Simple behavioural and physical interventions for nocturnal enuresis in children

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs can be great. Simple behavioural methods of treating bedwetting include reward systems such as star charts given for dry nights, lifting or waking the children at night to urinate, retention control training to enlarge bladder capacity (bladder training) and fluid restriction.

To assess the effects of simple behavioural interventions on nocturnal enuresis in children, and to compare these with other interventions.

We searched the Cochrane Incontinence Group trials register (searched 18 September 2003). The reference list of a previous version of this review was also searched.

All randomised or quasi-randomised trials of simple behavioural interventions for nocturnal enuresis in children up to the age of 16. Trials focused solely on daytime wetting were excluded.

Two reviewers independently assessed the quality of the eligible trials and extracted data.

Thirteen trials met the inclusion criteria, involving 702 children of whom 387 received a simple behavioural intervention. However, within each comparison each outcome was addressed by single trials only, precluding meta-analysis. In single small trials, reward systems (e.g. star charts), lifting and waking were each associated with significantly fewer wet nights, higher cure rates and lower relapse rates compared to controls. There was not enough evidence to evaluate retention control training (bladder training), whether compared with controls or dry bed training, or used as a supplement to alarms, or versus desmopressin. Cognitive therapy may have lower failure and relapse rates than star charts, but this finding was based on one small trial only. One small trial of poor quality suggested that star charts were initially less successful than amitriptyline but this difference did not persist after the treatments stopped. Another suggested that imipramine was better than fluid deprivation and avoidance of punishment.

Simple behavioural methods may be effective for some children, but further trials are needed, in particular in comparison with treatments known to be effective, such as desmopressin, tricyclic drugs and alarms. However, simple methods could be tried as first line therapy before considering alarms or drugs, because these alternative treatments may be more demanding and may have adverse effects.