care, health and development

Child:
Review Article

doi:10.1111/j.1365-2214.2010.01146.x

Treatment of primary nocturnal enuresis in

children: a review
cch_1146

153..160

M. L. Brown, A. W. Pope and E. J. Brown

Department of Psychology, St. Johns University, Jamaica, NY, USA
Accepted for publication 22 June 2010

Abstract

Keywords
evidence-based
treatment, literature
review, nocturnal
enuresis
Correspondence:
Alice W. Pope, PhD,
Department of
Psychology, St. Johns
University, 8000 Utopia
Parkway, Jamaica, NY
11439, USA
E-mail:
popea@stjohns.edu

Primary nocturnal enuresis is a common childhood disorder. Treatment approaches bridge the
psychological and medical fields. A substantial body of literature addresses the various ways
of treating enuresis, from pharmaceuticals to behavioural interventions. The medical and
psychological literatures have proceeded relatively independently from one another and there has
been little interconnection between the US and international literatures, resulting in a lack of
discourse and integration among researchers investigating treatment outcomes for enuresis. This
review examined the evidence base for treatments of primary nocturnal enuresis in children.
Psychological, pharmaceutical and multi-component interventions are discussed. This review sought
to provide an integrated interdisciplinary and international perspective on treatment efficacy for
nocturnal enuresis by expressly gathering publications from psychological and medical fields, as
well as US and international sources. The literature supported the urine alarm as the most effective
intervention for nocturnal enuresis and demonstrated the benefit of combining the urine alarm
with other components, both behavioural and pharmaceutical. In particular, recent literature
showed that the urine alarm, when used in conjunction with antidiuretic medication (i.e.
desmopressin), leads to more dry nights earlier in the conditioning process. Disparities between
the different literatures were discussed.

Introduction
The core element of nocturnal enuresis1 is the repeated voiding
of urine during the night into the bed while sleeping (American
Psychiatric Association 2000). The wetting must occur at least
twice per week for at least 3 months or must have a negative
impact on other important areas of functioning. The disturbance must not be due to effects of a substance or a general
medical condition. To meet criteria for diagnosis, the child must
be at least 5 years old, or have a mental age of 5 in populations
that are developmentally delayed. Prevalence of enuresis is
approximately 5%10% among 5-year-olds, 1.5%5% among
1

Definitions employed throughout this text conform to the standards recommended by the International Childrens Continence Society except where specifically noted (see Neveus et al. 2006).

2010 Blackwell Publishing Ltd

9- and 10-year-olds and about 1% among persons 15 years and

older (American Psychiatric Association 2000; Butler & Heron
2008). Prevalence rates are higher for males than for females at
all age-points (Butler & Heron 2008). Enuresis follows two types
of courses: primary and secondary (American Psychiatric Association 2000). In primary type enuresis, the child has never
achieved urinary continence, whereas in secondary type enuresis, the disorder appears after the child has established a period
of at least 6 months of urinary control (American Psychiatric
Association 2000; Butler & Holland 2000). Children with secondary type wetting need more careful medical and psychological assessment before considering intervention, as there could
be an external antecedent associated with the recurrence of
urinary incontinence (i.e. illness, trauma or abuse) (Mellon
&McGrath 2000). Another important distinction is between

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M.L. Brown et al.

