Chapter 12.  Disorders of Elimination: Nocturnal Enuresis

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12.4  Alternative Treatment

Other forms of treatment are widely available for nocturnal enuresis, including hypnosis, acupuncture, chiropractic medicine, energy therapy, and homeopathic or herbal therapy; however not all of these forms of therapy have published evidence to support their use. For families who desire another approach, alternative therapies may offer additional options for treatment. In terms of overall support, these options may provide a first-line treatment that is comparatively better than pharmacologic therapy, especially considering long-term cure rates after discontinuation of treatment.

12.5  Conclusion

Bedwetting is a common childhood condition that should be discussed as part of every child’s examination. Once nocturnal enuresis has been identified as a problem and the child demonstrates a desire for dryness, initiating management is imperative. Prolonging treatment can be detrimental to the child’s self-esteem and social development. A thorough history and exam are necessary in order to decide and address the underlying cause of the enuresis. Once the cause is identified, the treatment approaches can be introduced. Families are entitled to a full and balanced presentation of the treatment options available. This should include cost of those options, realistic expectations of time and effort, any negative effects, and probability of cure. In order for a family to make an informed decision and ensure the best possible adherence to therapy, all of the options must be offered.

Treatment options are available that will enable a child to sleep dry at night or wake to use the bathroom. Enuresis alarms and behavioral changes have much to offer enuretic children and appear to be more effective as first-line treatment when compared to pharmacological options.The benefit

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of supportive management like medication, absorbent undergarments, or waterproof bedding should still be considered however, because treatment alone has been shown to improve a child’s self-esteem, regardless of the type and success of the therapy. Needless to say, greater success results in greater improvement of self-esteem. No matter which option is chosen however, the provider, child, and the family need to outline a plan, including a system for measuring progress and regular follow-up visits.

12.5.1  Areas of Uncertainty

More research may help us better understand relationships between causative factors and enuresis. Children with enuresis do not arouse from sleep well. There is very limited evidence that these children may have abnormalities in the areas of the brain that mediate sleep arousal and micturation.

Constipation is another factor that plays a role in enuresis, but the mechanism is not well understood. Children have a smaller pelvic volume. Retained stool may cause decreased capacity of the bladder leading to enuresis. It has also been thought that a dilated rectum might stimulate colonic motility, which causes a contraction of the detrusor at lower than normal bladder volumes.

Lastly, behavioral therapy and alarm use are known to be helpful in enuresis. Better quality studies comparing alarms with other treatments are necessary, especially with follow-up to determine relapse rates.

12.5.2  Guidelines

The International Children’s Continence Society (ICCS) has published recommendations for the evaluation and treatment of enuresis. The information presented in this chapter is consistent with the recommendations of the Society

(Fig. 12.1).