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important, especially during the first few weeks of use. It may be necessary for parents to wake the child, remind the child what the alarm is for, physically swing the child’s feet to the side of the bed, and encourage them to employ the proper behavior – using the bathroom to empty the bladder. The alarm should not be turned off until the child is awake and standing on the floor.The child will gradually learn to awaken to the alarm without reminders or parental help. Finally, the child will use this new sensation to wake himself and use the bathroom without the use of the alarm. This process takes 2–3 months on average but may take up to 6 months of practice and patience.

Parents should also consider modifying sleeping arrangements to make the best of the learning process. If the child sleeps in a bunk or far away from the parent, promote moving the child to a position that allows for easier access to the bathroom or near enough for a parent to intervene if there is no response from the child. A baby monitor is another alternative. Make sure the route to the bathroom is clear of obstacles, including toys. A night light or flashlight may also be helpful for the child to find his way.

Alarms are simple to use and offer a permanent cure if used properly and for the length of time required. This therapy alone may not work for every enuretic child, but it will for the majority of children when used consistently and employed with additional treatments available. In addition, overlearning can be used to increase success with alarm therapy. This fluid challenge has been shown to reduce relapse rates among children using alarm therapy.10

12.3.3  Pharmacologic Therapy

Medications for the treatment of bedwetting include desmopressin, anticholinergics, and tricyclic agents. The most frequently prescribed medication for enuresis is desmopressin acetate or DDAVP. The synthetic form of the natural anti-diuretic hormone (ADH) vasopressin works by

concentrating urine, thereby decreasing the quantity of urine produced after dosing. For enuretic children, this allows them to sleep dry or wet less at night and can be very beneficial for social events, like sleepovers or overnight camps. A review by Moffatt11 concluded that in 18 controlled studies on desmopressin, only 24.5% of children were completely dry on the medication and 94.3% relapsed after discontinuation of the drug.

Desmopressin is available in nasal spray and tablet form; however, the spray now has a black-box warning from the Food and Drug Administration (FDA) and is no longer recommended due to the reported episodes of water intoxication.The nasal spray has a longer half-life,but is also associated with inconsistent absorption rates because of the changes to the nasal mucosa. Though the tablet has a shorter duration of pharmacologic action, it still works within the average sleep duration of an elementary school-aged child. As with any drug, it is important to discuss potential side effects and contraindications. Reinforce with the parents the importance of stopping fluids 2 hours before and 8 hours after administration to prevent side effects of headache, nausea, abdominal discomfort, and vomiting, which are symptoms suggestive of water intoxication. In addition, the medication should not be given during illness or on evenings when there is excessive water intake.

Dosage of DDAVP needs to be individualized. The dose can be slowly increased from one tablet (0.2 mg) if no effect after several nights. One to three tablets (0.2 mg) each night before bedtime is the recommended dosage. Some studies have shown a reduced pharmacodynamic effect after 6 months of continuous use. Parents should be informed that DDAVP does not cure enuresis, but may stave off bedwetting for a period of time.

Desmopressin can also be prescribed as combination therapy with an enuresis alarm. The dose will need to be decreased to allow enuresis to occur in order for the alarm to activate. The wetting should then occur in the early

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morning hours closer to waking and will be less in quantity. Most children who wet the bed do so within the first 90 minutes to 2 hours after going to sleep, which coincides with non-REM sleep. This makes them more difficult to awaken. By adding desmopressin to the enuresis alarm therapy and shifting the wetting episode to early morning, the child may become more successful with the alarm treatment. After a period of time, the medication can be reduced and then discontinued.12

Anticholinergic agents, such as oxybutynin, are also used for the treatment of enuresis, especially when there are concurrent symptoms of small bladder capacity, frequency, or urgency. Oxybutynin works by relaxing the smooth muscle of the bladder, allowing more urine to be stored and delaying the urge to void. Because of this effect, children should be followed closely for constipation or increased post-void residual, both of which can make enuresis worse. Tolterodine is another anticholinergic medication but has not been approved by the FDA for use in children.

For children with daytime symptoms, twice-a-day dosing may be helpful and can be increased to up to three times daily. For children without daytime symptoms, but a small bladder capacity, administration at bedtime is recommended. Immediate release tablets or syrup are the most useful options for these symptoms. As with desmopressin, oxybutynin can be used in conjunction with an alarm. As the child learns to wake to the alarm, the medication can be weaned.

Imipramine and other tricyclic antidepressants have been used to reduce bedwetting. The mechanism of action is an anticholinergic effect to increase bladder capacity combined with a noradrenergic effect that decreases the excitability of the bladder. In spite of this, due to unfavorable adverse effects such as mood changes and sleep disturbances and the risk of death with overdose, the International Children’s Continence Society does not recommend the use of imipramine unless all other therapies have failed.1