that of monosymptomatic and polysymptomatic enuresis. This

distinction is based on the respective absence or presence of
bladder overactivity, as indicated by frequent urinary voids (e.g.
10 or more per day) and/or daytime wetting or urgency (Butler
et al. 2006; Butler & Heron 2008). Approximately 30%35% of
children with nocturnal enuresis are reported to have the polysymptomatic form (Butler et al. 2006; Butler & Heron 2008).
While an important distinction with regards to the course and
treatment of the disorder, this review will not distinguish
between the two types, as research into the two classifications
continues to grow and new findings regarding treatment implications continue to be put forth (e.g. Butler et al. 2006). In a
similar vein, daytime incontinence, which occurs in approximately 20%35% of children with nocturnal enuresis (Butler &
Heron 2008), is thought to be aetiologically distinct from
primary nocturnal enuresis (Mellon & McGrath 2000; Houts
2003) and is seen as a more complex clinical problem associated
with polysymptomatic enuresis (Butler et al. 2006; Butler &
Heron 2008). Therefore, daytime incontinence will also not be
discussed herein.
To date, numerous empirical studies of treatment outcomes
and reviews of evidence-based treatments for nocturnal enuresis have been conducted. Evidence-based treatments in both
psychology and medicine refer to those that combine the best
available research evidence with clinical expertise while taking
into account patient-specific factors (Institute of Medicine
2001; American Psychological Association 2005). This work has
made important contributions to the ongoing conversation
among practitioners regarding the best treatments for children
who suffer from this disorder. Of issue is the fact that enuresis is
a disorder that bridges both the psychological and medical
fields; traditionally, each field has produced its own literature.
Similarly, it is a disorder that is researched and studied internationally, but with a lack of global discourse. This present review
seeks to provide a more integrated interdisciplinary and international view of the treatment outcomes and evidence-based
treatments for nocturnal enuresis.
The goals of this paper are: (1) to provide a comprehensive
review and critique of current treatment outcome and
evidence-based treatment literature and (2) to discuss clinical
applications and future directions for the study of enuresis. The
focus of this paper will be primary nocturnal enuresis, as the
majority of the extant literature focuses on this subtype.

Method
A literature review of articles on the methods of intervention
and treatments for primary nocturnal enuresis in children was

2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 153160

performed using the PsycINFO and MEDLINE research databases, which together contain publications from 1911 to the
present. Free text searches were conducted, involving the terms
enuresis, primary nocturnal enuresis and elimination disorders, combined with the terms treatment, behaviour and children. The resulting article titles and abstracts were scanned for
relevance and those that discussed methods of intervention and
treatments for childhood primary nocturnal enuresis were
obtained and included in the review. The reference sections of
these articles were then screened to identify other relevant
papers, with special attention given to accumulating both international and domestic publications in both the medical and
psychological fields.

Review of treatment outcome literature

Evidence-based behavioural interventions
Urine alarm
The urine alarm works by using a moisture-sensitive switching
system that, when closed by contact with urine, completes a
small-voltage electrical circuit and activates a stimulus, such as
a bell or buzzer, which is strong enough to cause the child to
wake (Friman 2008). The alarm is thus an aversive stimulus,
which leads to a conditioned avoidance response of contracting
the pelvic floor along with the external sphincter of the bladder
neck. In other words, the alarm stimulus may startle the child,
leading to muscle contractions and an interruption in the flow
of urine, as well as waking the child. In the classical behavioural
sense, this physiological reaction (the unconditioned response
to the alarm) becomes the conditioned response to feelings of a
full bladder and the child will wake before urinating in order to
avoid being startled by the alarm. Another conceptualization is
that the urine alarm is an operant, whereby the waking is an
avoidance response and is maintained by the negative reinforcement of not having to be awakened and not lying in a wet bed
(Mellon & McGrath 2000).
The original alarm began as a pad that was placed on the
childs bed, under the sheet (i.e. bell and pad); more recently
smaller units have been developed, which clip onto underwear
or pajamas (Moffatt 1997). Some alarms can be set up to wake
the childs parents first, who then wake the child. There is no
convincing evidence that any one type of alarm leads to significantly better results, yet there appears to be some evidence
supporting alarms that wake the child directly versus alarms
that wake the parents (Glazener et al. 2004). The urine alarm
has never been fully standardized or packaged as a clinical

