Bedwetting (nocturnal enuresis)
How to assess a child with bedwetting without unnecessary tests, choose the right treatment and recognize red flags.
Step 1 of 13
Objectives
After this course you will be able to
- Distinguish monosymptomatic from non-monosymptomatic, and primary from secondary enuresis.
- Explain the three main mechanisms of enuresis: nocturnal polyuria, small nocturnal bladder capacity, impaired arousal.
- Assess the child with a bladder diary and avoid unnecessary tests.
- Choose between the alarm and desmopressin, and know how to use desmopressin safely.
- Recognize red flags and referral criteria.
Key message: enuresis is not the child's fault, and it is treatable. If it persists beyond age 5, waiting and saying "it will pass on its own" is not the right approach.
Basics
Terminology (ICCS)
| Term | Definition |
|---|---|
| Enuresis | Intermittent incontinence during sleep in a child older than 5 years |
| Monosymptomatic enuresis (MNE) | No daytime lower urinary tract symptoms |
| Non-monosymptomatic enuresis (NMNE) | Daytime symptoms present: urgency, frequency, daytime wetting, holding maneuvers |
| Primary | The child has never been dry for longer than 6 months |
| Secondary | Wetting has restarted after at least 6 months of dryness |
Always ask about daytime symptoms. Parents often do not mention them on their own, yet in NMNE treatment starts with the daytime problem.
Basics
Enuresis in numbers
- 5–10%of 7-year-old children
- ~15%resolve spontaneously each year
- 0.5–2%persist into adulthood
- 2 timesmore common in boys
There is a strong genetic predisposition: if one parent had enuresis, the child's risk is about 40%; if both parents did, it is around 70%.
Enuresis has a serious impact on the child's self-esteem. Treatment is started when the child and family are ready, usually from age 6, but it can be discussed at age 5 as well.
Basics
Pathophysiology: three mechanisms
- Nocturnal polyuria: the circadian rhythm of nighttime vasopressin secretion is disturbed, and nighttime urine output exceeds bladder capacity.
- Small nocturnal bladder capacity or detrusor overactivity: at night the bladder empties at a smaller volume.
- Impaired arousal: the signal from a full bladder does not wake the child.
These mechanisms often coexist. The diary shows which one predominates and guides the choice of treatment.
Comorbid conditions: constipation, attention deficit hyperactivity disorder (ADHD), obstructive sleep apnea. When these are left untreated, treatment of enuresis often fails.
Diagnosis
History and examination
- How many nights per week does the child wet? Primary or secondary?
- Daytime symptoms: urgency, frequency, daytime wetting, holding maneuvers (squatting, crossing the legs).
- Bowel: constipation, encopresis. Ask using the Bristol stool scale.
- Fluid intake, especially in the evening. Snoring, breathing pauses during sleep.
- Psychosocial situation, signs of ADHD, the family's attitude.
Physical examination: abdomen (fecal mass), external genitalia (meatal stenosis, labial adhesions), lumbosacral region (skin changes, dimples, hair tuft) and neurological examination of the lower limbs.
Diagnosis
Bladder diary
The diary is the cornerstone of the assessment:
- 48-hour daytime diary: time and volume of each void, fluid intake, wetting episodes.
- 7–14-night nighttime diary: wet and dry nights, weight of the morning diaper.
| Parameter | How it is calculated | Meaning |
|---|---|---|
| Expected bladder capacity (EBC) | (age + 1) × 30 ml | Reference for comparison |
| Nocturnal urine production | Morning diaper weight (g) − dry diaper weight + first morning void | >130% EBC: nocturnal polyuria |
| Maximum voided volume | Largest volume in the diary (first morning void excluded) | <65% EBC: small capacity |
The bladder diary tool on this site calculates EBC automatically, and the 48-hour form can be printed and given to the family.
Diagnosis
Which tests are needed?
- Needed: urinalysis (glucose, specific gravity, leukocytes).
- Not routinely needed: ultrasound, blood tests, uroflowmetry, urodynamics, imaging.
In monosymptomatic enuresis, history, examination, diary and urinalysis are sufficient for the diagnosis. In the non-monosymptomatic form, ultrasound with post-void residual and uroflowmetry may be useful.
