Urinary Incontinence in Children
Clinical Snapshot
Urinary incontinence in children covers two related but distinct problems: daytime incontinence (repeated daytime wetting in a child 5 years of age or older) and nocturnal enuresis (bedwetting beyond the age most children achieve night-time dryness — beyond 5 years of age for girls and 6 years of age for boys). Most children achieve daytime toilet training by about 3 years of age, with a wide normal range, and continence continues to mature over the following years — a large share of both daytime wetting and bedwetting resolves on its own with time, which shapes how aggressively to intervene and how to counsel families on timing. The single most important branch point in management is whether nocturnal enuresis occurs in isolation (monosymptomatic) or together with daytime lower urinary tract symptoms (non-monosymptomatic) — the two need different workups and different first-line treatment sequencing.[1]
Recognize the Condition
Daytime incontinence
Defined as repeated daytime voiding into clothing at least twice weekly for at least 3 consecutive months in a child 5 years of age or older. It is considered a clinical problem in a child 4 years of age or older who wets daily (primary) or who relapses after at least 6 consecutive symptom-free months (secondary).
Nocturnal enuresis
Bedwetting, including during naps, occurring more than twice weekly beyond the age of 5 for girls and 6 for boys. In primary enuresis, night-time bladder control has never been achieved; in secondary enuresis, wetting resumes after at least 6 months of established dryness — secondary enuresis carries a higher likelihood of an identifiable trigger and deserves a more careful search for a cause (see Assessment and Diagnosis).
Monosymptomatic vs. non-monosymptomatic nocturnal enuresis
Monosymptomatic nocturnal enuresis (MNE)
Bedwetting occurring in the absence of any other lower urinary tract symptom or known urologic/neurologic condition. Subdivides into a volume-dependent pattern (nocturnal polyuria, often from an inadequate night-time rise in antidiuretic hormone) and a detrusor-dependent pattern (small functional bladder capacity) — the two patterns respond differently to desmopressin.
Non-monosymptomatic nocturnal enuresis (NMNE)
Bedwetting accompanied by at least one daytime lower urinary tract symptom — daytime incontinence, urgency, or an abnormal daytime voiding frequency (fewer than 4, or more than 7, voids per day). NMNE needs the daytime component assessed and treated as part of the same workup, not bedwetting managed on its own.[1]
Causes of daytime incontinence
| Functional causes | Organic causes |
|---|---|
|
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Causes of enuresis
| Primary enuresis | Secondary enuresis |
|---|---|
|
|
Developmental delay, a family history of enuresis, and obstructive sleep apnea are all recognized contributors to primary enuresis; treating sleep-disordered breathing (including adenotonsillectomy where indicated) has been observed to improve monosymptomatic nocturnal enuresis in children who have both conditions.[2]
Risk Factors
- Family history of urinary incontinence or enuresis.
- Functional constipation — one of the most common and correctable contributors to both daytime and night-time incontinence.
- Developmental delay or a neurodevelopmental disorder.
- Obstructive sleep apnea or habitual snoring.
- Male sex (primary enuresis is more common in boys; daytime incontinence is more common in girls).
- An unsupportive or punitive caregiver response to wetting episodes, which predicts poorer engagement with treatment rather than causing the incontinence itself.
- Prior urinary tract infection or urologic surgery.
- Never having achieved sustained dryness (primary) versus a period of established dryness followed by relapse (secondary) — each points toward a different set of likely causes.
Red Flags & Refer
Most childhood urinary incontinence is functional and managed by the strategies in this chapter, but the following findings need investigation or specialist referral rather than routine incontinence management:
- Secondary enuresis or daytime incontinence with new, severe daytime symptoms (marked urgency, significant straining, or a clear change in voiding pattern) suggesting an evolving neurologic or structural cause rather than a functional one.
- Signs of urinary tract infection — dysuria, urinary frequency with discomfort, fever, or foul-smelling/cloudy urine — confirm with urinalysis and culture rather than assuming functional incontinence.
- Polyuria and polydipsia, which raise concern for diabetes mellitus or diabetes insipidus rather than the ordinary nocturnal polyuria of enuresis.
