HOW TO TREAT ENURESIS (BEDWETTING) 2025

HOW TO TREAT ENURESIS (BEDWETTING) 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 31

ENURESIS (BEDWETTING)

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 31

ENURESIS (BEDWETTING)

I. DEFINITION  

Enuresis is the repeated, involuntary or intentional voiding of urine into clothing or bedding, occurring at least twice weekly for a minimum of 3 months, or causing significant distress or impairment in social or academic functioning. The child must be at least 5 years old, an age when bladder control is typically expected.

II. ETIOLOGY  

Normal bladder control develops gradually, influenced by neuromuscular and cognitive maturation, socio-emotional factors, toilet training, and genetics. Disruptions in these can delay mastery of urinary function:  

– Behavioral Origins: Non-neurological voiding dysfunction may stem from habits disrupting typical urination patterns, hindering the maturation of voluntary control. The severe Hinman syndrome involves conscious efforts to suppress urination or involuntary leakage via external sphincter contractions, reducing urge sensation over time and leaving residual urine, contributing to nocturnal enuresis (when the bladder relaxes without resistance).  

– Genetics: Higher incidence among first-degree relatives; 75% of affected children have a family history. Risk increases 7-fold if a father had enuresis.  

– Psychological Stress: In young children, linked to events like a sibling’s birth, starting school, or family breakdown.  

– Psychiatric Conditions: Intellectual developmental disorder, ADHD.

III. DIAGNOSIS  

1. Definitive Diagnosis  

– Enuresis involves repeated urination into clothes or bed, intentional or not, in a child with a mental age of at least 5 years. It occurs ≥2 times/week for ≥3 months, with organic causes excluded. Co-occurring encopresis (fecal soiling) is possible.  

– ICD-10 Subtypes:  

  – F98.00: Nocturnal only.  

  – F98.01: Diurnal only.  

  – F98.02: Both nocturnal and diurnal.  

– ICD-10 Criteria:  

1. Mental and chronological age ≥5 years.  
2. Involuntary/self-controlled urination into clothes/bed: ≥2 times/month (under 7 years) or ≥1 time/month (7+ years).  
3. Not due to seizures, neurogenic incontinence, structural urinary anomalies, or non-psychiatric medical conditions.  
4. No other ICD-10 psychiatric disorder fully explains it.  
5. Duration ≥3 months.
6. Ancillary Testing  

– No specific test for enuresis; focus is on ruling out organic causes (e.g., urinary tract infections, structural anomalies).  

– Psychiatric/Psychological Evaluation: Beck/Hamilton depression scales, Zung/Hamilton anxiety scales, DASS (anxiety-depression-stress), DENVER II (development), CBCL (child behavior).  

– Routine Tests: Complete blood count, biochemistry, urinalysis, ECG, abdominal ultrasound, chest X-ray.  

– Neurological Imaging: EEG, CT/MRI brain (if indicated).

3. Differential Diagnosis  

– Urogenital Organic Causes: Upper/lower urinary tract infections, obstructions, structural anomalies, spina bifida.  

– Polyuria Conditions: Diabetes mellitus, diabetes insipidus.  

– Sleep Disorders: Sleepwalking.  

– Consciousness Disorders: Epilepsy, intoxication.  

– Medication Side Effects: Antipsychotics.

IV. TREATMENT  

1. Treatment Principles  

– Combine behavioral interventions and pharmacotherapy.  

– Exclude organic causes.  

– Address co-occurring conditions (e.g., ADHD, constipation).

2. Treatment Framework  

Child with enuresis  

↓  

Clinical and ancillary evaluation  

↓  

Organic lesion identified → Treat underlying condition  

↓  

Confirmed enuresis diagnosis → Counseling and monitoring  

↓  

Treatment options: Behavioral therapy, pharmacotherapy, or both

3. Specific Treatments  

Behavioral Therapy:  

– Enuresis Alarm: Most effective, resolving 50% of cases. A sensor in bedding/clothing triggers an alarm when wet, waking the child to stop urination. Parents must ensure the child wakes fully, as children may turn it off and sleep. Used nightly, continued 2-3 months after 14 consecutive dry nights. Challenges include noncompliance due to family disruption or improper use.  

– Bladder Training with Rewards: Encourages control, tracked via charts that reinforce progress.

Pharmacotherapy:  

– Considered when enuresis impairs social/family/academic functioning and dietary/fluid restrictions fail.  

– Imipramine: Approved for enuresis; 30% achieve remission, 85% see reduced frequency. Effects wane after 6 weeks (tolerance), with relapse common post-discontinuation. Serious cardiovascular side effects limit use.  

– Tricyclic Antidepressants (e.g., Amitriptyline): Less common due to adverse effects.  

