Enuresis in children: a therapist's quick guide

1. The programme at a glance

Indication. This programme is for children aged five or six and over who wet the bed (nocturnal enuresis), once a doctor has seen the child and found nothing that falls within the doctor's remit. The enuresis may be primary or secondary. The programme is aimed mainly at the monosymptomatic form, with no other urinary symptoms; a non-monosymptomatic form qualifies only once the daytime symptoms are being managed by the doctor. These terms are defined in section 3.

Reference model. Enuresis alarm treatment: a sensor sets off an alarm as soon as the child starts to pass urine (section 10). It is recommended when simple measures have not been enough (section 9; National Institute for Health and Clinical Excellence, 2010; hereafter NICE), and placed first-line by the International Children's Continence Society (Nevéus et al., 2020; hereafter ICCS), alongside desmopressin, a medication that reduces urine production at night and that only the doctor prescribes (section 7).

Format. Five 45-minute sessions with the child and their parents, and a brief phone call one week after the alarm is set up. A session with the parents is added when their anger or exhaustion leads to the alarm being postponed (section 2). The second session follows the two weeks of baseline calendar (section 6); the last takes place when the child reaches fourteen consecutive dry nights, or at the latest after three months of alarm use.

Mechanism targeted. Teaching the child's brain to respond, during sleep, to the signal of a full bladder — by waking up or by holding on. The alarm does not punish: night after night, it pairs the start of voiding with waking.

Session	Focus	Session output
1	Assess, check the medical assessment	Warning signs ruled out, calendar started
2	Explain, lay the groundwork	Sanctions lifted, decision in writing
3	Set up the alarm	Sequence rehearsed, roles assigned
4	The four-week review	Early signs noted, decision dated
5	Fourteen dry nights, and what comes next	Written plan for stopping and for relapse

What the family takes away. Four printable worksheets, listed in section 15: my night calendar, when the alarm goes off, for parents, my efforts that count.

What distinguishes this programme from the other manuals on this site. It is short, and it is not primarily psychological: here the psychologist removes shame and sanctions, and makes feasible a treatment that fails mostly because it is abandoned.

2. Before you begin

The three prior decisions

Has a doctor seen the child for this problem? If not, that is the first thing to obtain.

Is there a warning sign? If so, the programme waits for the doctor's opinion. The list is in section 4.

Can the family take on an alarm now? Parents who are angry, exhausted, or who hold the child responsible make the treatment fail. NICE sees this as a reason not to offer the alarm as things stand: this climate is worked on first, through the explanation and the ending of sanctions at session 2 (section 9). If the parents remain angry or exhausted after this explanation, the alarm is postponed: you first work on the climate with them, in an additional session, before offering it.

What this guide does not cover

It does not treat daytime urinary problems (section 4) or constipation, which are for the doctor. Nor does it cover children under five, in whom wetting the bed is still common.

3. What the classifications say

The categories, reformulated

The formulations are our own: refer to DSM-5-TR (American Psychiatric Association, 2022) and to ICD-11 (World Health Organization, 2022) for the wording itself.

In DSM-5-TR. The manual describes repeated voiding of urine into the bed or clothes, most often involuntary, at least twice a week for three consecutive months or with clear distress or impairment, in a child who is at least five years old in age or developmental level, with no substance or medical condition to explain it. The manual distinguishes nocturnal, diurnal and mixed forms.

In ICD-11. Enuresis is listed among the elimination disorders, with the same age marker and the same three forms.

ICCS terminology

This is the terminology used by paediatricians and urologists (Austin et al., 2016).

Enuresis. The term is reserved for wetting during sleep; daytime wetting is called daytime incontinence. This is the main difference from the DSM.

Monosymptomatic or not. Enuresis is monosymptomatic when the child has no other urinary symptoms and no history of bladder problems; it is non-monosymptomatic as soon as there are other symptoms, particularly daytime ones (section 4). The distinction changes the treatment: daytime symptoms are managed by the doctor before this programme (section 1).

Primary or secondary. Enuresis is secondary when the child has previously been dry for more than six months, and primary if they have never been dry.

Two points of reference

It is common: 15 to 20% of five-year-olds, and up to 2% of young adults, according to the Cochrane reviews (Glazener et al., 2005). Enuresis is more common in boys, and clearly familial.

Many children become dry on their own, but not all, and untreated enuresis carries lasting psychosocial risks (Nevéus et al., 2020).

4. What is for the doctor, and what is for you

The rule

The programme only begins after a medical assessment. And any warning sign leads to a medical assessment before any behavioural intervention, including midway through treatment.

Warning signs

Intense thirst, large volumes of urine, tiredness or weight loss, especially with recent-onset enuresis: this is the picture of new-onset diabetes, and the assessment is sought the same day.

Secondary enuresis that has appeared over a few days or weeks, which is seen by the doctor before any psychological hypothesis.

Burning on passing urine, fever, or repeated urinary tract infections.

Daytime symptoms: leaks, urgency, voiding more than seven times a day or fewer than four, needing to push with the abdomen to pass urine, a weak stream.

Constipation or faecal soiling, the treatment of which sometimes makes the enuresis disappear.

Habitual snoring or pauses in breathing during sleep: some children become dry once the obstruction has been removed (Nevéus et al., 2020).

Neurological signs, such as difficulty walking or weakness in the legs, or an abnormality of the lower back, such as a tuft of hair, a dimple or a mark on the skin, which the doctor examines.

And enuresis that resists well-conducted treatments.

Division of roles

For the doctor: the examination, urine tests and measurements, the treatment of constipation and of daytime symptoms, and any decision about medication.

For you: the impact, the family climate, associated difficulties, the feasibility of the alarm, and the conduct of the behavioural treatment.

5. What maintains enuresis, and what does not cause it

Three mechanisms, often combined. Too much urine produced at night; a bladder that contracts early or whose night-time capacity is reduced; and waking that does not happen at the signal of a full bladder. It is this last mechanism that the alarm trains. The familial component is strong: telling the child that a parent was affected, when the parent agrees, is a great relief.

It is not willpower. None of these mechanisms can be controlled at will. The idea that a child "could make an effort" is false, and it is the most costly one.

It is not, in itself, a psychological disorder. Most children with enuresis do not have one. A sizeable minority do — around 20 to 30% according to the ICCS synthesis (von Gontard et al., 2011) — and more so when there is daytime incontinence. You look for it; you do not presume it.

What keeps it going: untreated constipation, and anything that makes treatment fail — shame and sanctions (section 14), an alarm abandoned before the first signs of response (section 11).

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