Table 1.

Problems with current recommendations and suggested further research and guideline changes.

Recommendations	Problems	Suggested research	Suggested interim guideline changes
All enuretic children need to be differentiated into monosymptomatic and nonmonosymptomatic subgroups before choosing therapy	Weak and contradictory evidence. Most studies have not subdivided according to guidelines	Prospective studies, examining the efficacy of first-line enuresis therapy on representative samples of unselected enuretic children. The predictive value (if any) of daytime voiding chart data and daytime bladder habits is assessed.	During initial evaluation in primary care put less emphasis on daytime voiding habits and voiding chart data and more on warning signs. If no warning signs, proceed directly to treatment with the alarm or desmopressin
All enuretic children need to complete voiding charts before choosing therapy	Firm evidence only for nocturnal polyuria predicting desmopressin response. Value of daytime bladder data questionable. Difficult to implicate in primary care.
All enuretic children need screening for psychiatric issues at initial evaluation	Insufficient evidence if this will influence final outcome. Socio-economic issues	Prospective studies of enuretic children with and without psychiatric comorbidity given the same antienuric treatment.	Evaluate psychiatric issues only if the child has substantial problems with social interaction
Concomittant daytime incontinence needs to be treated before adressing the enuresis	Insufficient and contradictory evidence	Prospective studies on children with combined enuresis and daytime incontinence randomized to urotherapy or no urotherapy before antienuretic therapy	Don’t let daytime incontinence delay treatment of the enuresis
Concomittant constipation needs to be treated before adressing the enuresis	Insufficient and contradictory evidence	Prospective studies on children with enuresis and constipation randomized to laxatives or no laxatives before antienuretic therapy	Treat constipation if the child has stomach ache, fecal incontinence or daytime urinary incontinence, or if the enuresis is therapy-resistant
Urotherapy is a first-line therapy against enuresis, at least for nonmonosymptomatic children	No supporting evidence. Recent studies show no effect	(Randomized studies of urotherapy in therapy-resistant enuresis)	Don’t use urotherapy as a first-line therapy in enuresis