Effectiveness of Individualized Pelvic Floor Muscle Rehabilitation in Addition to Standard Urotherapy and Alarm Therapy in Children With Primary Monosymptomatic Nocturnal Enuresis

The International Children's Continence Society (ICCS) defines nocturnal enuresis (NE) as involuntary urinary leakage during sleep in children aged five years or older. Enuresis is a common chronic condition in childhood, and a higher frequency of bedwetting has been associated with a lower likelihood of spontaneous resolution.

Nocturnal enuresis may be primary or secondary. Primary NE refers to children who have never achieved at least six consecutive months of nighttime dryness, whereas secondary NE refers to the recurrence of bedwetting after a dry period of at least six months. Primary NE may be associated with delayed maturation of the central nervous system, genetic factors, nocturnal polyuria, reduced bladder capacity, nocturnal detrusor overactivity, and failure to awaken in response to bladder signals during sleep. Secondary NE may occur in association with underlying medical conditions or psychological stressors. Clinically, NE is classified as monosymptomatic or nonmonosymptomatic. Nonmonosymptomatic enuresis is accompanied by additional lower urinary tract symptoms, such as urgency, daytime urinary incontinence, and voiding difficulties.

Although the pathophysiology of enuresis has not been fully elucidated, it is considered to result from the interaction of multiple factors rather than a single cause. Treatment includes pharmacological and nonpharmacological approaches individualized according to the subtype and severity of enuresis, the child's age, and the motivation and adherence of the child and family. Desmopressin is used to reduce nighttime urine production, particularly in children with nocturnal polyuria and normal bladder capacity. Anticholinergic medications may be combined with other treatments in selected resistant cases to address nocturnal detrusor overactivity. Tricyclic antidepressants may be considered by specialists in refractory cases when other treatments have failed or are contraindicated, but their use is limited by potentially serious adverse effects.

Nonpharmacological approaches include standard urotherapy, motivational therapy, bedwetting alarms, and pelvic floor muscle rehabilitation. Initial management includes education for the child and family, modification of voiding habits, and lifestyle advice. Bedwetting alarms provide an audible signal when urinary leakage occurs during sleep. Although their mechanism of action is not fully understood, alarm treatment is thought to involve conditioning to nighttime bladder signals and inhibition of the voiding reflex. Alarm treatment can provide sustained improvements and has been associated with lower relapse rates than some other treatment approaches.

Pelvic floor muscle rehabilitation is a targeted approach intended to improve children's awareness of pelvic floor muscle contraction and relaxation. It has been investigated as a behavioral and exercise-based intervention for enuresis. One proposed rationale is that pelvic floor muscle overactivity and connective tissue weakness may contribute to enuresis and daytime urinary incontinence by affecting the control of the voiding reflex. Reduced lumbopelvic muscle endurance, stability, and mobility have also been reported in children and adolescents with enuresis compared with asymptomatic individuals. These findings suggest that the lumbopelvic region, including the pelvic floor muscles, may warrant consideration during assessment and treatment.

Studies investigating pelvic floor muscle training, exercise-based approaches, and biofeedback have reported reductions in bedwetting frequency. However, intervention protocols and reported treatment outcomes vary, and no standardized exercise protocol has been established for enuresis.

Although standard urotherapy and alarm treatment are established components of PMNE management, some children require additional treatment. Evidence regarding the additional benefit of pelvic floor muscle rehabilitation alongside these approaches remains limited. Therefore, this study aims to evaluate whether adding pelvic floor muscle rehabilitation to standard urotherapy and alarm treatment over 12 weeks improves treatment outcomes in children with primary monosymptomatic nocturnal enuresis.