- Straining to void, or a weak or interrupted urinary stream, suggesting partial urethral obstruction (e.g., posterior urethral valve, meatal stenosis) rather than functional wetting.
- Signs of occult spinal dysraphism on examination of the lower back — a hair tuft, dimple, pigmented lesion, or subcutaneous lipoma over the spine, or asymmetry of the gluteal cleft — refer to pediatric neurosurgery; these findings can indicate a tethered cord causing progressive neurologic damage.
- Abnormal perineal sensation, perineal reflexes, or sphincter tone on examination, suggesting a neurogenic bladder.
- An abnormal voiding cystourethrogram, when obtained — refer to urology.
Assessment & Diagnosis
History
- Family history of urinary incontinence or enuresis — often present.
- Bowel habits and any symptoms of constipation — closely linked to incontinence through reduced functional bladder capacity from a loaded rectum.
- The detailed pattern of wetting: daytime, night-time, or both; frequency; approximate volume; whether the child has ever achieved sustained dryness (primary vs. secondary).
- History of urinary tract infections or prior urologic surgery.
- Daytime voiding frequency and any urgency, straining, or a weak stream.
- Snoring or other symptoms of sleep-disordered breathing.
- Psychological status of the child and family dynamics, including how the family currently responds to wetting episodes.
Physical examination
- Perineal sensation, perineal reflexes, and sphincter tone, to screen for a neurogenic bladder.
- Genitalia, particularly the urethral meatus, to screen for anatomical causes such as meatal stenosis (boys) or labial fusion (girls).
- The lower spine, for signs of occult spinal dysraphism (hair tuft, dimple, pigmented lesion, subcutaneous lipoma, gluteal cleft asymmetry) — refer to pediatric neurosurgery if present.
- Direct observation of voiding, when feasible, to assess the urinary stream.
- Abdominal examination for a palpable fecal mass suggesting significant constipation.
Investigations
- A voiding and/or bowel-movement diary kept by the family — the single most useful tool for characterizing the actual pattern.
- Urinalysis and urine culture in every child being assessed for incontinence.
- No further investigation is necessary for straightforward primary enuresis with a normal history, normal exam, and normal urinalysis.[3]
- Renal and bladder ultrasound plus a voiding cystourethrogram are reserved for children with a history of urinary tract infections, to look for vesicoureteral reflux, partial urethral obstruction, or a neurogenic bladder — refer to urology if the voiding cystourethrogram is abnormal.
Interpreting the history
Certain findings point toward a specific mechanism and should shape the assessment rather than being treated as incidental detail. A large volume of urine passed early in the night is typical for uncomplicated bedwetting; a variable volume, or urine passed more than once a night, raises concern for an underlying overactive bladder. Bedwetting every single night is less likely to resolve on its own than infrequent bedwetting. Daytime frequency, urgency, straining, or pain with voiding all point toward a bladder disorder rather than isolated night-time enuresis. Constipation and soiling are common, frequently under-recognized comorbidities — soiling in particular is usually secondary to fecal impaction rather than a primary behavioural problem. Inadequate daytime fluid intake can mask an underlying bladder problem and impede the development of normal bladder capacity, so ask about it directly rather than assuming low daytime output is reassuring. Practical barriers — a shared bedroom, difficulty accessing a bathroom at night, or family circumstances that make an alarm hard to use consistently — should be identified early, since they change which treatment is realistic for a given family.
Treatment Targets
- Identify and manage any serious underlying cause (structural, neurologic, infectious, or endocrine) before treating as functional incontinence.
- Treat constipation, since resolving it frequently improves daytime and night-time bladder symptoms directly.
- Reduce the frequency of daytime incontinence episodes and increase the number of dry nights, working toward complete, durable dryness.
- Choose a treatment approach the child and family can realistically sustain, since motivation and consistent participation are the strongest predictors of success.
- Avoid treatment-related harm — most importantly, prevent desmopressin-associated water intoxication and hyponatremia through correct fluid-restriction counselling.
- Provide ongoing reassurance and practical guidance to reduce the distress and social impact incontinence causes for the child.
Choose Initial Treatment
Three treatment tracks
Enuresis alarm therapy
Conditioning-based first-line treatment for monosymptomatic nocturnal enuresis. Slower to work than medication, but produces the most durable dryness with the lowest relapse once successful.