Treatment of enuresis in children 155

procedure with scripted instructions to parents and children

(Nawaz et al. 2002). Instead it is available for purchase at
medical supply stores or from online vendors, with each variation of the alarm (i.e. the particular brand or make) providing
its own instructions for use.
Several review studies and well-controlled experiments have
established the basic urine alarm as an effective treatment for
nocturnal enuresis, alone or in combination with other treatment components, such as dry-bed training (DBT) (Houts et al.
1994; Moffatt 1997; Mellon & McGrath 2000; Van Hoeck et al.
2007; Glazener et al. 2009). In a meta-analytical review of over
75 randomized trials conducted until 1989, Houts and colleagues (1994) concluded that urine alarm treatment is superior
to every other type of intervention for enuresis. In a more recent
review by Glazener and colleagues (2004) that used data from
randomized and quasi-experimental designs dating back to the
1960s, the authors determined that the urine alarm was the
most effective treatment for children suffering from enuresis
with a reduction in night-time incontinence seen in approximately 50% of children during treatment and at follow-up.
Controlled comparative trials have demonstrated that the
alarm has greater efficacy than other forms of therapy, such as
individual talk psychotherapy and medication (Mellon &
McGrath 2000; Houts 2003). It is considered the most effective
current treatment and costs considerably less than available
medications (Friman 2008). In a review by Mellon and McGrath
(2000), the authors determined that the average success rate
(defined as 14 consecutive dry nights) for the urine alarm is
77.9%. Other controlled evaluations of the alarm indicate that it
is 65%75% effective, with a duration of treatment of 512
weeks and a 6-month relapse rate of 15%30% (Wagner 1987;
Houts 2003; Friman 2008). Treatment is usually terminated
when the child reaches a specified goal, usually 14 consecutive
dry nights.
Despite its effectiveness, not all children respond successfully
to the urine alarm. Pre-treatment factors associated with poor
outcome or dropout with urine alarm treatment are daytime
wetting, multiple occurrences of wetting at night, family history
of enuresis, prior failed treatment experience, childrens
psychological problems (e.g. psychopathology, developmental
delay), childrens behavioural problems (e.g. oppositional
behaviour, lack of motivation to change), parental intolerance
of bedwetting, aversive home environment and stressed familial
relationships (Mellon & McGrath 2000; Butler & Gasson 2005).
Within-treatment factors found to be associated with urine
alarm failure are wetting early in the night and the childs inability to wake in response to a triggered alarm (Butler & Gasson
2005).

Over-learning
Over-learning is initiated after successful treatment and refers to
the process of training children to a higher criterion than is
normally thought to be necessary, with the goal of further
reducing the relapse rate (Christophersen & Mortweet 2001).
Over-learning is not well understood in terms of its mechanism
of action (Moffatt 1997; Friman 2008; Glazener et al. 2009). As
an intervention for enuresis, the process is achieved by having
the child drink between 16 and 32 ounces of fluid before
bedtime and generally results in a relapse of wetting. The overlearning process is then continued until a success criterion (anywhere from 14 to 28 nights without wetting) is again met. Houts
(2003) utilized a graduated over-learning procedure during
which the child begins by drinking a specified amount of water.
That amount is then increased by two ounces after two consecutive dry nights. The process continues until the child reaches a
maximum amount of water, defined as one ounce for each year
of age plus two ounces. Moffatt (1997) found that when conditioning is not followed by over-learning, relapse ranges from
20% to 40%. With over-learning, the relapse rate drops to
approximately 10%. Graduated over-learning has not yet been
tested in randomized clinical trials.

Evidence-based medical interventions

Reviews of the literature indicate that the common healthcare
practice among physicians and paediatricians is to treat enuretic
children with medication rather than behavioural interventions
(Houts et al. 1994; Friman 2008). Although pharmacotherapy
has been demonstrated to be an effective treatment for the
short-term management of enuresis, it is thought by researchers
to be more appropriate as a second line of management when
the urine alarm has failed or is impractical (Moffatt 1997;
Brown et al. 2008). The two types of medications that are most
commonly used for the treatment of enuresis are antidepressants and antidiuretics.

