Enuresis: How to evaluate and treat

Nocturnal enuresis is a common, distressing condition that a primary care provider will encounter frequently. A thorough history, physical examination, and urinalysis need to be performed to ensure that an underlying disease or contributory condition (e.g., constipation) is not present. Any underlying problems, such as constipation or stress, should be addressed to optimize the patient's care. The family and child will have to be educated about the problem and the risks, benefits, and long-term success rates of the available treatments. Overall, the enuresis alarm is the most effective in the long term, and bladder training, desmopressin, and anticholinergics are helpful in a subset of patients who have small bladder capacities, produce large amounts of urine at night, or experience detrussor instability. In the primary care provider's office, it is not possible to determine if these underlying conditions exist. A daytime bladder capacity can be obtained, but the functional night-time bladder capacity cannot. Therefore, treatments can be prescribed on a trial-and-error basis with guidance from the clinician. The family will decide which intervention is most suitable to their own situation. Some families are resistant to administering any medications at all, while others express impatience with use of the alarm. The physician will have to advise if combination therapy should be tried. Probably the most important aspect of care is that the child and family are reassured frequently that nocturnal enuresis resolves with time in the overwhelming majority of patients.