Desmopressin
Pharmacologic first-choice alternative when a rapid response is needed or alarm use is not feasible. Works quickly, but relapse is common once stopped unless the response is consolidated.
Combination therapy
Alarm plus desmopressin, or desmopressin plus an antimuscarinic, reserved for relapse after single-modality treatment or for enuresis refractory to either alone.
Address constipation first, or at minimum concurrently, in every child with daytime or night-time incontinence and any evidence of functional constipation — bladder symptoms frequently improve directly once the bowel is managed, and starting bladder-directed treatment without addressing significant constipation undermines the response to everything else.
Monosymptomatic nocturnal enuresis, 1st line enuresis alarm therapy in a motivated child (generally 6-7 years of age or older) with a family able to commit to consistent overnight use — it has the best long-term cure rate and the lowest relapse of any single treatment.
Desmopressin — use when a rapid response is specifically needed (for example, an upcoming camp or overnight visit), the family cannot commit to alarm use, or alarm therapy has been tried without success.
Non-monosymptomatic enuresis / daytime symptoms, 1st line urotherapy (scheduled voiding, correct posture, adequate — not restricted — daytime fluids, treating constipation) before or alongside night-time treatment; add oxybutynin if daytime urgency/incontinence persists despite urotherapy.[3]
Combination therapy — use when enuresis relapses after alarm or desmopressin monotherapy, or is refractory to either alone, especially when nocturnal polyuria and reduced bladder capacity coexist.
Avoid routine use of tricyclic antidepressants — reserve for specialist-directed use only, after alarm, desmopressin, and combination therapy have all failed, given their narrow therapeutic window and cardiotoxicity risk in overdose.
Non-Pharmacologic Treatment
Caregiver approach and general counselling
- Advise caregivers to avoid humiliating or punishing the child for wetting episodes — an intolerant caregiver attitude predicts early dropout from treatment, and there is no good evidence that enuresis itself reflects a behavioural or psychological problem.
- Use positive reinforcement: reassurance, a diary of dry days/nights, and easy, unhindered access to a bathroom at home and school.
- Have the child avoid excessive fluid intake within 2 hours of bedtime and empty the bladder immediately before going to sleep.
- Encourage the child not to defer or "hold" urination during the day.
- For daytime incontinence, use bladder training: a scheduled voiding routine (for example, every 2-3 hours) and pelvic floor/abdominal muscle exercises.
Treat constipation
Functional constipation is a major, frequently overlooked contributor to both daytime incontinence and nocturnal enuresis — a loaded rectum reduces effective bladder capacity and can trigger detrusor overactivity. Screen for it in every child with incontinence and treat it concurrently with bladder-directed therapy; see the Constipation in Children chapter for disimpaction and maintenance laxative dosing. Resolving constipation alone is often enough to substantially improve or resolve associated bladder symptoms.
Enuresis alarm therapy
Alarm therapy is the preferred first-line treatment for monosymptomatic nocturnal enuresis and has the strongest evidence base of any single intervention, reducing the average number of wet nights compared with no treatment and — unlike desmopressin — producing durable dryness with a low relapse rate once successful.[4] The alarm is a small, moisture-sensitive sensor worn in the underwear or on an absorbent pad that vibrates or sounds at the very first sign of voiding. Because children with enuresis are often deep sleepers, the caregiver frequently needs to be the one who wakes the child when the alarm sounds; the child then finishes voiding in the toilet and returns to bed after changing into dry underwear/bedding. Alarm therapy tends to work best in children with normal urine output and a small or normal bladder capacity, and may be tried from about 5 years of age in a motivated, well-supported family, with the best results generally seen from about 7 years of age onward. Response builds gradually — give an adequate trial (generally at least 6-8 weeks of consistent use) before concluding it has failed. Adding dry-bed training (a strict schedule for waking the child overnight until they learn to wake independently) or overlearning (having the child drink extra fluid before bed once the alarm is producing dry nights, while continuing to use the alarm) after initial dryness is achieved lowers the relapse rate compared with stopping the alarm alone.[2]
Complementary and other non-pharmacologic approaches
There is no good evidence of effectiveness for hypnosis, chiropractic manipulation, faradization (electrical stimulation to the genital area), or homeopathy — these should not be recommended as a substitute for alarm therapy or medication. There is some evidence that transcutaneous parasacral electrical nerve stimulation, functional magnetic stimulation, laser acupuncture, or limiting evening milk intake (to reduce hypercalciuria) may modestly improve response or reduce relapse when added to standard treatment, though the trial base behind each remains small.[2]
Special Populations
Pregnancy and breastfeeding
This chapter covers prepubertal and adolescent children; pregnancy is not a consideration for most patients. In a post-menarchal adolescent, confirm pregnancy status before starting or continuing desmopressin or an antimuscarinic — the pediatric dosing and safety information in this chapter assumes a non-pregnant patient, desmopressin's hyponatremia risk has not been specifically studied for this indication in pregnancy, and antimuscarinic agents are not well characterized in pregnancy. If pregnancy is identified, manage under adult obstetric/urology guidance rather than continuing pediatric incontinence dosing unchanged. Breastfeeding is not a relevant consideration for a patient being treated for pediatric urinary incontinence.
