By Steve Hodges, M.D.
In my two decades as a pediatric urologist, my thoughts on bedwetting medication have evolved quite a bit.
For years, I was a purist. I rarely prescribed enuresis drugs because 1.) overall, they have a dismal success rate, and 2.) some medications actually exacerbate constipation, the very cause of enuresis.
I viewed medication as a stop-gap measure for sleep-away camp or overnights, nothing more than a Band-Aid. Instead, I focused laser-like on treating the child’s clogged rectum. After all, the proven way to resolve enuresis permanently is to empty the rectum and keep it clear. Only then will the rectum to shrink to normal size and stop aggravating the bladder nerves.
These days, I still emphasize treating the clogged rectum. In fact, I recommend even more aggressive treatment than I did in the past.
However, I also prescribe medication for patients more often than I used to. I’ve come to realize that, like Band-Aids, enuresis drugs can be pretty darned useful.
Medication, when it works, can boost a child’s and motivation to stick with constipation treatment while they wait for the rectum heal and the bladder nerves to settle down. What’s more, newer drugs have been developed that can calm an overactive bladder without exacerbating constipation.
Still, I am choosy about which patients I prescribe medication to, and I emphasize to families that enuresis drugs 1.) often do not work and 2.) are only an adjunct to, not a replacement for, constipation treatment.
In this post, I will discuss which children are, and aren’t, good candidates for enuresis medication.
As I mentioned, enuresis drugs, on the whole, have a poor track record. Often, they are no better than a placebo at reducing accident frequency — about 30% of children see a significant benefit — and for most kids, the effect is temporary. They’ll start wetting again if they stop the medication.
This meager success applies to desmopressin, a drug that reduces overnight urine production, as well as to anticholinergics and beta-agonists, two drug categories developed to calm bladder overactivity.
However, the overall statistics obscure an important distinction I see in my practice: When a child’s constipation has resolved, medication tends to work well; when a child’s rectum remains clogged with stool, drugs are pointless. The bulging rectum places so much force on the bladder that medications cannot counteract it.
No study exists evaluating the effectiveness of enuresis medication based on a child’s constipation status (as confirmed by an x-ray, not a patient history or exam). But I feel confident the pattern I just described is what such a study would find.
In my clinic, the best candidates for medication are children who, based on x-rays, have made significant progress with an enema-based regimen such as the Modified O’Regan Protocol (M.O.P.) but who, to their great frustration, still have wetting accidents.
In other words, the x-ray will show the rectum is empty but still enlarged (and therefore is still aggravating the bladder nerves). In my experience, the empty rectum suggests dry nights are on the horizon. The child just needs more time.
How much more time? It's impossible to predict. For a child with highly sensitive bladder, even the slightest rectal bulge can trigger bladder contractions and accidents. So, it may take many months for the rectum, even when empty, to shrink enough for accidents to stop. That is longer than many kids, especially teens, can tolerate.
For a teen who has diligently complied with M.O.P., waking up wet day after day can feel demoralizing. It’s enough to make a kid throw in the towel. The kid may think: What’s the point in doing enemas every day? I’m still wet, anyway.
Of course, quitting will backfire, allowing the rectum to refill and prolonging even further the resolution of their bedwetting. So, for a child on the verge of quitting treatment, medication can bring a big psychological boost.
“The medication helped me and my son persevere [with M.O.P.],” the mom of a 14-year-old posted in our private Facebook support group.
Her son took desmopressin, the oldest and most commonly prescribed enuresis medication. The drug mimics antidiuretic hormone (ADH), the hormone that regulates fluid levels, and essentially fools the kidneys into producing less urine at night. Since children with enuresis don’t actually overproduce urine, desmopressin isn’t a permanent fix. Still, the drug can stop bedwetting in some kids.
Not all children like the idea of desmopressin. One mom said her son called desmopressin-aided dry nights a “fake dry” and stopped taking the medication. It was important to him to know whether a dry night was due to medication or his own body.
But for other children, dry is dry — “fake” or not — and that’s reason enough to take medication.
READ: Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable
How do you know when a “fake” dry becomes a “real” dry? Trial and error: You periodically skip desmopressin to see whether the dryness holds.
Another mom of a teenager posted in our support group that her son took desmopressin “to keep his morale up” while he continued on M.O.P.
“It took 13 weeks before he could drop desmopressin,” she wrote. “Once a week, we’d experiment and skip desmopressin to see if he still needed it. Finally, he didn’t.”
After a full month of dry nights without the medication, the boy felt confident enough to start a slow taper off enemas.
Would I recommend desmopressin for child who just started on M.O.P. or who has only treated their constipation with Miralax? No. The drug is highly unlikely to work in a kid with a clogged rectum.
But for children who’ve been tackling constipation with M.O.P. for several months and whose x-rays look much improved, I think it’s worth a try.
While desmopressin is designed to treat nighttime enuresis, bladder-calming medications can be prescribed for both daytime and nighttime enuresis. However, I find these drugs are more effective for children with daytime-only enuresis (a relatively uncommon scenario I discuss in the M.O.P. Anthology).
Children who experience wetting both day and night wetting tend to be quite constipated and are not ready for medication. Typically, these kids need more time and/or a different variation of M.O.P. before drugs have a chance of helping.
Anticholinergics are the most commonly prescribed bladder-calming drugs. Just beware: With first-generation anticholinergics, such as oxybutynin, a common side-effect of is constipation. This drug can backfire big-time.
“I think oxybutinin really set us back,” one mom in our support group posted. “I don’t feel we were adequately warned about the side effects.”
Another mom posted: “Oxybutynin worked wonderfully for 6 weeks and then stopped working entirely. Based on an x-ray, I think it made things worse.”
The easiest way to test this medication is to purchase the Oxytrol patch, sold over the counter and made for adults with overactive bladders. Adult-sized kids can use a whole patch. For smaller children, cut the patch in half. You apply the patch to an area of clean, dry skin on the child’s abdomen, hips, or bottom. Or, a doctor can prescribe oxybutynin in a liquid, gel, or pill form.
For children taking oxybutynin, I strongly recommend maintaining an aggressive, daily bowel-clearing regimen such a M.O.P. Taking this medication in conjunction with oral laxatives alone is unlikely to work.
In general, I prefer the newer anticholinergics, such as Toviaz and Vesicare, which are less constipating than oxybutynin. However, these drugs only come in pill form and are expensive. Also, their success rate, in general, is not stellar.
One mom in our support group posted that her 5-year-old found Vesicare “slightly more successful than oxybutinin,” but she decided to stop medication altogether and just focus on constipation treatment.
The other class of bladder-calming medications are the beta-agonists, such as mirabegron. These work somewhat differently than anticholinergics and are not constipating at all.
Mirabegron, historically quite expensive, has gone generic, so the price has come down considerably. It’s a decent option for kids who are pretty well cleaned out but who are not yet dry.
An in-depth discussion of bladder medications is beyond the scope of this blog post, but I do want families to be aware of them. I feel strongly that resolving the constipation that underlies enuresis is critical.
One final note: There is a small minority of kids who, even with M.O.P. and medication, continue to have wetting accidents — these are the kids who are good candidates for bladder Botox or the InterStim device. However, in the United States, insurance will not cover Botox or InterStim unless the child has been unsuccessful with all three classes of bladder medication. So for persistent cases of enuresis, that fact alone is a good reason to try medication.