Diagnosis
Red flags
If any of the following is present, the child is referred to a pediatric urologist or the appropriate specialist.
| Sign | What to consider |
|---|---|
| Secondary enuresis + excessive drinking, polyuria, weight loss | Diabetes mellitus. Urine glucose the same day |
| In girls, constant dribbling incontinence alongside normal voiding | Ectopic ureter |
| Weak stream, straining, post-void residual | Bladder outlet obstruction (posterior urethral valves in boys) |
| Skin changes in the lumbosacral region, leg weakness | Occult spinal dysraphism, neurogenic bladder |
| Febrile urinary tract infections | Reflux or obstruction |
| Snoring, sleep apnea | Obstructive sleep apnea, ENT evaluation |
Treatment
Basic advice (urotherapy)
- Inform the child and family: this is not the child's fault. Punishment is not allowed.
- Spread fluid intake across the day: enough in the morning and during the day, little in the evening.
- Void before bedtime and regularly through the day (5–7 times).
- If constipation is present, treat it first.
- Waking the child at night to void and putting the child to sleep in a diaper are not treatment, but they may be accepted for the family's comfort.
In non-monosymptomatic enuresis, daytime symptoms are treated first. This often reduces bedwetting as well.
Treatment
First line: alarm or desmopressin
| Enuresis alarm | Desmopressin | |
|---|---|---|
| Best suited for | Normal nocturnal urine output, small capacity; motivated family | Nocturnal polyuria, normal capacity; family does not want an alarm or a quick result is needed |
| How it works | "Trains" arousal and capacity | Reduces nocturnal urine output |
| Effect | Success in about two thirds, few relapses | About 30% full and 40% partial response; frequent relapse after stopping |
| Duration | At least 6–8 weeks, until 14 consecutive dry nights | Effect assessed at 2–4 weeks, given in 3-month courses |
The alarm requires patience and nighttime involvement from the family. Choosing the option that fits the family's daily life increases the chance of success.
Treatment
Safe use of desmopressin
- Dose: 120 mcg sublingual tablet (or 0.2 mg standard tablet) about 1 hour before bedtime. If there is no effect, it can be increased to 240 mcg (0.4 mg).
- Fluids are restricted from 1 hour before the dose until morning (about 8 hours), with only a few sips at night.
- The nasal spray is not used for enuresis.
Risk of hyponatremia: if headache, nausea, vomiting or confusion occur, the drug is stopped. During vomiting and diarrhea, or when a lot of fluid is consumed in hot weather, the drug is not given that night.
Tapering the dose gradually (structured withdrawal) instead of stopping abruptly reduces the risk of relapse.
Treatment
When there is no response to treatment
- Check adherence: is the drug taken correctly, is the alarm used every night?
- Reassess constipation, daytime symptoms and sleep apnea.
- Consider combining the alarm with desmopressin.
- In a child who does not respond to desmopressin and is suspected of having an overactive bladder, an anticholinergic may be added (after post-void residual and constipation have been checked).
- Refer to a pediatric urologist.
The psychological impact of enuresis must be taken into account. When ADHD or emotional problems are suspected, working together with a child psychiatrist or psychologist increases the success of treatment.
Quiz
Quiz: Bedwetting
Test yourself: choose one answer.
-
A 7-year-old boy wets every night, has no daytime complaints, and his urinalysis is normal. Which test is not needed?
Routine imaging is not needed in monosymptomatic enuresis. History, examination, diary and urinalysis are sufficient.
-
What is the expected bladder capacity in an 8-year-old child?
EBC = (age + 1) × 30 ml = (8 + 1) × 30 = 270 ml.
-
A child taking desmopressin develops headache and vomiting. What should be done?
These may be signs of water intoxication and hyponatremia. The drug is stopped and the child is examined.
-
A 6-year-old girl has continuous dribbling incontinence throughout the day alongside normal voids. What is the most likely diagnosis?
Continuous incontinence on a background of normal voiding is typical of an ectopic ureter opening below the sphincter. The child is referred to a pediatric urologist.
-
Which statement about the enuresis alarm is true?
The alarm is used for at least 6–8 weeks, requires the family's nighttime involvement, and after successful treatment relapse is less frequent than with desmopressin.
Course completed
Related articles for parents
Sources
- Nevéus T, Fonseca E, Franco I, et al. Management and treatment of nocturnal enuresis: an updated standardization document from the International Children’s Continence Society. J Pediatr Urol. 2020;16(1):10–19.
- Austin PF, Bauer SB, Bower W, et al. 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. Neurourol Urodyn. 2016;35(4):471–481.
- EAU Guidelines on Paediatric Urology, 2025: Monosymptomatic nocturnal enuresis.
This material is intended for medical professionals and is based on current clinical guidelines. Decisions about an individual patient are made by the treating doctor.