Young children
Given the high rate of spontaneous resolution before school age, avoid starting alarm therapy or medication before about 5-6 years of age unless daytime symptoms or a red flag are present — reassurance and expectation-setting alone are appropriate first-line management in a younger child with isolated bedwetting.
Developmental delay / neurodevelopmental disorders
Developmental delay is a recognized predictor of a poorer response to both alarm therapy and desmopressin. These children can still be offered treatment, but set realistic expectations with the family, allow a longer trial before judging response, and consider earlier referral if progress stalls.
Obstructive sleep apnea
Ask about snoring and witnessed apneas in any child with monosymptomatic nocturnal enuresis that is not responding as expected — treating obstructive sleep apnea, including adenotonsillectomy when indicated, has been observed to improve or resolve associated enuresis, and a sleep medicine or otolaryngology referral is appropriate when sleep-disordered breathing is suspected.[2]
Renal, hepatic, and cardiac disease
Desmopressin is contraindicated in hyponatremia, severe liver disease, nephrosis, and cardiac insufficiency associated with fluid-retention risk, and should be used with caution — ideally with specialist input — in cystic fibrosis, heart failure, and other conditions that predispose to fluid or electrolyte imbalance, since all of these increase the risk of dangerous hyponatremia on desmopressin.[7]
Antimuscarinic cautions
Avoid oxybutynin, tolterodine, solifenacin, and propiverine in narrow-angle glaucoma, significant gastrointestinal obstruction or motility disorders, and myasthenia gravis, consistent with standard antimuscarinic precautions.
Monitoring & Follow-Up
- Keep a voiding and/or bowel diary throughout treatment — the most useful single tool for tracking response and guiding dose/therapy changes.
- For alarm therapy, review progress with the family at regular intervals (for example, every 2-4 weeks); an adequate trial is generally 6-8 weeks before judging effectiveness, and initial dryness should be consolidated with continued use, dry-bed training, or overlearning before stopping.
- For desmopressin, reinforce fluid-restriction counselling at every visit or refill, and plan a treatment interruption of about 1 week roughly every 3 months to confirm ongoing need before continuing for a further course.
- Ask specifically about prodromal hyponatremia symptoms (headache, nausea, vomiting) at every desmopressin follow-up, and instruct the family to stop the dose and seek urgent care immediately if these occur.
- For antimuscarinic therapy, reassess at about 4 weeks for effect and tolerability (dry mouth, constipation, drowsiness), and actively monitor bowel habits given the constipating effect of these agents.
- Reassess constipation status at every visit, since ongoing bowel dysfunction undermines the response to bladder-directed therapy.
- Track dryness against the child's own baseline rather than against peers, and continue positive reinforcement throughout.
Common Errors to Avoid
- Starting pharmacotherapy before addressing constipation, missing a bowel-management opportunity that alone resolves many cases.
- Failing to counsel fluid restriction around desmopressin dosing — the single highest-stakes safety gap, since untreated water intoxication can cause seizures.
- Using an intranasal desmopressin formulation for primary nocturnal enuresis — contraindicated in Canada given a materially higher hyponatremia risk than with oral formulations.
