Larning with awareness is much more effective and more likely during the daytime while awake. Also, we have
to pee much more often than we have to poop, so getting through the night without having to empty the bladder
may not be very easy. Adding having to awaken and leave your warm comfortable bed is another difficulty to
overcome. The use of the bedwetting alarm to arouse the child and instantaneously arrest the very act of wetting
would appear to be a relevant approach then in treating this problem. I suspect that the natural alarm for many
children in the normal course of development is the discomfort that comes with a filling bladder and the startle
response to the very act of wetting oneself while asleep. However, bedwetters are so good at sleeping that they
can overcome this disruption and continue sleeping. Actually, we must be very concerned with these children also
learning to sleep through a bedwetting alarm.

Complications with bowel control can affect bladder control both during the day or night. Most often the complication
with bowel control comes from a backing up of stool into the colon when the child resists voiding stool normally into
the toilet. This problem is often associated with soiling, overly large stools, constipation, and an enlarged colon
(sometimes called a megacolon). Therefore, if there are any indications of soiling whatsoever (e.g., tire tracks in
underpants, prune drops, or other accidents) or toilet clogging with large stools (even without soiling) this problem
should be treated BEFORE using procedures for bedwetting. Children holding their bowels in excess of three days
show another indication of constipation and they should form a more normal daily or, at most, an every other day
voiding habit. The “Clean Kid Manual” definitively addresses these issues. Occasionally, the successful control of
soiling, or Encopresis, can lead to bladder control without any intervention.

If daytime enuresis is present it can be treated simultaneously with a treatment for bedwetting. That would be my
recommended strategy, but if that is not possible, or is too exhausting, you must focus your efforts on one or the
other. I would recommend starting on the daytime bladder accidents followed by treating the bedwetting. In the
unusual case where the daytime treatment is not showing any progress after a true sustained effort for two weeks
then you should reverse the treatment sequence. There was a recent study that showed treating nocturnal enuresis
can be helpful in dealing with diurnal enuresis when it persists.

Medication Overview

The most commonly prescribed medication for enuresis is DDAVP, which is a synthetic form of ADH or Anti-Diuretic
Hormone. ADH functions to increase the concentration of our urine--this is especially critical for bedwetters because
some of them appear not to have developed the natura,l night-time increase in ADH secretion, which occurs in the
normal course of development. Basically, it reduces the volume of urine entering the bladder giving a greater
statistical likelihood of having your child sleep through the night dry. DDAVP comes both in an oral form and as a
nasal spray, which is taken before bedtime.

Another medication that has been used to treat enuresis is an antidepressant, Tofranil (imipramine). This is an old
"tricyclic" antidepressant, which has been around for over thirty-five years. It is typically prescribed in low dosages,
below antidepressant therapeutic benefit levels for bedwetting (e. g. 25, 50 or 75 mg. with higher dosages being
more effective). Its mechanisms of action for a beneficial effect in a child's getting through the night are various (one
is to relax the bladder and somewhat tighten up the resting level of the sphincter). It is quite cheap, but its use has
been associated with some deaths because children may locate the medication and overdose on it without parental
supervision.

Finally, there is Ditropan (oxybutynin) and other more recent antispasmodic medications for children who tend to
show a lot of "urgency" associated with sudden voiding urges at fairly low volume thresholds. They may have "hair
triggers" so to speak, and I suspect that this could be more typical of daytime wetters. Basically, it relaxes the
bladder and possibly lowers the sensory threshold for voiding, which would allow for more accommodation of urine
in the bladder.

All of these medications are only effective for the length of time that the child is on them and the most frequent
recommendation from major research institutions is that they should be used and reserved for limited use, e. g.,
going camping, overnight stays, etc. A learning, or conditioning approach, is more effective for the longer run with
lower relapse rates, but it does indeed require time, effort, and a likely loss or interruption of sleep. Yet it is also an
excellent investment in your child's well-being and pride in his finally gaining control over a basic function of his body.
He or she will sleep much easier for the rest of his or her life!