According to the DSM-IV-TR, enuresis is defined as the repeated voiding of urine into the bed or clothes at least twice a week for at least three consecutive months in a child who is at least five years of age. The definition can be further categorized into primary enuresis, occurring in children who have never been consistently dry throughout the night and secondary enuresis, consisting of the resumption of wetting after at least six months of consistent dryness (American Psychological Association, 1994). Nevertheless, nocturnal enuresis, more commonly referred to as “bed-wetting”, is a major concern for children and families. For at least five million children in the United States, bed-wetting is a fact of life, with consequences resulting in embarrassment, low self-esteem and anxiety (Sears, 2004).

Enuresis may present alone or in conjunction with other childhood and adolescent disorders such as diabetes, kidney abnormalities, sleep apnea and developmental immaturity. Identifiable psychological factors such as stress related to life changes such as divorce, the birth of a new sibling, moving and beginning a new school may also be responsible for enuresis in children. Furthermore, a clear genetic component to enuresis has been identified with 44% and 77% of children enuretic when one or both parents were enuretic after the age of six. In addition, the small size of a child’s bladder may become overfilled easily and studies have noted that the lack of antidiuretic hormone (ADH) is the culprit in some cases of nocturnal enuresis. Factors such as these may be identified through a thorough physical as well as psychosocial, emotional and familial assessment (Fritz, et. al. 2003).

Once the previously mentioned potential factors have been eliminated as the cause, bed-wetting may safely be attributed to the normal and common immaturity of the communication system between the bladder and the brain. In this case, the brain does not recognize the signal sent from the full bladder during the unconscious nighttime hours, and enuresis results (Benson-Harrington, 2004). In infants, voiding is a reflex in response to a full bladder. By the age of two or three years, most children learn that they may manipulate this reflex, resulting in conscious daytime bladder control. However, nighttime control is achieved through the unconscious control of the voiding reflex, which according to Dr. William Sears, M.D., is unrealistic to expect a child under the age of four or five to wake up dry (Sears, 2004).

With this in mind, Dr. Sears (2004) advises parents to address the issue more aggressively if the child is six years or older and either the child and/or parent(s) are bothered with the issue. Furthermore, Dr. Sears presents the following “7 Steps to Dry Nights” (Sears, 2004).

Step One: Educate the child by explaining to the child that bed-wetting is a common problem and that it is not his/her fault. Explain to the child the mechanism of the bladder-brain communication, in terms that the child will understand.

Step Two: Positive reinforcement has been successful in decreasing enuresis episodes in 80 to 85% of cases. Dr. Sears suggests utilizing a sticker board, rewarding the child with a sticker for each “dry” night. After a designated amount of dry nights per week, reward the child with a mutually agreed-upon prize.

Step Three: Teach the child to “triple void” or to go to the bathroom three times prior to bedtime to avoid going to bed with urine in the bladder.

Step Four: Teach the child “positive talk” to encourage the bladder and brain to communicate at bedtime. Encourage the child to repeat phrases such as “When my bladder is full I will go to the bathroom”.

Step Five: Fully awaken the child a few hours after he/she has retired to bed and encourage the child to attempt to void.

Step Six: Encourage bladder training throughout the day by having the child drink large amounts of fluid and holding it in for longer periods. Dr. Sears advises that this practice will help to increase bladder capacity and strength as well as teach the child to control the bladder. However, this practice may not be advised if the child has a history of urinary tract infections.

Step Seven: If all previously strategies have failed, Dr. Sears advises highly motivated and compliant families to invest in a bladder-conditioning device. The device, consisting of a sensor pad worn on the underwear or bedding and a buzzer that alarms when the devise senses moisture, awakens the child and serves as a reminder to use the bathroom. Over time, the child subconsciously learns to pay attention to bladder signals (Sears, 2004).

Many current studies support this advice, noting that “conditioning” through the use of an enuresis alarm has proven to be highly effective as a first line treatment of nocturnal enuresis with cooperative and motivated families (Fritz, et. al. 2004).

In one double-blind, placebo-controlled trial, researchers studied children (n = 358; age range, 6-16 years) experiencing nocturnal enuresis, and determined those that were unsuccessful with pharmacotherapy as a primary intervention (n=207, following four weeks of Desmopressin therapy 20mg-40mg). All of the subjects were introduced to a nighttime alarm device, with half continuing with the drug Desmopressin and the other given placebo (for 8 weeks). Results of the study concluded that half of the subjects regardless of Desmopressin or placebo, achieved remission during alarm therapy. In closing, the researchers conclude that in children unresponsive to Desmopressin, continuation of the drug during alarm therapy was not beneficial (Gibb, et. al, 2004).

Similarly, another study examined the effectiveness of enuresis alarm therapy as second line therapy for monosymptomatic nocturnal enuresis (MNE), for partial and non-responders to pharmacotherapy alone. Results suggested that of the twenty-eight eligible subjects, 90.5% of partial responders and 71.4% of non-responders showed initial response to alarm treatment and exhibited a 61.9% and 57.1% overall lasting cure rate. Researchers suggest that although highly effective, alarm therapy be reserved for highly committed and compliant families. Overall, the researchers believe that due to low compliance, alarm devices should be used as second line therapy in partial and non-responders to pharmacological intervention (Woo & Park, 2004).

The Cochran Library has prepared a review of all randomized trials of alarm interventions for nocturnal enuresis in children. Inclusion criteria required that the trials were randomized to alarm treatment in comparison to control subjects, behavioral or pharmacological intervention. Trials including organic causes of enuresis, baseline assessments of the level of bedwetting and trials focused on daytime enuresis were excluded from the review. Of the eligible studies, a total of twenty-two randomized trials and 1,124 children were summarized. Findings concluded that children treated with solely with an alarm intervention were more successful than untreated subjects to become dry during the treatment phase. Likewise, studies concluded that there is lacking evidence in the comparison of different alarm systems as is there in comparing the efficacy of alarm treatment alone, behavioral interventions alone, or in combination. Lastly, comparison of the studies reviled the use of medications such as Desmopressin and tricyclic antidepressants equally as efficacious as alarm treatment, however relapse rates were higher after discontinuation of the drug as compared to that of alarm intervention, suggesting that alarm treatment may be more beneficial for long term results (French, 2002).

Another study sought to determine the effect of alarm treatment in children with day and nighttime wetting as compared to those with nighttime wetting only. Inclusion criteria included children ages 5 to 13 that experienced at least two wet nights per week within the previous four weeks or combined with daytime wetting. Subjects were divided into two groups consisting of 37, one group with day and nighttime enuresis and the other experiencing nocturnal enuresis solely. Results concluded that 65% of the daytime and nighttime subjects became dry at bedtime within 49 days of alarm use. Of these subjects, 42% also became dry during the daytime. 76% of subjects with only nocturnal enuresis became dry at nighttime within 52 days of use of the alarm device. Follow-up data determined that two years after alarm treatment, 15/16 of the followed subjects continued to be dry at night and 10/10 subjects followed for daytime dryness remained dry during the day. With these results, researchers concluded that the use of the alarm device is beneficial for nighttime as well as daytime enuresis (Fritz, et. al, 2004).

In conclusion, nocturnal enuresis can serve as an emotional burden and may be socially crippling for the many children that face it each day. As Dr. Sears has suggested to parents and readers of Parents Magazine, many current studies support the use of alarm devices for children over the age of six, suffering from nocturnal enuresis.