– Desmopressin (DDAVP): Antidiuretic, ICI 2009 Level A recommendation. Reduces enuresis in 10-90% of cases. Forms: tablets (0.2-0.6 mg) or spray/melt (120-360 µg), taken 1 hour before bed. Restrict fluids 1 hour before and 8 hours after. Daily use, initial trial 2-6 weeks; if effective, continue 3-6 months. Side effects: headache, nasal congestion, nosebleeds, stomach pain; rare but severe hyponatremia.  

Psychotherapy:  

– Addresses co-occurring psychiatric conditions or secondary emotional/family issues.

V. PROGNOSIS AND COMPLICATIONS  

– Often resolves spontaneously without lasting psychological impact.  

– ~80% don’t fully resolve within 1 year; typically resolves between ages 5-8. Persistent cases into adulthood warrant organic evaluation.  

– Prolonged cases may link to psychiatric comorbidities, with relapse possible during natural recovery or treatment.  

– Complications: Low self-esteem, social withdrawal, family conflict.

VI. PREVENTION  

– Limited specific measures, but ensuring proper sleep may help.  

– Teach toilet use when children can control their bladder; occasional “accidents” during this learning phase are normal.

REFERENCES

Vietnamese

1. Department of Psychiatry, Hanoi Medical University (2016), Lectures on Psychiatry. Medical Publishing House.  
2. Department of Psychiatry, Hanoi Medical University (2000), Organic Mental Disorders. Postgraduate Lecture Series.  
3. Department of Psychiatry & Medical Psychology, Military Medical Academy (2007), Psychiatry and Psychology. People’s Army Publishing House.  
4. Military Medical Academy (2016), Textbook of Psychiatric Disorders. People’s Army Publishing House, Hanoi.  
5. World Health Organization (1992), The International Classification of Diseases, 10th Revision (ICD-10): Mental and Behavioral Disorders. WHO, Geneva, 1992.  
6. World Health Organization (1992),ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research (translated by the Department of Psychiatry, Hanoi Medical University).  
7. David A., et al. (2010), Geriatric Psychiatry, Medical Publishing House, 2014. Translated by Nguyễn Kim Việt.  
8. Eduard V. (2009), Bipolar Disorder in Clinical Practice, Medical Publishing House, Hanoi.  
9. Kaplan & Sadock (2013), Pervasive Developmental Disorders, Synopsis of Child and Adolescent Psychiatry, Translated book, Medical Publishing House.  
10. Trần Hữu Bình (2016), Textbook of Psychiatric Disorders: Depressive Phase,Medical Publishing House, Hanoi.  
11. Lê Quang Cường (2005), Epilepsy, Medical Publishing House.  
12. Cao Tiến Đức (2017), Epilepsy: Mental Disorders in Epilepsy and Treatment, Medical Publishing House, pp. 9-15.  
13. Trần Viết Nghị (2000), Mental and Behavioral Disorders Due to Psychoactive Substance Use, Department of Psychiatry, Hanoi Medical University.  
14. Trần Viết Nghị, Nguyễn Minh Tuấn (1995), Treatment of Drug Addiction with Psychotropic Medications, Proceedings of the Scientific Conference on Drug Addiction Treatment Methods, Ministry of Health, Institute of Mental Health.  
15. Nguyễn Viết Thiêm (2000), Mental and Behavioral Disorders Due to Psychoactive Substance Use, Department of Psychiatry, Hanoi Medical University, pp. 103-111.  
16. Nguyễn Minh Tuấn (2016), Textbook of Psychiatric Disorders, Medical Publishing House.  
17. Nguyễn Minh Tuấn (2004), Heroin Addiction: Treatment Methods, Medical Publishing House.  
18. Nguyễn Minh Tuấn (2004), Diagnosis and Treatment of Dependence (Addiction), Medical Publishing House.  
19. Nguyễn Kim Việt (2016), Textbook of Psychiatric Disorders, Medical Publishing House, Hanoi.  
20. Nguyễn Kim Việt (2000), Mental and Behavioral Disorders Due to Psychoactive Substance Use,Department of Psychiatry, Hanoi Medical University.  
21. Nguyễn Kim Việt (2000), Organic Mental Disorders, Department of Psychiatry, Hanoi Medical University.  
22. Nguyễn Kim Việt, Nguyễn Văn Tuấn (2016), Textbook of Psychiatric Disorders, Department of Psychiatry, Hanoi Medical University, Medical Publishing House, pp. 74-79.

