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Sleep urinary incontinence in children
Medical expert of the article
Last reviewed: 08.07.2025
Nocturnal enuresis is the incontinence of urine during sleep.
Primary nocturnal enuresis (lack of developed bladder control during sleep) occurs in 30% of children at age 4, 10% at age 6, 3% at age 12, and 1% at age 18. It is more common in boys, may run in families, and is sometimes associated with sleep disorders. Enuresis usually represents only a delay in maturation that resolves over time.
Diagnosis of urinary incontinence during sleep in children
Only 1-2% of patients with nocturnal enuresis have an organic etiology, usually UTI. UTI can be excluded by urine analysis and culture. Rare causes - congenital anomalies, sacral nerve disease, diabetes mellitus or insipidus, pelvic mass - can be excluded with a careful anamnesis and physical examination. Nocturnal enuresis accompanied by urinary dysfunction during the day (eg, frequent urination, imperative urges, urinary incontinence) may indicate the need for renal ultrasound, EU, menstrual cycle, or urologist consultation. Secondary nocturnal enuresis, in which a "dry" period was noted (i.e., bladder control was present but was subsequently lost), is usually a consequence of a psychologically traumatic event or condition. The likelihood of organic pathology (eg, UTI, diabetes mellitus) is higher than in primary nocturnal enuresis. Further evaluation or consultation is indicated when secondary nocturnal enuresis is combined with daytime urinary symptoms or bowel symptoms such as constipation or encopresis.
[ Treatment of urinary incontinence during sleep in children
In most cases, in the absence of organic disorders, urinary continence is established spontaneously by the age of 6 years; treatment is not recommended. The probability of spontaneous resolution of enuresis in children over 6 years of age is 15% per year. The psychological consequences of enuresis that may develop (e.g., shyness) make the need for treatment more urgent after the age of 6 years.
An initial consultation aimed at dispelling misconceptions about nocturnal enuresis is very useful. The child is told about the etiology and prognosis of enuresis, with the aim of removing feelings of guilt and shame. The child is given an active role, including conversations with the doctor, urination before bedtime, keeping a diary in which dry and wet nights are noted, and independent change of wet clothes and bed linen. The child should not drink liquids for 2-3 hours before bedtime, and caffeinated drinks should be strictly limited. Positive reinforcement is given for dry nights (e.g., a star calendar and other age-appropriate rewards).
In addition, special alarm devices are effective and are often recommended in conjunction with behavioral therapy. Two studies of children aged 5-15 years found a 70% success rate, with a relapse rate of only 10-15%. These devices are easy to use, readily available, and produce an alarm by squirting a few drops of urine. The disadvantage is the time required to achieve full success: during the first few weeks, the child wakes up with a complete void; in the next few weeks, partial retention is achieved; and eventually the child wakes up with a bladder contraction response before voiding occurs. The device should be used for three weeks after the last wet night.
Drug therapy may be effective in patients who do not respond to the above methods. Short courses (4–6 weeks) of desmopressin acetate (a synthetic analogue of ADH) as a nasal spray are usually used in patients 6 years of age and older with persistent, frequent nocturnal enuresis. The recommended starting dose is one inhalation in each nostril (20 mcg total) at bedtime. If effective, the dose may sometimes be reduced to one inhalation (10 mcg); if not effective, the dose may be increased to 2 inhalations in each nostril (40 mcg total). Side effects are rare, particularly if dosing recommendations are followed, but may include headache, nausea, nasal congestion, epistaxis, sore throat, cough, sudden facial flushing, and mild abdominal cramps.
Imipramine and other tricyclic antidepressants are no longer recommended as first-line drugs because of their side effects (eg, agranulocytosis), potential danger and life-threatening effects if taken accidentally in excess, and higher success rates with bed-wetting alarms. If other treatments are ineffective and the family is highly committed to treatment, imipramine (10-25 mg orally at bedtime, increased by 25 mg at weekly intervals to a maximum of 50 mg in children aged 6-12 years and 7 mg in children over 12 years) may be used. The response to imipramine is usually seen in the first week of treatment, which gives it an advantage, especially if rapid response is important to the family and the child. If the child has not wept for a month, the drug can be gradually withdrawn over 2-4 weeks. Relapse of bedwetting is very common, reducing the success rate to 25%. If symptoms return, a 3-month course of treatment may be tried. Blood tests to detect agranulocytosis, a rare effect of therapy, should be performed every 2-4 weeks of treatment.