The evaluation and treatment of therapy-resistant enuresis: a review.

Children with enuresis that neither responds to the alarm or to desmopressin medication usually have nocturnal detrusor over-activity combined with high arousal thresholds as a cause for their bedwetting. The evaluation of these children is focused on 1) excluding underlying pathology such as kidney disease, urinary tract infection or neurogenic bladder, 2) looking for concomitant day-time bladder problems or constipation, and 3) detecting possible reasons for failure of alarm treatment. A bladder diary is essential, but blood tests, radiological examinations or invasive procedures are seldom informative. The non-pharmacologic treatment of these children consists of eradication of constipation, if present, and the provision of advice regarding sound drinking and toilet habits. Such treatment is essential but not uniformly sufficient by itself. The first-line pharmacologic treatment of therapy-resistant enuresis is anticholinergic medication, although this is, as yet, not evidence-based. Anticholinergics can be combined with desmopressin for better efficiency. For children failing all these measures there is still a place for tricyclic antidepressant therapy, provided that adequate safety precautions are strictly observed.