English

1. The British Association for Psychopharmacology (2011). Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology. J Psychopharmacol (Oxf), 25(5), 567–620.
2. The National Institute for Health and Care Excellence (NICE) (2014). Psychosis and schizophrenia in adults: prevention and management. NICE guideline. CG178, 5-46.
3. The National Institute for Health and Care Excellence (2014). Bipolar disorder: the assessment and management of bipolar disorder in adults,children and young people in primary and secondary care. September 2014.
4. The National Institute for Health & Care Excellence – NICE (2010). The Treatmentand Management of Depression in Adults (updated edition). National Clinical Practice Guideline 90, 2010.
5. NICE(2012), “Epilepsies: diagnosis and management ”, NICE 
6. Abdul S. K., Manjula M, Paulomi M. S., et al (2013), “Cognitive Behavior Therapy for Patients with Schizotypal Disorder in an Indian Setting: A Retrospective Review of Clinical Data”, the German Journal of Psychiatry, pp 1-7.
7. Addington D., Abidi S., Garcia-Ortega I., et al. (2017). Canadian Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia Spectrum and Other Psychotic Disorders. Can J Psychiatry, 62(9), 594–603.
8. American Psychiatric Association (1994), “Amphetamine-type stimulants” Diagnostic and Statistical Manual of Mental Disorders”, Fourth Edition, DSM-Washington, DC
9. American Psychiatric Association (2013). Alcohol-Related Disorders, Diagnostic and statistical manual of mental disorders DSM-5, American Psychiatric Publishing, 490-503.
10. AmericanPsychiatric Association (2013). Opioid  Diagnostic and statistical manual of mental disorders DSM-5, American Psychiatric.
11. AmericanPsychiatric Association (2013). Diagnostic and statistical manual of mental disorders DSM-IV.
12. Apurv K., Pinki D., Abdul K. (1997), “Treatment of acute and transient psychoticdisorders with low and high doses of oral haloperidol”, Indian Journal of Psychiatry, pp 2-8
13. American psychiatric association (2010). Practice guideline for the Treatment of Patients With Schizophrenia, Second Edition. 184.
14. Andreas M. (2012), “Schizoaffective Disorder”, Korean J Schizophr Res, pp 5-12.
15. American Psychiatric Association (1994). The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
16. Babalonis S, Haney M, Malcolm R.J, et al (2017). Oral cannabidiol does not produce a signal for abuse liability in frequent marijuana smokers. DrugAlcohol Depend. 172, 9-13.
17. Benjamin J. S, Virginia A. S, Pedro R (2017). Substance-Related Disorders, Kapland & Sadock’s Comprehensive Textbook of Psychiatry, Lippincott Williams & Wilkins, Baltimore, Vol. 1.
18. Benjamin J. S., Virginia A. S. (2007), “Substance-Related Disorders- Amphetamine (or Amphetamine-like) Behavioral Sciences/Clinical Psychiatry ”, Kaplan & Sadock’s Synopsis of Psychiatry 10th Edition, Lippincott Williams & Wilkins (2007)
19. Bergamaschi M.M, Queiroz R.H.C, Zuardi A.W., et al (2011). Safety and side effects of cannabidiol, a Cannabis sativa constituent. Curr Drug Saf. 6(4), 237-249.
20. Benzoni O., Fàzzari G., Marangoni C., Placentino A., Rossi A. (2015), “Treatment of resistant mood and schizoaffective disorders with electroconvulsive therapy: a case series of 264 patients”, Journal of Psychopathology, pp 266-268.
21. Daniel R. R., Larry J. S., et al (2014), “Schizotypal personality disorders: a current review”, New York, pp 1-10.
22. Dervaux A.M. (2010). Influence de la consommation de substances sur l’émergence et l’évolution des troubles psychotiques: le cas du cannabis. La these doctotraie, Universit ´e Pierre et Marie Curie – Paris VI, Paris, France.
23. Dieter S., Steven C. S. (2014). “Drug treatment of epilepsy in adults ”, BMJ, p2-19.
24. Early Psychosis Guidelines Writing Group (2010). Australian clinical guidelines for earlypsychosis 2nd  Natl Cent Excell Youth Ment Health Melb, 2, 4–24.
25. Elisa C., Amir H. C., Peter B. (2009), “Treatment of Schizoaffective Disorder”, Psychiatry (Edgemont),p 15-17.
26. Felix-Martin W., Rafael C., (2016), “Current Treatment of Schizoaffective Disorder According to a Neural Network”, Neural Network. J Cytol Histol, pp 2-5
27. Gary R., Donald A., Wiliam H., et al (2017), “Guideline for the pharmacotherapy of schizophrenia in adul”, The canadian journal of schiatry,pp 605-612.
28. Galletly C., Castle D., Dark F., et al. (2016). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for themanagement of schizophrenia and related disorders. Aust N Z J Psychiatry, 50(5), 410–472.
29. Gautam S., Jain A., Gautam M., Vahia V. N., et al (2017). Clinical Practice Guidelines for the management of Depression. Indian J Psychiatry;59, Suppl
30. Grunze H., et al. (2009). The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar
31. Hasan A., Falkai P., Wobrock T., et al. (2012). World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 1: Update 2012 on the acute treatment of schizophrenia and the management of treatment resistance. World J Biol Psychiatry, 13(5), 318–
32. Hasan A., Falkai P., Wobrock T., et al. (2013). World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia,Part 2: Update 2012 on the long-term treatment of schizophrenia and management of antipsychotic-induced side  World J Biol Psychiatry, 14(1), 2–44.
33. JakobsenD., Skyum E., Hashemi N., et al. (2017). Antipsychotic treatment of schizotypy and schizotypal personality disorder: a systematic review. J Psychopharmacol (Oxf), 31(4), 397–405.
34. Jinsoo C., Theo C. M. (2017), “Current Treatments for Delusional Disorder”, Psychiatry, pp 5-20
35. Jonathan K. B., Saeed F. (2012), “Acute and transient psychotic disorders: An overview of studies in Asia”, International Review of Psychiatry, pp 463-466
36. Jochim, J., Rifkin-Zybutz, R., Geddes, J., et al (2019).Valproate for acute mania. Cochrane Database of Systematic Reviews.
37. Kaplan& Sadock’s. Pocket Handbook of Psychiatric Drug Treatment
38. Kennedy S. H., Lam R. W., McIntyre R. S., et al (2016). Canadian Network forMood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder. The Canadian Journal of Psychiatry, 61(9), 540–560.
39. Krishna R.P., Jessica C., et al(2014), “Schizophrenia: overview and treatment options”, New York, pp 638-643.
40. Lakshmi N. Y., Sidnay H. K., Saga V. P., et al (2018). Canadian network for mood and anxiety treatments (CANMAT) and international society for bipolar disorders (ISBD) 2018 guidelines for the management of patient with bipolar disorder. Bipolar disorders; 20:97-170
41. Laskshmi N.Y., Sidney H. K. (2017). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry: Pharmacological treatment of depression and bipolar disorders, Wolters Kluwer.
42. Lakshmi N. Y., Sidney H. K., Saga V. P., et al (2018). Canadian network for mood and anxiety treatments (CANMAT) and international society for bipolar disorders (ISBD) 2018 guidelines for the management of patient with bipolar disorder. Bipolar disorders; 20:97-170
43. Loya M., Dubey V., Diwan S., Singh H. (2017), “Acute and transient psychotic disorder and schizophrenia: On a continuum or distinct? A study of cognitive functions”, International Journal of Medicine Research, pp-4-7.
44. Manschrec, Nealia L. K. (2006), “Recent Advances in the Treatment of Delusional Disorder”, The Canadian Journal of Psychiatry, pp-114-118
45. Marcos E. M. B., Hermes M. T. B. (2016), “Schizoaffective Disorder and Depression. A case Study of a patient from ceará, Brazil”, iMedPub Journals, pp1-8
46. Mesut Cetin (2015), “Treatment of Schizophrenia: Past, Present and Future”, Bulletin of Clinical Psychopharmacology, pp 96-98.
47. Michael S., Christina Z., Gerd B., (2011), “Prevalence of delusional disorder among psychiatric inpatients: data from the German hospital register”, Neuropsychiatry, pp 319-322.