Antidepressants
The pharmacological treatment of nocturnal enuresis has
included antidepressants in particular, tricyclic antidepressants ever since a report in the 1960s that a depressed adult
suffering from incontinence became continent as a side effect of
taking the antidepressant imipramine (Wagner 1987; Houts
et al. 1994). Although it is unknown exactly how these drugs
work, the most common theories are that they work as a

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M.L. Brown et al.

stimulant, lightening sleep levels and thus allowing children to

arouse more easily to the need to urinate, and through their
anticholinergic effect, whereby they inhibit the transmission of
parasympathetic nerve impulses and reduce spasms of smooth
muscle (such as that in the bladder) (Moffatt 1997). Little
support has been found for the anticholinergic theory, as other
anticholinergics do not have similar effectiveness; thus the
stimulant theory is typically the one more accepted by experts
(Moffatt 1997). Reviews of the literature indicated success rates
ranging from approximately 20% to 43% for imipramine and
33% for other tricyclics (Houts et al. 1994; Glazener et al. 2004).
However, relapse rates for these drugs tend to be quite high and
most outcomes at follow-up are no better than placebo or baseline (Glazener et al. 2004). Because the onset of drug effects is
rapid, imipramine can be utilized as needed, for specific occasions, such as sleepovers or camping trips. Imipramine is also
relatively inexpensive. Of concern for children is the fact that
antidepressants have potentially severe side effects such as cardiovascular problems, rashes, mood alterations and sleep disturbances, as well as risk of overdose (Moffatt 1997; Nield &
Kamat 2004).

Antidiuretics
The synthetic anti diuretic hormone, desmopressin, has been
put forth as an effective medical alternative. It is a synthetic
version of vasopressin, which is the bodys natural antidiuretic
hormone (Moffatt 1997). The rationale for the use of these
drugs is that there is evidence that children with nocturnal
enuresis may not have the same nocturnal increase in vasopressin as children without enuresis. Desmopressin works by
decreasing night-time urine production. It is efficacious,
reducing the number of wet nights by about 50%. Desmopressin mainly reduces symptoms, rather than curing the
problem, as removal of the drug almost always results in the
child reverting to wetting behaviour (Glazener et al. 2004;
Brown et al. 2008). The relapse rate is high, with most children
reverting to wetting after the medication is stopped (Glazener
et al. 2004). Desmopressin typically has a more rapid onset of
dry nights than the urine alarm (Sukhai et al. 1989). Like antidepressants, it is a popular choice for intermittent use (Moffatt
1997; Glazener et al. 2004). Although it produces fewer side
effects than antidepressants, fluids must be restricted once the
drug is taken, as there is a risk for seizures resulting from
water intoxication, as well as electrolyte abnormalities (Nield
& Kamat 2004). It is also quite expensive (Houts 2003; Brown
et al. 2008).

2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 153160

Interventions with inconclusive evidence base

Retention control training
Retention control training (RCT) was born out of evidence
indicating that enuretic children had reduced bladder capacity.
RCT expands bladder capacity by having the child drink a high
amount of fluids and delay urination as long as possible. The
thought is that the bladder will expand and the length of time
between urination will increase. This technique is used to help
the child gain control over the urination reflex (Schroeder &
Gordon 1991). RCT has had success rates of up to 50% (Friman
2008). However, more recent studies found that increasing
bladder capacity through holding exercises had a negligible
effect on wetting behaviour and did not affect response to later
alarm therapy (Van Hoeck et al. 2007, 2008). Therefore, most
experts no longer view it as an evidence-based treatment for
nocturnal enuresis.

Cleanliness training
The goal of cleanliness training is focused on returning soiled
beds, linens, pyjamas and clothing to their pre-soiled state. After
wetting, children are directed to remove wet bed linens and
pyjamas, rinse off their body, put on dry pyjamas and make the
bed with clean linens. This process is thought to punish the
wetting and encourage the child to take responsibility for
keeping dry at night (Christophersen & Mortweet 2001). It is a
standard procedure, which usually follows activation of the
urine alarm. Despite its popularity, it has not been evaluated
independently of other components so the extent of its contribution is unknown (Friman 2008).

