Simple behavioural interventions
These include lifting, waking, reward charts and retention control training. Bedwetting alarms and overlearning are also considered simple interventions, however these require purchase of an enuresis alarm and so may be considered second-line interventions.
This involves lifting the child from bed while they sleep and taking them to the toilet, without necessarily waking the child.
This involves waking the child up and walking them to the toilet. Children can be woken at set times or randomly through the night.
These are calendars with a space for each day, where a sticker can be placed indicating a dry night. These act as visual reminders of progress.
Retention control training (also known as ‘bladder training’)
This involves encouraging children to hold voiding urine as long as possible once a day, as a means of expanding bladder capacity and enabling recognition of a full bladder.
These are typically reserved for children older than 7 years. Alarms work by using a sensor that detects the first drops of urine in the underwear. When the sensor is activated, it sends a signal to an alarm device, which is intended to wake the child with a sound, light or vibration. The alarm helps to train the child to wake up or stop urinating before the alarm goes off.
Children should be in charge of their alarm and should test it every night before sleeping. Parents should give positive reinforcement for dry nights and for successful use of the alarm sequence.
As alarm therapy begins, some children will not awaken when the alarm goes off. Parents should wake the child initially, although most children will eventually learn to awaken on their own. It is critical for success of alarm therapy that the child is awake and conscious during the process of going to the bathroom in the middle of the night and not ‘sleepwalking’ through the experience.
Use the alarm continuously until the child has 3–4 weeks of consecutively dry nights. This usually takes 3–4 months but can range between 5 weeks and 6 months. The alarm sequence can be restarted if bedwetting recurs.
This also involves use of an enuresis alarm, as described above, until the child is dry for 3–4 weeks. The child is then allowed to drink three-quarters of a cup (approximately 200 mL) of water in the hour before bedtime. The child then wears the enuresis alarm to sleep. Filling the bladder challenges the child’s ability to awaken before wetting the bed, hence the concept of ‘overlearning’.
Complex behavioural interventions
These include dry bed training and full-spectrum home training.
Dry bed training
This consists of a strict schedule for waking the child up at night until the child learns to wake up alone when needed. The training is implemented over 7 nights.
- Night 1: Wake the child every hour until 1 am and have them go to the toilet. The parent may stay with the child on the first night.
- Nights 2–6: Wake the child once a night, 3 hours after falling asleep on the second night and earlier on each subsequent night. On the sixth night, wake the child 1 hour after bedtime.
- Night 7: The child should wake on their own. After training is complete, repeat the steps if the child wets the bed 3 nights in a row.
Full-spectrum home training
This includes behavioural interventions such as encouraging the child to remove soiled sheets and remake the bed, overlearning, dry bed training and bladder training.
Complex interventions alone have not been shown to be better than alarms used alone.