48. MIMS neurology & psychiatry disease management guidelines

49. RajivTandon (2018), “Pharmacological Treatment of Schizophrenia 2017-2018 Update Summary”, org, pp 37-40.
50. Robert E., et al (2014). Substance-Related and Addictive Disorders. The AmericainPsychiatric Publishing Textbook of Psychiatry, 6 th, DSM-5 Edition, Bristish Library, USA, 735 – 814.
51. Rong C, Lee Y., Carmona N.E., et al (2017). Cannabidiol in medical marijuana: Research vistas and potential opportunities. Pharmacol Res. 121, 213-8.
52. Skelton M., Khokhar W.A., Thacker S.P. (2015). Treatments for delusional disorder. Cochrane Database Syst Rev.
53. Stahl S.M, Stein D.J, Lerer B (2012). Evidence based pharmacotherapy of illicit substance use disorders, Essential evidence based psychopharmacology
54. Stephen M.S., Dan J.S., Bernard L. (2012). Evidence based pharmacotherapy of illicit substance use disorders, Essential evidence based
55. Stahl S. (2009). Stahl’s essential psychopharmacology: neuroscientific basis and practical implications: Cambridge University Press.
56. Stahl, M. (2013). Stahl’s essential psychopharmacology: neuroscientific basis and practical applications, Cambridge University Press.
57. Vieta, Berk M., Schulze&nbspT. G., et al (2018). Bipolar disorders. Nature Reviews Disease Primers, 4, 18008
58. Update2009 on the Treatment of Acute  The World Journal of Biological Psychiatry. 10(2); 85-116.

If you need legal consulting, please Contact Us at NT International Law Firm (ntpartnerlawfirm.com)

You can also download the .docx version here.