Arousal therapy
Arousal therapy is a combination of urine alarm training and
rewarding the child for awakening (Christophersen & Mortweet
2001). It is a product of the theory that a child must be fully
aroused from sleep to learn from the intervention. Upon activation of the alarm, the parents must ensure that the child gets
up, goes to the bathroom, urinates in the toilet, returns to bed
and resets the alarm within 3 min of the alarm going off
(Moffatt 1997). A sticker-system or other token economy is
used, rewarding arousal with stickers and taking them away for
failure to arouse. Studies have found success rates ranging
between 79% and 98%; however, this technique lacks randomized controlled trials and it has not been examined independently of the urine alarm (Moffatt 1997).

Treatment of enuresis in children 157

Techniques of reinforcement
Interventions using reinforcement and contingency management (e.g. reward systems, such as star charts) are thought to
increase and reward a childs motivation to participate in treatment and move the focus of attention from wet to dry beds
(Glazener et al. 2009). These interventions are a standard
element in most treatment interventions (Friman 2008).
Although often used, they have been shown to have minimal
effect when used without being combined with the urine alarm
(Moffatt 1997).

Talk psychotherapies
During the early 1900s, the study and treatment of enuresis in
the field of mental health was almost exclusively dominated by
psychodynamic theory, which considered urinary incontinence
to be symptomatic of underlying emotional dysfunction,
unconscious conflicts and/or neurosis (Schroeder & Gordon
1991). Thus the suggested intervention was psychodynamic
psychotherapy. This form of psychotherapy has not proven
effective for the majority of children with enuresis (Wagner
1987; Friman 2008). There is little research evaluating other talk
psychotherapies, such as cognitive therapies focusing solely on
cognitions (i.e. thoughts and feelings); the few studies that have
been conducted had questionable results, which have not been
replicated (Friman 2008). Thus, the few studies conducted on
psychotherapies focusing on changing thoughts and feelings in
order to produce a change in enuretic behaviour have found it
to be no more effective than no treatment (Christophersen &
Mortweet 2001; Brown et al. 2008).

package for enuresis (Azrin et al. 1974; Friman 2008). The urine
alarm is the key component of this treatment and is combined
with a night-time waking schedule to shape the childs wakefulness, RCT with positive practice of urinating in the toilet and
cleanliness training. Additional techniques involve role plays in
which the child lies down and imagines having a full bladder
and envisions getting up and going to the bathroom (Moffatt
1997). Positive reinforcement also is a component, whereby the
child is reinforced for dry nights by token and social contingencies (Nawaz et al. 2002). DBT is typically completed in less than
4 weeks, with relapse rates of approximately 40% (Nawaz et al.
2002). Nawaz and colleagues (2002) found that DBT, which
included the urine alarm, was more efficacious than the urine
alarm alone for treating nocturnal enuresis, indicating that
adjunct behavioural components may enhance the effect of the
urine alarm. Removal of the urine alarm component from DBT
reduces the efficacy of this training package (Mellon & McGrath
2000). A meta-analysis by Glazener and colleagues (2009) that
compared studies of DBT without the urine alarm with studies
using the urine alarm alone found no benefit of using DBT
without the urine alarm component as compared with the urine
alarm alone.
Despite its efficacy, there are several drawbacks to DBT. DBT
has been criticized for the burden it places on children and
caregivers, such as the intensive night-time waking schedule,
during which parents are required to wake the child throughout
the night (Nawaz et al. 2002). Perhaps as a result of the elaborate
combination of components and the need for thorough instruction to the parents by a clinician, this package has enjoyed only
limited adoption by practitioners.

