Definitions for the grades of recommendations (A, B, C, D) are provided at the end of the "Major Recommendations."
Prevention
The following attitudes have been shown to be beneficial in achieving daytime urinary continence at an earlier age and avoiding dysfunctional voiding. Although it is not known if they will also bring about the onset of nocturnal urinary continence, it is recommended [C]:
- Start toilet training before the age of 18 months, perhaps when the child is able to wake up dry from his/her nap.
- Use of a pot or potty chair that properly supports his/her thighs and feet.
- Suggest to the child that they should urinate when you see or imagine that they feel the urge, so that they can do so on the first try. Do not keep the child seated on the pot until he/she urinates and do not insist that they strain if the first attempt fails.
- Be persistent in this training, because the objective can be achieved in less than three months. Do not dilute the effort by continually changing the technique.
Risk Factors Associated with Primary Monosymptomatic Nocturnal Enuresis (PMNE)
(See Table II "Factors Associated with Primary Monosymptomatic Nocturnal Enuresis" in the original guideline document.)
Chronic Headache
Inquiring about chronic headache in children with nocturnal enuresis is recommended [B].
Epilepsy
An electroencephalogram is not justified in the assessment of nocturnal enuresis [B].
Attention Deficit-Hyperactive Disorder (ADHD)
Given the high prevalence of these two conditions (ADHD and PMNE) and their association, it is clinically important to know if there is concomitant ADHD in enuretic children. Hence, ADHD symptoms in children that present enuresis should be investigated [B].
Other Psychological Problems
Early treatment of enuresis is recommended in Primary Care to improve [A] or prevent low self-esteem [D].
Sleep/Arousal Disorders
Although waking up plays an important role in the pathogenesis of enuresis, no clinical implications have been found. Sleep patterns need not be studied as part of the clinical history of a child with enuresis [B].
Sleep Apnoea Syndrome
It is recommended that a history of sleep apnoea symptoms in children with PMNE be obtained, despite the fact that the level of evidence is low [C]. It should always be ruled out in cases of secondary enuresis [A].
Asthma/Allergy
It is not recommended that the presence of asthma/allergy in children with primary PMNE be specifically investigated [C].
Caffeine
Although it has never been studied, it is reasonable to recommend that caffeine-containing beverages should be avoided late in the evening given their diuretic effect [D].
Encopresis/Constipation
The presence/absence of constipation or encopresis is worth investigating in all patients with enuresis; if present, treat the constipation first [C], since constipation is easy to diagnose on clinical grounds (fewer than 3 bowel movements per week), and given the possibility that constipation can be the cause of enuresis.
Pinworm Infestation
At present, and in the Primary Care setting, Graham's technique is not justified in all children with primary PMNE [C].
Urinary Tract Infection/Bacteriuria
In PMNE, adopting the same attitude toward urinary tract infection/bacteriuria as in the general population is recommended [B].
Diabetes Mellitus
Routine testing to rule out diabetes mellitus in children with PMNE is not recommended [C].
Diabetes Insipidus
Routine testing to rule out diabetes insipidus in children with PMNE is not recommended
[D].
Detrusor Overactivity
The usefulness of anticholinergics in PMNE should be evaluated in clinical trials [C].
Diagnosis
It is recommended that medical professionals actively search for cases (of PMNE) in all children 5 years of age or greater in any visit for illness or routine check-up. [D].
Bladder Diary
It is essential that the bladder diary be filled in for at least 3 days [A]. It can be done conveniently over two weekends.
Dipstick Urinalysis
Urinary Infection
In monosymptomatic nocturnal enuresis, it is recommended that the same attitude toward urinary tract infection as in the general population be adopted [B].
Diabetes Mellitus and Diabetes Insipidus
Routine testing to rule out diabetes mellitus in children with PMNE is not recommended [C].
It is not recommended that dipstick urinalysis be used as a screening device for diabetes insipidus in children with PMNE [B].
Treatment
How Efficacious Are Behavioral Interventions?
Simple Behavioural Interventions
Bladder retention training by toileting schedule does not provide any benefit in PMNE; hence, it is not recommended in Primary Care [B].
Despite the lack of quality PMNE data, motivational therapy using charts with stars, drawings... helps to objectify the baseline situation regarding the number of wet nights and can be recommended before and together with other treatments, since it lacks adverse effects [D].
There are no data available that evaluate the efficacy of bladder training by mid-stream urine interruption, and its use is not recommended in light of the fact that it can predispose to dysfunctional voiding [D].
Complex and Educational Behavioural Interventions
Given the scant efficacy of complex and educational interventions, their use is not recommended in Primary Care [B].
How Efficacious Is the Behavioral Intervention with Alarm Therapy?
Alarm/No Intervention
Alarm intervention is a treatment option for PMNE if the family is motivated and collaborative [B].
Alarm/Alarm Associated with Other Behavioral Interventions
Associating bladder retention training by toileting schedule techniques or dry bed training with alarm therapy is not recommended [B].
The reinforcement technique should be recommended before completing alarm therapy in children with PMNE [B].
