Desmopressin for nocturnal enuresis in children

Enuresis (bedwetting) affects up to 20% of five-year-old children and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Desmopressin has been used to treat bedwetting since the 1970s. This is an update of a Cochrane review first published in 2000 and last updated in 2006.

To assess the effects of desmopressin on treating nocturnal enuresis in children.

We searched Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched January 2023) and reference lists of relevant articles.

We included randomised or quasi-randomised trials of desmopressin or desmopressin combined with another intervention for treating nocturnal enuresis in children between five and 16 years old.

Three review authors independently extracted data and assessed the risk of bias in the eligible trials. We used standard methodological procedures expected by Cochrane.

We identified 50 new studies for this review, which now includes 95 studies (8473) participants, of whom 5434 received desmopressin. In this review we continued the assessment of the effect of combination therapy involving desmopressin. The majority of the trials were in children between the ages of five to 16 years in an outpatient setting. The quality of the evidence was assessed as low or very low. The first comparison was desmopressin versus placebo. Desmopressin may reduce the mean number of wet nights per week compared with placebo (MD -1.81, 95% CI -2.24 to -1.39; participants = 1267; studies = 16; low-certainty evidence). Desmopressin probably leads to more children achieving 14 consecutive dry nights by the end of treatment compared with placebo (RR 3.18, 95% CI 1.75 to 5.80; participants = 922: studies = 11; moderate-certainty evidence). There may be little to no difference in children experiencing adverse effects with desmopressin compared to placebo (RR 1.11, 95% CI 0.81 to 1.52; participants = 269; studies = 3; low-certainty evidence). Desmopressin was compared with alarm therapy. It is uncertain if there is any difference between desmopressin compared with alarm training in reducing the number of wet nights per week (MD 0.63, 95% CI -0.49 to 1.75; participants = 285; studies = 4; I² = 82%; very low-certainty evidence). There may be little or no difference between desmopressin and alarm therapy in the number of children achieving 14 consecutive dry nights (RR 0.98, 95% CI 0.88 to 1.09; participants = 1530; studies = 15; low-certainty evidence). There may be little to no difference in children experiencing side effects with desmopressin therapy compared with alarm therapy (RR 1.50, 95% CI 0.33 to 6.78; participants = 461, studies = 4; low-certainty evidence). We compared desmopressin with other medications, including tricyclics and anticholinergics. It is uncertain if there is any difference between desmopressin compared to tricyclics in reducing the mean number of wet nights per week (MD 0.23, 95% CI - 0.88 to 1.33; participants = 331; studies = 4; I² = 79%; very low-certainty evidence) or in the number of children achieving 14 consecutive dry nights at the end of treatment (RR 0.94, 95% CI 0.63 to 1.38; participants = 371; studies = 7; I² = 71%; very low-certainty evidence). It is uncertain whether children experience more side effects with desmopressin compared with tricyclics (RR 0.29, 95%CI 0.06 to 1.39; participants = 351; studies = 4, very low-certainty evidence). This review included studies with combination therapies. It is uncertain if desmopressin combined with alarm therapy reduces the mean number of wet nights at the end of treatment compared with alarm monotherapy (MD -0.80, 95% CI -1.34 to -0.25; participants = 528; studies = 6; I² = 84%; very low-certainty evidence); or if it increases the number of children achieving 14 consecutive dry nights (RR 1.25, 95% CI 0.96 to 1.63; participants = 822; studies = 10; very low-certainty evidence). Desmopressin plus alarm therapy may make little to no difference in children experiencing side effects compared with alarm therapy alone (RR 1.05 95% CI 0.07 to 16.56; participants = 207; studies = 1; low-certainty evidence). Combining desmopressin with alarm therapy probably reduces the number of wet nights at the end of treatment (MD -0.88; 95%CI -1.38 to -0.38; participants = 156; studies = 2; moderate-certainty evidence), and may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin monotherapy (RR 1.26, 95% CI 1.06 to 1.51; participants = 370; studies = 5; low-certainty evidence). It is uncertain if combined desmopressin and anticholinergic therapy versus desmopressin monotherapy reduces the mean number of wet nights at the end of therapy (MD -0.50; 95% CI -1.05 to 0.06; participants = 188; studies = 3; I² = 66%; very low-certainty evidence); or if it may increase the number of children achieving 14 consecutive dry nights at the end of treatment (RR 1.53, 95% CI 1.10 to 2.11; participants = 611; studies = 8; low-certainty evidence). There may be little to no difference in adverse events between desmopressin plus anticholinergics and desmopressin monotherapy (RR 1.51 95% CI 0.73 to 3.09, participants = 187; studies =2; low-certainty evidence). Minor adverse effects were common for desmopressin, including dizziness, headache, mood changes, gastrointestinal discomfort, nasal discomfort, hyponatraemia and one report of a convulsion.

Desmopressin compared with placebo may increase the number of dry nights per week at the end of treatment in children. Desmopressin therapy may be as effective as alarm therapy at the end of treatment. However, the quality of evidence was assessed as low or very low. Alarm therapy compared to desmopressin may improve the number of children who are dry at follow-up (moderate-certainty evidence).