Full spectrum home training

Multi-component packages
The advantage of multi-component treatment approaches over
the urine alarm alone is the inclusion of additional components
intended to reduce treatment time and relapse rates (Mellon &
McGrath 2000; Brown et al. 2008). Component analyses have
been conducted on two treatment packages involving use of the
urine alarm in combination with other behavioural techniques;
the findings show the alarm to be the critical element. Success
rates, usually defined as 14 consecutive dry nights, increase as
more components are added (Friman 2008).

Introduced by Houts in the early 1990s, full spectrum home

therapy (FSHT) is a manualized treatment package consisting
of four components: the urine alarm, cleanliness training, RCT
and graduated over-learning (Houts 2003). Average success
rates for FSHT are approximately 79% with an associated
relapse rate of 40%, with success defined as a period of 14
consecutive dry nights. Although FSHT has demonstrated efficacy, it has been studied only by the treatment developers. Independent evaluation is warranted. As with DBT, removal of the
urine alarm negatively impacts efficacy (Glazener et al. 2009).

Dry-bed training

Combined behavioural and pharmacological interventions

Introduced by Azrin, Sneed and Foxx in 1974, DBT is the oldest,

best-known and most evidence-based manualized treatment

Early studies found that children receiving desmopressin in combination with the urine alarm had more dry nights per week than

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M.L. Brown et al.

children who received the urine alarm with a placebo medication

(Sukhai et al. 1989; Bradbury 1997). Moffatt (1997) hypothesized that the medication postponed the wetting accidents to
the early morning hours when the child is able to be aroused
more easily and is perhaps more susceptible to conditioning. A
recent randomized controlled study found that the mean
number of dry nights increased for those participants in the
desmopressin plus urine alarm condition versus the urine alarm
only condition, but only in the first 6 weeks of treatment while
desmopressin was being administered (Ozden et al. 2008). Once
administration of desmopressin ceased, no significant difference
in mean number of dry nights between the two groups was
found. This suggests that desmopressin is effective only as long as
it is being administered and, over time, urine alarm therapy alone
may have the same results as combined treatment. The need is
clear for more randomized clinical trials that combine behavioural and medical interventions (Brown et al. 2008).

Conclusions and future directions

Because nocturnal enuresis impairs adjustment and well-being
for children and adolescents concurrently, and predicts future
psychopathology, it is imperative that the most effective treatments be utilized (Liu et al. 2000; Redsell & Collier 2000). Successful treatment for the disorder can result in improvements in
self-concept and self-esteem, attitude and behaviour (Moffatt
et al. 1987; Hagglof et al. 1998; Longstaffe et al. 2000). The literature on the treatment of nocturnal enuresis is well established, demonstrating the superior efficacy of the urine alarm,
either alone or as a key element in a multi-component treatment programme. Combination treatments, including medication or behavioural components with the urine alarm, appear
promising and merit further investigation.
Although both the psychological and medical fields acknowledge the efficacy of the basic urine alarm to treat the disorder,
there appears to be insufficient interdisciplinary exchange of
ideas, despite some consistency of empirical findings. The
medical literature tends to maintain a primary focus on managing symptoms, with a secondary focus on pharmacological
interventions, medication dosages and physical/anatomical
issues related to the disorder. The psychological literature tends
to centre around behavioural interventions and psychosocial
characteristics of children who suffer from the disorder. The
focus tends to be on eliminating the disorder by using strategies
involving external resources (e.g. parents, alarms). The more
recent use of combination (alarm with medication) treatments
is a promising step in integrating psychological and medical
approaches, in that symptoms are reduced rapidly with

