Nocturnal enuresis (NE), commonly known as bed-wetting, affects millions of school-age children worldwide and can have profound effects on self-esteem, sleep, and family dynamics. An updated expert consensus, published in the World Journal of Pediatrics, offers a comprehensive framework to improve diagnosis and treatment, addressing long-standing inconsistencies in clinical practice.
The consensus, developed by researchers from the Children's Hospital of Fudan University and the Chinese Cooperative Group for the Management of Pediatric NE, establishes 18 recommendations covering diagnosis, classification, evaluation, first-line therapy, comorbidity management, and referral. A key update is the lowered diagnostic threshold: children aged five years or older who experience at least one involuntary nighttime void per month for three months now meet the criteria, a shift from the previous weekly standard that allows for earlier intervention.
The guidelines emphasize distinguishing between monosymptomatic NE (MNE) and non-monosymptomatic NE (NMNE). MNE occurs without daytime lower urinary tract symptoms, while NMNE includes daytime symptoms such as urgency, frequency, or incontinence. This classification is crucial because it drives treatment decisions. The voiding diary is now a cornerstone of diagnosis, requiring patients to record at least two daytime charts and seven consecutive nights of fluid intake and voids. This helps clinicians phenotype children as having nocturnal polyuria, reduced bladder capacity, or both, enabling tailored first-line therapy: desmopressin for nocturnal polyuria and enuresis alarm for reduced bladder capacity, with combination therapy for mixed types.
For NMNE, the consensus prioritizes managing daytime lower urinary tract symptoms and comorbidities, especially constipation, which affects 36–80% of these children. The framework also outlines clear referral criteria: primary care can manage MNE, but non-responders or suspected NMNE require specialist evaluation with urodynamics and lumbosacral magnetic resonance imaging (MRI). For refractory cases, defined as less than 50% improvement after three months, the consensus advises systematic re-evaluation of adherence, diary findings, and underlying causes before escalating treatment.
The authors stress that NE should not be treated as a uniform disorder. “The updated pathway asks clinicians to identify the child's specific pattern, look for daytime symptoms and comorbidities, and match treatment to the likely underlying mechanism while keeping the family involved,” they noted. They also highlight that apparent treatment failure should trigger a careful review of adherence, voiding records, and possible missed conditions before adding stronger therapy.
These recommendations could help pediatricians and primary-care clinicians identify children who can be managed locally and those needing specialist assessment. Clearer use of voiding diaries and symptom-based classification may reduce trial-and-error treatment, while earlier attention to constipation, sleep-disordered breathing, ADHD, and daytime urinary symptoms could improve response rates. The framework also encourages timely referral when first-line therapy fails or NMNE is suspected, supporting better coordination across levels of care.
The authors acknowledge that some recommendations reflect Chinese practice patterns and that evidence remains limited for areas such as desmopressin withdrawal strategies. Future trials and multidisciplinary care models could further refine individualized treatment. The full consensus is available in the World Journal of Pediatrics (DOI: 10.1007/s12519-026-01051-4).
