"My child has enuresis" — this is a broad term. However, from a clinical perspective there are 4 distinct types of enuresis, and each has its own treatment pathway. The correct diagnosis is the correct treatment.

What is PMNE?

PMNE — Primary Monosymptomatic Nocturnal Enuresis:

  • Primary — the child has never had 6 consecutive dry months (secondary means the child was dry, then the wetting resumed)
  • Monosymptomatic — only nocturnal incontinence, no daytime symptoms
  • Nocturnal — only during sleep
  • Enuresis — uncontrolled passage of urine

PMNE accounts for 70–80% of all enuresis cases. The prognosis for this type is the best.

PMNE Criteria (DSM-5 and ICCS 2020)

  • Age 5 and older (under 5 is considered normal)
  • At least twice a week for 3 months
  • Causes clinically significant distress
  • Medical causes (medications, drugs, neurological conditions) have been excluded
  • No daytime urination problems

Pathophysiology — Why Does This Happen?

Three primary mechanisms:

1. Insufficient nocturnal production of antidiuretic hormone (ADH). In a healthy person, vasopressin (ADH) rises at night — the kidneys produce less urine. In children with PMNE this hormonal rhythm is disrupted — urine is produced at night at the same rate as during the day.

2. Small bladder capacity or heightened sensitivity. The bladder sends a contraction signal before it is fully filled.

3. Deep sleep. Children with PMNE spend a large amount of time in stage 3 sleep (deep sleep). The brain does not "receive" signals from the bladder — the child urinates without waking.

The genetic component is pronounced: if both parents had enuresis in their history, the child's risk is 77%. One parent — 44%. Neither parent — 15%.

4 Types of Enuresis — Differences in Treatment

1. PMNE (described above) — Treatment: enuresis alarm + fluid schedule.

2. Polysymptomatic Nocturnal Enuresis (PNE) — nocturnal and daytime symptoms (daytime frequency, inability to hold urine for long). Treatment: urological assessment + bladder training + medication in some cases.

3. Secondary Enuresis — the child was dry, then the wetting resumed. The trigger is typically psychological stress (divorce, new sibling, school change) or a medical cause (urinary tract infection, diabetes). Treatment: addressing the underlying cause + standard enuresis protocol.

4. Daytime Wetting — only during the day, dry at night. Usually bladder dysfunction, in some cases a behavioural issue. Treatment: urological assessment first.

Diagnostic Steps

  1. History — urination frequency (night, day), volume, fluid intake, family history
  2. Urinalysis — infection, glucose, protein
  3. Physical examination — neurological and genitourological
  4. Voiding diary — the child's urination frequency and volume are recorded for 2–3 days
  5. Ultrasound if needed — assessment of the bladder and kidneys

PMNE Treatment Protocol (International)

ICCS 2020 and EAU/ESPU 2019 recommendations:

First line:

  1. Psychoeducation (child and parents)
  2. Fluid schedule and sleep hygiene
  3. Enuresis alarm (12 weeks)

Second line (if the alarm is insufficient):

  1. Desmopressin (synthetic ADH) — short term

Third line (in rare cases):

  1. Anticholinergic medications (oxybutynin) — for bladder dysfunction
  2. Combined treatment

Imipramine is not recommended as a first-line option — due to cardiovascular side effects.

Treatment Duration and Effectiveness

  • Enuresis alarm: 8–12 weeks, success in 70–80%
  • Desmopressin: rapid result, but relapse in 60% of cases upon discontinuation
  • Combined approach: highest effectiveness (over 85%), low relapse rate

Important: upon completing treatment, 14 consecutive dry nights are required to consider the outcome successful. This is the international standard.