Evidence is conflicting for increased efficacy for combining desmopressin with enuresis alarms. There is some limited evidence that children receiving combination treatment with desmopressin and alarms had fewer wet nights than children treated with alarms and placebo.6 This combination treatment did not show a benefit with failure rates (not attaining 14 consecutive dry nights) or a statistically significant difference in failure and relapse rates once treatment stopped. In addition, one RCT in which desmopressin nonresponders were supplemented with alarms showed no added benefit in remission rates compared with conditioning alarms plus placebo (51% vs 48% in achieving 28 dry nights).7 Neither was there added benefit in relapse rates once treatment stopped.
Children treated with tricyclic drugs compared with those treated with placebo had approximately 1 less night of enuresis per week (WMD=1.19; 95% CI, –1.56 to-0.82).8 More children achieved 14 dry nights while on imipramine compared with placebo (21% vs 5%; NNT=6); however, this advantage was not sustained once treatment finished (96% vs 97% relapsed). Little evidence exists to compare desmopressin with tricyclic drugs.2,8
Simple behavior methods may be more effective than no treatment, but there is little evidence for how these methods compare with one another, or with more successful means of treatment.9 Behavior techniques include lifting (taking a sleeping child to urinate in the bath-room), waking, rewards, and evening fluid restriction.
Dry bed training refers to comprehensive regimes, including enuresis alarms, waking routines, positive practice, cleanliness training, and bladder training in various combinations. A meta-analysis examining dry bed training including an enuresis alarm showed children had fewer wet nights compared with children receiving no treatment (relative risk [RR] of failure=0.17; 95% CI, 0.11-0.28).2,10 Additionally, more children remained dry after treatment stopped (RR of relapse=0.25; 95% CI, 0.16-0.39). However, evidence was not sufficient to show a remission benefit for dry bed training without an alarm (RR of failure=0.82; 95% CI, 0.6-1.02), highlighting the key role for alarm therapy. On the other hand, dry bed training including bed alarms may reduce the relapse rate compared with alarm monotherapy (RR for failure or relapse=0.5; 95% CI, 0.31-0.8)
TABLE
Nocturnal enuresis treatments and efficacy
TREATMENT | EFFICACY |
---|---|
Enuresis alarms |
|
Desmopressin |
|
Tricyclic drugs |
|
Dry bed training with an alarm |
|
Recommendations from others
A recent evidence-based practice parameter from the American Academy of Child and Adolescent Psychiatry states once the history and physical suggest primary nocturnal enuresis, treatment should include education demystification and withholding punishment.4 Although insufficient evidence exists to recommend behavioral interventions such as journal keeping, fluid restrictions, and night awakenings, these supportive approaches are acceptable, benign starting points. Conditioning with an enuresis alarm and overlearning, which involves giving extra fluids at bedtime after successfully becoming dry and intermittent reinforcement before ending treatment, is a highly effective first-line management approach. Medication choices include desmopressin and imipramine, although relapse rates are high. Short-term use of desmopressin may be used for sleepovers or camping trips.