- Abandoning alarm therapy too early — response builds gradually over weeks, and stopping after only a few nights without improvement discards the treatment most likely to produce durable dryness.
- Treating non-monosymptomatic enuresis (daytime symptoms present) the same as monosymptomatic enuresis — daytime symptoms need urotherapy, with or without an antimuscarinic, addressed as part of the same plan.
- Punishing or shaming the child for wetting episodes — this undermines motivation and predicts treatment dropout.
- Missing red-flag findings (new severe daytime symptoms, spinal dysraphism signs, straining/weak stream) by assuming straightforward primary enuresis without a proper history and exam.
- Prescribing an antimuscarinic without addressing constipation risk, since these agents can worsen pre-existing constipation and undercut the exact bowel-management strategy that helps bladder symptoms.
Clinical Decision Algorithm
Drug Tables
How to use this table: Doses are pediatric doses (generally 5 years of age and older unless noted) and require patient-specific confirmation, including renal/hepatic adjustment and weight-based dosing where applicable. Select any drug name to open its complete Pharmasist Drug Database page.
Antidiuretic hormone analogues
First-line pharmacotherapy for monosymptomatic nocturnal enuresis. Oral formulations only.
| Drug | Dosage | Adverse effects | Comments |
|---|---|---|---|
| Desmopressin | Disintegrating tablet (melt): Initial 120 mcg SL 1h before bedtime; if a wet night occurs after 3 days, increase by 120 mcg increments every 3 days to a maximum of 360 mcg Standard tablet: Initial 200 mcg PO 1h before bedtime; if a wet night occurs after 3 days, increase by 200 mcg increments every 3 days to a maximum of 600 mcg Combination therapy dose (with an antimuscarinic): A lower dose is generally sufficient - melt 120 mcg or tablet 200 mcg QHS | Headache (transient), abdominal pain; rare but serious water intoxication/hyponatremia, which can cause seizures | Used together with non-pharmacologic treatment (address constipation, fluid timing, avoid punishment). Avoid without specialist input in kidney disease, heart failure, diabetes, ileitis, or cystic fibrosis. Withhold during acute illness causing reduced fluid intake or fluid/electrolyte loss. May continue treatment for up to about 3 months at a time, then interrupt for about 1 week to reassess ongoing need before restarting if still needed. |
Anticholinergics / antimuscarinics (antispasmodics)
For daytime urgency/incontinence from detrusor overactivity (urge syndrome, overactive bladder), or combined with desmopressin for enuresis refractory to either agent alone.
| Drug | Dosage | Adverse effects | Comments |
|---|---|---|---|
| Oxybutynin | Extended-release: Over 5y: 5 mg PO once daily at bedtime; may increase to 10 mg once daily at bedtime if no improvement after 4 weeks Immediate-release: 0.1-0.2 mg/kg/dose PO BID-TID | Dry mouth, constipation, drowsiness, dizziness, blurred vision, flushing, occasional mood changes | 1st-line antimuscarinic. Extended-release generally preferred over immediate-release for efficacy; also available as an oral syrup for children who cannot swallow tablets. Actively manage constipation alongside therapy, since oxybutynin itself slows GI motility. |
| Tolterodine (extended-release) | Children 6-17 years: 2-4 mg PO once daily at bedtime | Dry mouth, constipation, drowsiness, dizziness, blurred vision, flushing, occasional mood changes | Reserve for children who do not tolerate oxybutynin — trial data show similar efficacy with fewer anticholinergic effects. Swallow the extended-release capsule whole. May be combined with desmopressin in enuresis refractory to desmopressin monotherapy. |
| Solifenacin | Children and adolescents: 5 mg PO once daily | Dry mouth, constipation, drowsiness, dizziness, blurred vision, flushing, occasional mood changes | Reserve for children who do not tolerate oxybutynin. Randomized trial data in pediatric overactive bladder show a well-tolerated profile with minimal anticholinergic burden, sustained through extended follow-up. May be combined with desmopressin in refractory cases. |
