🔑 Key Learning

  • Defined as bedwetting during sleep in children > 5 years old, occurring ≥ 2 times/week.
  • Can be primary (never dry at night) or secondary (relapse after ≥ 6 months dry).
  • Assess for daytime symptoms and underlying causes (e.g. UTI, constipation, diabetes).
  • 1st line treatment is enuresis alarm; desmopressin may be used for short-term (e.g. school trip) or 2nd line.

🧬 Pathophysiology

  • Primary enuresis:
    • Child has never previously achieved sustained night time continence
    • Delayed maturation of bladder control; often due to sleep arousal difficulty, nocturnal polyuria, or overactive bladder.
  • Secondary enuresis:
    • Bedwetting in a child who was previously dry at night > 6 months
    • Often triggered by stress, infection, constipation, or systemic illness (e.g. diabetes).

👀 Clinical Features

  • Involuntary voiding of urine during sleep ≥ twice/week in children over age 5.
  • Important to ask about daytime symptoms (e.g. urgency, frequency, wetting) - this may suggest an organic cause. 
  • Associated symptoms may suggest an underlying cause (e.g. constipation, UTI, psychological stress).

💊 Management

👶 Age < 5 years

  • Reassure: many children spontaneously improve.
  • Advise on fluids, toileting patterns, and reward systems.

👧 Age > 5 years – Primary, without daytime symptoms

  • Start with education, fluid restriction in evenings, and reward charts.
  • Short-term control: desmopressin (e.g. for sleepovers or school trips).
    • Reduces urine output via ADH mimic.
    • Important: fluid restrict from 1 hour before to 8 hours after to avoid hyponatraemia.
  • Long-term control:
    • 1st line: enuresis alarm (most effective).
    • 2nd line: desmopressin (if alarm is refused/inappropriate).
  • Refractory cases: consider specialist referral ± imipramine or oxybutynin.

💡 If daytime symptoms present

  • Refer to paediatrics/enuresis clinic.
  • Assess for bladder dysfunction or underlying pathology.

🔍 Secondary enuresis

  • Investigate for:
    • Constipation
    • UTI
    • Diabetes
    • Psychosocial stress
  • If no clear cause: refer to enuresis clinic.

📝 Exam Clues & Clinchers

  • Primary + no daytime symptoms + age > 5 → start with alarm.
  • Sleepover coming up? → offer short-term desmopressin.
  • Daytime symptoms or secondary enuresis? → refer to enuresis clinic/paeds for further work-up.
  • Desmopressin advice → fluid restriction essential to avoid hyponatraemia.

🔗 Useful Links and References