The boy who longed for a ‘dry spell’
Chronic enuresis has destroyed 12-year-old Jimmy’s emotional and social functioning. The challenge: restore his self-esteem and find out why can’t he stop wetting his bed.
Five months after starting combination therapy, Jimmy seems much more confident. He has gone 2 months without a bedwetting accident, and his face lights up while discussing the fun he had last week in summer camp. He remains free of side effects, and his parents are thrilled with his progress.
We see Jimmy three more times, once every 2 months. He is staying “dry” but says he wishes to stop his medication because he wants to control his bladder without it.
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The authors’ observations
Medications and behavioral treatments can preserve the child’s self-esteem until he or she outgrows enuresis (Table).
No guidelines address drug regimen duration. Tapering Jimmy’s medications after 7 to 8 months seemed reasonable, but children with enuresis often relapse after stopping treatment. Researchers have recorded relapse rates as high as 60% after stopping imipramine and 80% after stopping desmopressin.1,4
Taper medications slowly to avoid withdrawal, immediate relapse, and anticholinergic effects. If the child relapses, restart medication at the previous therapeutic dosage(s), then start tapering after the child has been accident-free for 3 months.
Table
Medication strategies for treating enuresis
| Medication | Dosage | Risks |
|---|---|---|
| Desmopressin acetate (first-line) | Start with 0.2-mg tablet or 1 to 2 10-μg puffs of nasal spray (half in each nostril) in children age >6; increase to 0.6 mg/d or 4 puffs daily after 1 week if necessary Stop after approximately 6 months without an accident | High relapse rate Reduced urine production Water intoxication, hyponatremia are rare but can result in seizures, coma |
| Oxybutynin (second-line) | 2.5 to 5 mg tid (immediate-release) or 15 mg/d (extended-release) Start at 5 mg at bedtime for children age >5; increase to 15 mg/d after 1 to 2 weeks if needed Stop after approximately 6 months without an accident | High relapse rate Anticholinergic effects (dry mouth, facial flushing, drowsiness, decreased GI motility) Few efficacy studies done Mostly used with other medication |
| Desmopressin with oxybutynin or imipramine; medication plus alarm method (third-line) | Dosages of individual medications as listed | Limited data available Positive results seen in resistant cases, particularly in older children |
| Imipramine (last option) | 1 to 2.5 mg/kg/d Start with 25 mg/d at bedtime; if no response, increase in weekly 25-mg increments to 50 mg/d for children ages 7 to 12 or up to 75 mg/d for children age >12 Stop after approximately 6 months without an accident | High relapse rate after stopping medication Risk of arrhythmias (order ECG when starting medication, 1 month later, then every 6 months) Fatal in overdose (do not prescribe >75 mg/d in enuresis) Associated with suicidal behavior in youths (carries FDA “black box” warning) |
Follow-up: Still dry
After discussing the relapse risk with Jimmy’s parents, we withdraw both oxybutynin and desmopressin over 2 months, reducing each dosage 25% every 2 weeks. We see Jimmy every 4 to 6 weeks during the taper period, then for two bimonthly follow-up visits. He reports no adverse effects and has been accident-free for 8 months.
After consulting with his pediatrician and family, we refer Jimmy, now age 13, back to the pediatrician. We have not seen him for more than 1 year.
Related resources
- National Association For Continence. www.nafc.org.
- Mayo ME, Burns MW. Urodynamic studies in children who wet. Br J Urol 1990 65;641-5.
- Desmopressin • DDAVP
- Imipramine • Tofranil
- Oxybutynin • Ditropan
Dr. Williams is a speaker for Wyeth.
Dr. Singh reports no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.