2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 153160

medication, and the alarm effects the elimination of symptoms

over a somewhat longer time span.
The US and international literatures have been bifurcated;
researchers have conducted comparable studies and reached the
same general conclusions, but without the benefit of international discourse and a global dissemination of knowledge.
Research in the area would progress more rapidly if there were
greater communication among researchers, rather than conducting entirely parallel paths of inquiry. Databases, such as the
Cochrane Collaboration, an organization that conducts systematic reviews of interventions in health care for a global audience
to enhance health-related decision making, and the National
Institute for Health and Clinical Excellence, an organization in
the UK that provides guidance for the public and healthcare
professionals on the treatment and prevention of various illnesses, seem to be a promising new direction for creating a
worldwide database that combines literatures across fields and
locations (Cochrane Collaboration n.d., para. 1; National Institute for Health and Clinical Excellence n.d., para. 1).
Of interest is that outcome literature seems to be reported
differently by the psychological versus medical fields (Houts
et al. 1994). In the psychological literature, outcomes are
reported as the percentage of children who ceased bedwetting
entirely over the long term. In the medical literature, outcome is
reported in terms of reductions in wetting frequencies. Thus, the
psychological approach emphasizes the goal of treatment being a
cure, whereas the medical approach emphasizes management
but not elimination of the problem. In practice, medications are
aimed primarily at reducing the amount of times the child wets
and generally do not cure the disorder, as seen by the high relapse
rates once medication is stopped (Wagner 1987; Moffatt 1997).
Future research might address limitations in work to date.
The most glaring limitation is that many empirical studies were
conducted with small sample sizes, calling into question the
validity of findings (e.g. Sukhai et al. 1989; Nawaz et al. 2002;
Ozden et al. 2008). Randomized clinical trials using adequate
sample sizes would improve the knowledge base, as would systematic examination of patient characteristics that might serve
as moderators and/or mediators of treatment effectiveness (e.g.
age, gender, race and ethnicity, socioeconomic status, parent
motivation). Comprehensive meta-analyses, such as those provided by the Cochrane Collaboration and the National Institute
for Health and Clinical Excellence, should continue to be performed so as to combine the findings and maximize sample
sizes of the existing literatures across all fields and locations.
Furthermore, the examination and study of enuresis from the
perspective of monosymptomatic versus polysymptomatic
forms shows the potential for a greater understanding of the

Treatment of enuresis in children 159

disorder. For example, the three systems approach is one that

seeks to better conceptualize the clinical heterogeneity of enuresis by classifying children based on their symptomology and
individual functioning so as to provide the most appropriate
treatment intervention (Butler & Holland 2000).
Because nocturnal enuresis is not uncommon in adults, especially during periods of distress, exploration of ways of extending the paediatric literature to treatment of adults is warranted
(McDonald & Trepper 1977). Furthermore, although daytime
incontinence may have a different aetiology than nocturnal
enuresis, and thus may be less amenable to psychological treatments, the harmful psychosocial sequelae of daytime wetting
are sufficient to justify evaluation of behavioural treatments
(Christophersen & Mortweet 2001).
Despite compelling evidence of the efficacy of the urine alarm,
this treatment approach is relatively unknown to parents and
used less commonly by physicians than medication, a less efficacious approach (Houts 2003). Houts (2003) argues that this
trend exists because behavioural treatments for enuresis have no
corporate backing, as do pharmaceutical treatments. Thus, physicians are more familiar with medications because of the efforts
of pharmaceutical companies to promote them. Houts also
argues that the issue of managed care hinders the dissemination
of behavioural interventions for enuresis, as insurance companies routinely pay for prescription medications and often questionnon-medicalservices. These issues appear to be particularly
salient in the USA. It seems that the international medical communities, primarily in the UK and Europe, have viewed treatment with the urine alarm as the first choice option for the past
several years, as evidenced by the literature and standardization
documents put forth by the International Childrens Continence
Society (e.g. Neveus et al. 2006, 2010).
With this in mind, the continuation of the dissemination of
the efficacy of the urine alarm must be prioritized as a next
step in addressing this common yet debilitating disorder of
childhood.

Key messages
The urine alarm continues to be the most effective treatment for primary nocturnal enuresis in children.
Recent literature has shown the benefit of combining the
urine alarm with both behavioural and pharmaceutical
components when treating children with primary nocturnal enuresis.

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