and an enuresis alarm.

Refractory Symptoms

A less than 50% improvement in symptoms with active intervention warrants further investigation.[26][56][57][58] Possible causes are inconsistent or incorrect use of the alarm, unrecognized constipation, overactive bladder, or other underlying conditions like diabetes, sleep apnea, and neurodevelopmental or behavioral issues. The evaluation and management of refractory enuresis typically involves specialty referral to developmental-behavioral pediatrics, behavioral psychology, child psychiatry, and pediatric urology. In addition, abdominal radiographs may be necessary to assess for unrecognized constipation. A pelvic and abdominal ultrasound may reveal increased bladder wall thickness in children with an overactive bladder or a distended rectum in the presence of constipation. A sleep study and neurodevelopmental screening may be necessary if not already done. 

Once further evaluation is complete, clinicians can utilize additional trials with an enuresis alarm with or without desmopressin. Anticholinergic agents like oxybutynin reduce bladder contractions and, combined with desmopressin, increase bladder capacity during sleep. Oxybutynin alone is not effective for MNE. However, 2.5 to 5 mg at bedtime, combined with desmopressin, may be helpful in children with enuresis and daytime incontinence. Tricyclic antidepressants (TCAs) like imipramine improve enuresis by a variety of mechanisms. A combination of central nervous system arousal at the brainstem level, inhibition of urination, weak anticholinergic properties, detrusor muscle relaxation, increased ADH release, and suppression of rapid eye movement sleep all contribute to the success of TCAs. Given the potential toxicity of TCAs, clinicians only use these medications after other treatment options have failed.

TCAs may be potentially cardiotoxic, with the primary concern being QT prolongation. Caregivers must understand how to keep the medication out of reach of children to prevent accidental overdose.[26][59] Before starting TCAs, clinicians must obtain the patient's personal and family cardiac history, including any history of syncope, dizziness, palpitations, and family history of early cardiac disease in family members younger than 40. Clinicians should obtain a pretreatment blood pressure, cardiovascular examination, and electrocardiogram.(B2)

Postpubertal females should also have a urine pregnancy test. Any history of cardiac disease or family history of early cardiac disease should prompt a referral to pediatric cardiology before starting TCA therapy. The starting dose is 10 to 25 mg 1 hour before bedtime, which can be increased by 25 mg after 1 week. The maximum dose is 50 mg for children and adolescents 6 to 12 and 75 mg for those 12 and older. If successful, clinicians should taper TCAs to the lowest effective dose, and the medication should be discontinued every 3 months for 2 weeks to help prevent the development of tolerance. The relapse rate is high upon TCA discontinuation. Gradually taper TCAs if there is no improvement within 3 months.

Additional Interventions

Intuitively, waking the child from sleep to urinate may seem helpful. However, this practice will not provide the proper conditioning for the child to wake to the sensation of a full bladder. Some methods recommend bladder training in which the child is asked to drink large quantities of fluid and hold their bladder for increasing amounts of time to increase bladder capacity. This therapy involves teaching the child not to respond to the normal sensation of a full bladder, which is quite uncomfortable. While bladder training increases bladder capacity, studies reveal no improvement in enuresis or response when using a bladder alarm.[60][61] (A1)

Neuromodulation or neurostimulation devices help modulate detrusor muscle contractions, stimulate pelvic floor muscle contractions, and are effective for some forms of daytime incontinence. Currently, insufficient information regarding appropriate treatment protocols for using this modality in treating enuresis is available.[62] Caregivers may also inquire about alternative or complementary treatments like acupuncture and hypnotherapy. To date, small, poorly designed studies show some potential benefits. However, larger controlled studies are necessary.[63][64] (A1)

Clonidine, propranolol, indomethacin, diclofenac, and diazepam have been investigated as potential off-label treatments for enuresis, and some have shown benefits. However, none are superior to desmopressin, and further randomized controlled trials are necessary to confirm their safety and effectiveness. Atomoxetine, a selective norepinephrine reuptake inhibitor used to treat attention-deficit/hyperactivity disorder (ADHD), may have a role in refractory cases, especially in patients with coexisting ADHD.[58]

Differential Diagnosis

The differential diagnosis of enuresis includes medical conditions that may present with similar symptoms or cause enuresis. Healthcare professionals should consider the following:

• Urinary tract infection
• Chronic kidney disease
• Ectopic ureters (females only)
• Posterior urethral valves
• Constipation
• Diabetes
• Arginine vasopressin disorders
• Obstructive sleep apnea
• Spinal dysraphism
• Pinworms
• Primary polydipsia
• Sickle cell disease
• Bladder dysfunction
• Physical or sexual abuse
• Behavioral or developmental disorders
• Medication adverse effects
• Urethral obstruction
• Overactive bladder
• Prolonged QT syndrome or other underlying cardiac condition

Prognosis

With a spontaneous resolution rate of 15% per year, the overall prognosis of MNE is good.[3][10] However, nearly one-third to one-fourth of parents punish their children because of enuresis.[21][65] Some children have experienced fatal abuse due to enuresis, and significant morbidity exists concerning the psychosocial effects. After 6 months of treatment, children with enuresis achieve self-esteem levels comparable to their peers without enuresis.

Approximately 5% of children remain affected at 10, and 1% to 2% continue with enuresis into adulthood.[66][67] Children who wet every night are likelier to continue having symptoms into adolescence. Bedwetting alarms are successful in approximately 66% of children.[68] Desmopressin reduces bedwetting by 1.3 nights per week and imipramine by 1 night per week.

The prognosis of NMNE is dependent on the underlying condition. The natural history is more complex, and patients often require longer and more intensive treatment. Children and adolescents with enuresis due to cystitis, ectopic ureter, obstructive sleep apnea, diabetes, arginine vasopressin disorders, or seizure disorder have a good prognosis. However, the underlying conditions complicate management and delay symptom resolution.[10][69]

Complications

Enuresis can cause distress and low self-esteem in children and impact the entire family socially and economically. The condition, at times, leads to mood problems, elevated stress levels, and difficulties socializing with peers. Children often experience shame, embarrassment, and teasing and hesitate to attend overnight camps or sleepovers with friends. Daytime incontinence, in particular, has an adverse psychological impact on children and is often associated with stressful life events, such as divorce, the death of a family member, or abuse. Some parents and caregivers believe enuresis is a disciplinary issue and punish children, which further increases emotional distress. Additionally, the wetness caused by enuresis can predispose to genitourinary skin infections and rashes. The financial burden of diapers, pull-ups, and replacing soiled linens or mattresses further strains families. 

Complications associated with enuresis alarms are minimal. The primary adverse events are alarm failure, failure to wake the child, false alarms, skin irritation, and disruption to other family members. Nearly 30% discontinue the use of enuresis alarms due to these effects. Dilutional hyponatremia and seizures due to water intoxication are the most common potential adverse effects of desmopressin.[50][70] Limiting water intake to 200 mL or 6.75 ounces 1 hour before bed and for 8 hours after administration of desmopressin and discontinuing desmopressin during fluid and electrolyte imbalance periods helps prevent hyponatremia.[6][71][50]

The adverse events of oxybutynin, such as dry mouth and eyes, constipation, flushing, sedation, and central nervous system depression, may limit its use.[3][72][73] TCAs can cause nervousness, personality changes, and disordered sleep. More concerning are cardiac conduction abnormalities and the boxed warning of increased risk of suicidal thinking in children, adolescents, and young adults. Caregivers must understand the risks of TCAs and receive adequate education on how to keep this medication in a safe place out of reach of children to avoid possible overdose.