For Clinicians
Rethinking how we address nocturnal enuresis in primary care.
Most families are told to wait. For many that is the right call. For the ones where it is not, there is usually nothing to hand them. This is that thing.
Outcome figures are from the Enuresis Clinic at Schneider Children's Medical Center of Israel, 1994 to 2002. Study detail below.
- A two page printable handout written for parents, in plain language.
- A link version to paste into a patient portal message or an email.
- Print as many as you need straight from your own printer, no PDF to manage.
A printable handout for families who ask about bedwetting.
Two pages. What is actually happening, what does not work and why, and what a structured behavioral program involves. Print it for the exam room, or send it as a link.
Here is your handout.
Two pages, written for parents. Open it, print as many copies as you need, or send it to a family as a link.
Open the printable handoutOpens in a new tab · Print it, or send the link to a family
When parents ask about bedwetting, what do we tell them?
Nocturnal enuresis affects roughly 15 to 25 percent of children aged four to six, and at eleven about 7 percent are still wetting. Yet in most primary care settings the condition is undertreated, and each of the three standard responses runs out somewhere.
"They'll grow out of it"
The most common answer, and often true. But many children do not outgrow it for years, and the interval is not neutral. Lost self-esteem, social withdrawal, declined sleepovers and family strain accumulate the whole time. Waiting is not a treatment strategy.
Diagnostic testing
Urinalysis, bloods, ultrasound, occasionally invasive urological procedures. Costly for the family and, in the large majority of cases, normal. If the bladder works during the day, the urinary system is not where the problem is.
Desmopressin
Addresses the symptom, not the cause. It reduces nocturnal urine production without training the arousal reflex, and relapse rates on discontinuation are high. A temporary measure rather than a solution.
If the bladder works during the day, the problem is not urological.
Children with nocturnal enuresis typically have entirely normal daytime bladder function. The same bladder that copes perfectly while awake fails at night. That points away from structure and toward a conditioned reflex that has not finished developing: the arousal response to bladder filling is simply not firing during sleep. It is also why the workup comes back normal. It is examining a system that is working.
In a study of 257 patients covering 4,796 enuretic episodes, Dr. Jacob Sagie demonstrated that enuresis alarm treatment works through behavioral conditioning of the reflex response to bladder filling, not by altering sleep patterns. The reflex improves progressively, with measurable reductions in urine volume per episode appearing before the child learns to wake independently.
Sagie, J. "The Relationship between Nocturnal Enuresis, Time of Night and Waking Response in the Process of Treatment with Enuresis Alarm." Children's Hospital Quarterly, 8(1), 1996.
Documented in an institutional pediatric setting.
The figures below are from the Enuresis Clinic at Schneider Children's Medical Center of Israel, the country's largest pediatric hospital, affiliated with the Sackler School of Medicine at Tel Aviv University. The clinic was founded and directed by Dr. Jacob Sagie.
Schneider Children's Medical Center, 1994 to 2002
Study population of 3,004 patients, ages 4 to 35. Outcomes reported on 2,308 completed cases.
2,119 of 2,308 completed cases. A further 1.9 percent showed significant improvement.
A structured, time limited intervention with a defined endpoint and measurable progress throughout.
No anatomic or psychological cause identified. 82 percent were primary enuretics.
As described by parents, consistent with an arousal mechanism that has not yet matured.
Why the alarm your patient already bought did not work.
A large share of families arriving for treatment have tried an alarm before. Almost none of them ran a program alongside it. This is the single most useful thing you can tell a parent in ninety seconds.
Bought a device, not a treatment
The alarm creates the learning moment. On its own it does not tell anyone what to do with it.
Stopped at week three
The point at which disrupted sleep peaks and dry nights have not yet appeared. Most abandonment happens here.
Read a setback as failure
Regression is an expected feature of the conditioning curve, not evidence that the treatment is not working.
A protocol that adapts
The schedule responds to the child's recorded results rather than running a fixed course.
Progress visible before dryness
Urine volume per episode and waking response shift before the first dry night. Showing parents that is what carries them through.
Guidance at the drop-off points
Support arrives when the curve dips, which is the difference between a family finishing and a family quitting.
TheraPee™ is not simply an alarm.
Developed by Dr. Jacob Sagie, Ph.D. and Dr. Tal Sagie, Ph.D., TheraPee is built on the same multimodality approach that produced the clinical results above. For 30 years, from 1984 to 2013, that treatment was delivered face to face. In 2013 it was rebuilt as an interactive online program that mirrors every step of the clinical protocol, now accessible from the patient's home.
StoPee alarm device
A proprietary sensor pad that detects the first sign of moisture and activates the conditioning cycle at the moment it matters.
Adaptive treatment algorithm
An online system that tailors the protocol to the individual patient's presentation and to their week by week progress.
Progress tracking
Monitoring of reflex response, wetting frequency and urine volume per episode, producing measurable outcomes throughout treatment.
Behavioral exercises
Daily bladder capacity training, sphincter strengthening, positive reinforcement protocols and guided exercises for child and parent.
Keep a stack in the exam room.
Get the two page handout, print as many as you need, and hand one to the next family who raises it. You can also send it as a link in a patient portal message or an email.
Get the handoutDr. Jacob Sagie, Ph.D.
Enuresis specialist in the psychophysiology of enuresis. Treating patients since 1984, with more than 30,000 cases. Founded and directed the Enuresis Clinic at Schneider Children's Medical Center, Israel's largest pediatric hospital, and established the first enuresis clinic in China at Shanghai Children's Medical Center. His research on enuresis and sleep was presented at the International Scientific Conference of the European Sleep Society.
Dr. Tal Sagie, Ph.D.
Enuresis specialist with expertise in children's behavioral problems. Treating patients since 1999, with more than 8,000 cases worldwide. The first bedwetting specialist to conduct online treatment globally. Developed the TheraPee interactive platform and led R&D for the StoPee device. Published researcher and invited guest lecturer at academic institutions in Poland and Israel.
Selected publications and presentations
- Sagie, J. "The Relationship between Nocturnal Enuresis, Time of Night and Waking Response in the Process of Treatment with Enuresis Alarm." Children's Hospital Quarterly, 8(1), 1996.
- Sagie, T. "The Gap between Social Functioning to Emotional Functioning among Young Adolescents with Nocturnal Enuresis." Studia Edukacyjne, 32/2014, pp. 357 to 373.
- Sagie, T. "THERAPEE: Behavioral Cyber Therapy for Enuresis (Bedwetting)." II International Conference: The Educational and Social World of a Child, Poznan, 2014.
- Sagie, T. "Enuresis as a Risk Factor among Youngsters in the Educational System in Israel." International Conference: Challenges of Today's Education, Poznan, 2015.