Nocturnal enuresis (NE), commonly known as bed-wetting, affects millions of school-age children worldwide and can have significant psychosocial impacts if left untreated. An updated expert consensus, published in the World Journal of Pediatrics, now offers a comprehensive framework to guide clinicians in diagnosing and managing this condition. The new guidance, developed by researchers from the Children's Hospital of Fudan University and the Chinese Cooperative Group for the Management of Pediatric NE, aims to standardize care and improve outcomes by moving from a one-size-fits-all approach to a more individualized strategy.
The consensus, which includes 18 recommendations, introduces several key changes from previous guidelines. Notably, it lowers the diagnostic threshold for NE: children aged five years or older who experience at least one involuntary nighttime void per month for three months now qualify for diagnosis, a shift from the previous weekly standard. This change is intended to enable earlier intervention and prevent prolonged distress for children and families. The framework also emphasizes the importance of distinguishing between monosymptomatic NE (MNE), where no daytime urinary symptoms are present, and non-monosymptomatic NE (NMNE), which involves daytime symptoms such as urgency, frequency, or incontinence. This classification is crucial because it guides treatment decisions.
A cornerstone of the new approach is the use of voiding diaries, which require patients to record at least two daytime charts and seven consecutive nights of fluid intake and voids. This allows clinicians to phenotype children as having nocturnal polyuria (excessive nighttime urine production), reduced bladder capacity, or both. For MNE, the consensus specifies phenotype-driven first-line therapy: desmopressin for nocturnal polyuria and the enuresis alarm for reduced bladder capacity, with combination therapy for mixed types. For NMNE, the focus shifts to managing daytime lower urinary tract symptoms (LUTS) and comorbidities, particularly constipation, which affects 36–80% of these children, before addressing nighttime wetting.
The authors stress that NE should not be treated as a single disorder but rather as a condition with multiple underlying mechanisms. They advocate for a systematic approach that includes assessing for daytime symptoms, comorbidities, and adherence to treatment. If a child does not respond to first-line therapy, the consensus advises a thorough re-evaluation, including reviewing the voiding diary and checking for missed conditions, before escalating treatment. This approach aims to reduce trial-and-error prescribing and improve response rates.
In practice, these recommendations could help pediatricians and primary-care clinicians identify which children can be managed locally and which require specialist referral. The use of voiding diaries and symptom-based classification may lead to more targeted treatments, while earlier attention to constipation, sleep-disordered breathing, ADHD, and daytime urinary symptoms could improve outcomes. The framework also encourages timely referral for refractory cases, defined as less than 50% improvement after three months, and for suspected NMNE, which may require urodynamics and lumbosacral MRI.
The authors acknowledge that some recommendations reflect Chinese practice patterns and that evidence is limited for certain areas, such as desmopressin withdrawal strategies. They call for future research and multidisciplinary care models to further refine individualized treatment. The full consensus is available in the World Journal of Pediatrics, with a DOI of 10.1007/s12519-026-01051-4.