Tolerability
A change in treatment is recommended if, once alarm treatment has begun, the child never wakes up [C]. Monitoring this response over a minimum period of one month is recommended [D].
How Efficacious Is Drug Treatment?
Desmopressin
Intranasal desmopressin should be administered at bedtime. Because orally administered desmopressin has its onset of action 30 minutes post-administration, it is recommended that it be taken 30 minutes before the last void and going to bed [D].
Desmopressin versus Placebo
Drug treatment with desmopressin is a therapeutic option in PMNE [B].
Dosage
Because the optimal dose of desmopressin is yet unknown, whether orally or intranasally administered, it is recommended to customize treatment to the minimum effective dose (0.2 to 0.4 mg oral and 10 to 40 micrograms intranasal). There are two trends: 1) to begin treatment with the minimum dose and titrate up if the response is insufficient, or 2) start directly with the higher dose, which can subsequently be titrated down, although there are no data that provide guidance as to when to do this [D].
Tolerability
To prevent water intoxication, it is recommended that fluid intake the evening that desmopressin is taken be limited to no more than 240 ml (1 glass of water), 1 hour before to 8 hours after [D].
Without taking cost-effectiveness studies into account, the oral mode of delivery is recommended because it is safer [A] and easier to administer, which improves treatment compliance [D].
Treatment Duration
If the objective is to cure the condition, discontinuation should be started one month after attaining initial success [B]. In case of prolonged treatments, withdrawing therapy periodically for 1-2 weeks in order to re-evaluate is recommended [D].
Relapses after Treatment Completion
Precipitous interruption of treatment with desmopressin that is achieving good response is not recommended [B].
Using a structured withdrawal plan (at full doses) when finishing treatment with desmopressin is recommended [B].
Association with Other Treatments
Except for specific situations in which there is great interest in achieving a higher rate of dryness at the beginning of treatment, routinely associating desmopressin and alarm is not recommended [A].
In the case of children who wet the bed more than once a night, the use of desmopressin might be recommended with the aim of decreasing the number of nocturnal micturitions to just one, to make alarm therapy more tolerable [D].
There is not enough evidence to recommend the association of anticholinergics, although it might be an alternative after treatment failures [D].
Strategy with Alarm Therapy following Desmopressin Failure
Associating alarm therapy to desmopressin is not recommended in children who have not responded to desmopressin [A].
Advantages and Disadvantages of Different Treatments
(See Table III "Advantages and Disadvantages of the Different Treatment Options" in the original guideline document.)
When the treatment objective is dryness in the short term, desmopressin and not alarm therapy is recommended [A]. If the aim is to maintain dryness without relapses when concluding treatment, alarm therapy offers obvious advantages over desmopressin [A].
Prognostic Factors of Treatment
(See Tables IV and V "Predictive factors for alarm therapy" and "Predictive factors for treatment with desmopressin" in the original guideline document.)
Sex
Gender is not a prognostic factor to be taken into account when initiating therapy with alarm or desmopressin [A].
Age
Age is not considered a decision criterion in treatment selection [A].
Inheritance in Enuresis
Family history of enuresis does not intervene in the choice of treatment [B].
It is recommended that alarm treatment not be started if low motivation is detected in the family or child [B]. In this case, desmopressin is the treatment of choice [B].
Number of Wet Nights
Alarm therapy is a good treatment option when there is a high frequency of wet nights [B]. Based on the data in the literature, it is not possible to establish a precise number that defines "high frequency of wet nights", although it has been observed that the greater the number of wet nights, the better the response.
Desmopressin is a good treatment option when there are few wet nights [B], even in young children [B].
Number of Incidents Per Night
Determining maximum daytime voided volume (MDVV) by filling in bladder diaries is recommended [A]. Do not administer desmopressin in children with a MDVV less than 75% of the amount calculated by Koff's formula [B] and refer the child to the urologist if this volume is less than 45% [C] because it is a poor predictor for response to both treatments (desmopressin and alarm).
Family or Child Attitudes
It is recommended not starting alarm treatment if low motivation is detected in the family or the child [B]. In this case, desmopressin is the treatment of choice [B].
Neuropsychological/Psychiatric Problems
In children with enuresis and the suspicion or diagnosis of ADHD or a psychiatric condition, it is recommended starting treatment with desmopressin instead of alarm [B].
Rey-Osterrieth Complex Figure Test
Given the complexity of the test (time consuming and difficult to interpret), the guideline developers do not consider it to be helpful in clinical practice, and therefore do not recommend its use in Primary Care [D].
Hypercalciuria
There is not sufficient evidence to recommend urinary calcium (Ca)/creatinine ratio determinations in children with PMNE and nocturnal polyuria in Primary Care, although it could be examined in those children who have failed on desmopressin [D].
Definitions:
Grades of Recommendation*
- Consistent level 1 studies
- Consistent level 2 or 3 studies or extrapolations from level 1 studies
- Level 4 studies or extrapolations from level 2 or 3 studies
- Level 5 evidence or troublingly inconsistent or inconclusive studies of any level
* See the "Rating Scheme for the Strength of the Evidence" field for the definitions of the levels of evidence.