| Propiverine | 12-16 kg: 5 mg AM + 5 mg PM 17-22 kg: 5 mg AM + 10 mg PM 23-28 kg: 10 mg AM + 10 mg PM 29-34 kg: 10 mg AM + 15 mg PM 35 kg or more: 15 mg AM + 15 mg PM | Dry mouth, dizziness, headache, accommodation disorder/visual impairment, constipation, abdominal pain, dyspepsia, fatigue | Supplied as 5 mg tablets specifically to allow the weight-based dosing schedule below. Divide the total daily dose into a morning and evening dose. |
Tricyclic antidepressants (specialist-directed, 3rd-line option)
| Drug | Dosage | Adverse effects | Comments |
|---|---|---|---|
| Imipramine | Age 6-12 years: Initial 10 mg PO at bedtime, increase by 10 mg increments after 1-2 weeks as needed to a maximum of 50 mg/day Age over 12 years: Initial 10-25 mg PO at bedtime, increase as needed to a maximum of 75 mg/day | Dizziness, GI discomfort, headache, mood changes; cardiotoxicity/arrhythmia risk in overdose — a genuinely dangerous drug to have in the home of a young child | Maximum course generally about 3 months; taper rather than stopping abruptly. Do not exceed 2.5 mg/kg/day. |
| Desipramine | Dosing: Individualized by a specialist experienced in pediatric tricyclic dosing for enuresis - not a standard first-choice tricyclic for this indication | Dizziness, GI discomfort, headache, mood changes; cardiotoxicity/arrhythmia risk in overdose | Alternative tricyclic with a similar evidence base to imipramine; use under the same specialist-directed precautions. |
| Amitriptyline | Dosing: Individualized by a specialist experienced in pediatric tricyclic dosing for enuresis - not a standard first-choice tricyclic for this indication | Dizziness, sedation, GI discomfort, headache, mood changes; cardiotoxicity/arrhythmia risk in overdose | Alternative tricyclic with a similar evidence base to imipramine; use under the same specialist-directed precautions. |
Evidence note: Drug inventory, dosing, contraindications, and comments verified against current Health Canada-regulated desmopressin product monographs, the ICCS 2020 and 2016 standardization documents, and the 2021 CUA/PUC guideline for bladder dysfunction in children.[7][2][3]
References
- The standardization of terminology of lower urinary tract function in children and adolescents: update report from the standardization committee of the International Children's Continence Society — Neurourology and Urodynamics (Austin PF, Bauer SB, Bower W, et al.). Neurourol Urodyn 2016;35(4):471-481
- Management and treatment of nocturnal enuresis - an updated standardization document from the International Children's Continence Society — Journal of Pediatric Urology (Neveus T, Fonseca E, Franco I, et al.). J Pediatr Urol 2020;16(1):10-19
- Canadian Urological Association guideline for the treatment of bladder dysfunction in children — Canadian Urological Association Journal (Afshar K, Dos Santos J, Blais AS, et al.). Can Urol Assoc J 2021;15(2):13-18
- Alarm interventions for nocturnal enuresis in children — Cochrane Database of Systematic Reviews (Caldwell PHY, Codarini M, Stewart F, et al.). Cochrane Database Syst Rev 2020;5(5):CD002911
- Solifenacin in children and adolescents with overactive bladder: results of a phase 3 randomised clinical trial — European Urology (Newgreen D, Bosman B, Hollestein-Havelaar A, et al.). Eur Urol 2017;71(3):483-490
- Combination therapy with desmopressin and an anticholinergic medication for nonresponders to desmopressin for monosymptomatic nocturnal enuresis: a randomized, double-blind, placebo-controlled trial — Pediatrics (Austin PF, Ferguson G, Yan Y, et al.). Pediatrics 2008;122(5):1027-1032
- DDAVP MELT (desmopressin acetate) - primary nocturnal enuresis dosing and contraindications — Health Canada-regulated product monograph, Ferring Inc.. Product Monograph, revised May 2, 2017
- DDAVP Spray and Rhinyle (desmopressin acetate) - intranasal formulations contraindicated for primary nocturnal enuresis — Health Canada-regulated product monograph, Ferring Inc.. Product Monograph, revised May 24, 2019
- Tricyclic and related drugs for nocturnal enuresis in children — Cochrane Database of Systematic Reviews (Caldwell PHY, Sureshkumar P, Wong WC). Cochrane Database Syst Rev 2016;1(1):CD002117
Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.