Andrew J. Kirsch, MD,FAAP, FACS
In this interview with Urology Times, Andrew J. Kirsch, MD, FAAP, FACS, discusses his book “The Ultimate Bedwetting Survival Guide” which he co-wrote with his Brazilian colleague, Ubirajara Barroso, Jr, MD, PhD. Kirsch outlines the complex realities of treating nocturnal enuresis; explaining that although bedwetting often resolves with age—about 15% of 5-year-olds are affected, and 15% improve annually—a significant proportion continue into adolescence and even adulthood, affecting millions worldwide. His motivation for the book was to provide parents with clear, evidence-based guidance on causes and treatment options.
Kirsch outlines current therapies, ranging from behavioral strategies, such as limiting fluids before bedtime, to bedwetting alarms and medications like DDAVP. However, he notes that success rates remain modest, with behavioral interventions offering placebo-level improvement, alarm adherence hampered by high drop-out rates, and medications only effective in 30% to 50% of cases, with potential risks like water intoxication.
Dispelling misconceptions is a central focus. Kirsch emphasizes that bedwetting is not the child’s fault but a sleep-related condition outside of conscious control. He also stresses that it is not limited to young children, as many older children, teens, and even adults are affected.
Kirsch advocates for a multidisciplinary approach, working with pediatricians, nephrologists, and occasionally psychologists or dietitians, especially in refractory or secondary cases linked to underlying conditions such as diabetes, anxiety, or neurologic issues. He underscores the importance of distinguishing primary nocturnal enuresis from secondary causes and recognizing “red flags” like daytime wetting, urgency, or bowel dysfunction, which warrant further evaluation.
Finally, Kirsch highlights the psychological toll of enuresis and the need for education—both for parents, many of whom are unaware of available treatments, and for pediatricians. Looking ahead, he points to new device-based therapies, such as the investigational device SoluuTM, as potential breakthroughs in providing safer, more effective solutions. Kirsch is a professor and chief of pediatric urology at Emory University School of Medicine in Atlanta, Georgia and a partner at Georgia Urology.Along with Dr. Barroso, he is the co-inventor of SoluuTM and chief executive officer at Global Continence Inc (www.globalcontinence.com), a biotech company dedicated to treating enuresis and pelvic floor disorders with neuromodulation.
Urology Times: What was the impetus behind writing your book “The Ultimate Bedwetting Survival Guide”?
Kirsch: The impetus for writing the book was basically a 25-year career trying to reassure parents that their child’s bedwetting will go away. Realistically, about 15% of 5-year-olds have the problem, and only 15% get better each year. So, although you reassure them, there’s a huge number of children who still have the problem when they’re 7 to 10 years old, and about 3% of teenagers still have bedwetting. What’s also alarming is that 1% of adults have bedwetting. It’s not a small number; 200 million people have bedwetting. We wrote the book in a simple fashion to try to help parents understand what causes the problem, what the current treatments options are, and what results they can expect.
The treatments are fairly simple. One group we call behavioral therapy. That means you have your child go to the bathroom before they go to sleep, and they limit their fluids. But if you look at the largest published study on behavioral therapy and its ability to correct bedwetting, the success is approximately 18%, so it’s really like a placebo, but everybody does it because you’re basically just trying to buy time. When kids are little; when they’re 5 or 6, they may not care that much about it. When they get to be a little older, then they start having social concerns, like anxiety and depression, and many parent are even worried that their child’s going to go to college and still have this problem. So, we try to address it with the different treatment combinations.
Next, there are bedwetting alarms. These devices basically sense moisture, and then they make a loud sound, and hopefully that’ll wake a child up. But bedwetting is also a sleep disturbance, so these kids often sleep through it, and the problem with the current bedwetting alarms is that they don’t do anything to directly stop the wetting. They basically alert the child or their parents or siblings that the event occurred, but they frequently fail to wake up and they fail to sense a full bladder. The recommendation, even though this is the gold standard treatment right now for bedwetting, is to use bedwetting alarms for 4 to 6 months. And you can see why, after weeks and weeks of frustration with this, the drop-out rate is between 60% and 80%. They really get frustrated. By the time they come to a urologist—in particular, a pediatric urologist—we’re offering medications like DDAVP or vasopressin that decreases the amount of urine produced, but even that has a 30% to 50% success rate, and it has potential adverse events like water intoxication. Although that’s rare, it’s a concern. Parents, in general, don’t want their kids to be on medications long term.
Those are the only treatments we have.
When we talk about the future of bedwetting, we talk about devices such as ours, Soluu™. Following our upcoming clinical trial and FDA review, we expect to show that Soluu™ is a safe and effective treatment. Unlike conventional alarms that only react once a child is already wet, Soluu™ uses gentle, noninvasive pudendal neuromodulation to help children sense a full bladder before an accident occurs. It’s the first solution designed to address the underlying neurophysiology of nocturnal enuresis rather than just the symptoms.
The device is paired with a smartphone app that tracks progress, provides real-time feedback, and engages families with motivational tools. With more than 200 million children affected worldwide, the potential impact is substantial—clinically, emotionally, and economically. We believe Soluu™ represents not just the next step, but a real shift in how urologists and families approach the treatment of enuresis.
Urology Times: What are some of the common misconceptions or areas of misinformation you’ve encountered regarding bedwetting in children?
Kirsch: There are many myths and misconceptions about bedwetting. The most important thing for parents to understand is that it’s not the child’s fault. Bedwetting happens during sleep, when the brain signals the bladder to contract and, as a reflex, the sphincter relaxes. Children have no control over this process. During the day, we feel an urge and consciously relax the sphincter to urinate, but at night, the brain essentially drives the event automatically. That’s why reassurance is critical for families.
We also encourage parents to reward dry nights but not to bribe or promise rewards in advance—because when progress is slow, that approach can become frustrating for both children and parents. Another misconception is that bedwetting only affects very young kids. In fact, millions of children of all ages struggle with it every year. In my own practice, we see 10 to 15 patients with enuresis each week, and pediatricians report seeing several cases every month.
Finally, parents often believe that restricting fluids before bedtime, or waking their child to use the bathroom, called timed awakening, will solve the problem. While well-intentioned, those behavioral strategies are rarely effective beyond a placebo effect.
Bedwetting is a physiologic issue involving the brain–bladder connection, and it needs to be treated as such. Children who struggle with enuresis aren’t choosing to wet the bed — their brains simply fail to suppress bladder contractions during sleep. During the day, we urinate by feeling the urge and relaxing the sphincter, but at night, the brain can involuntarily trigger bladder contractions, and the sphincter relaxes reflexively. That’s why this condition cannot be solved by willpower, fluid restriction, or behavioral strategies alone.
What urologists need to understand is that traditional bedwetting alarms represent aversion therapy — they wake the child after an accident, creating a negative association meant to condition the child to avoid future episodes. While this can work for some, it’s disruptive, slow, and often abandoned by families.
With Soluu™, we’re taking a fundamentally different approach. By using gentle, noninvasive pudendal neuromodulation, we help the brain recognize when the bladder is full before an accident occurs. It’s a physiologic solution to a physiologic problem — proactive rather than reactive. We believe this approach represents the future of enuresis care, providing families with a treatment that is faster, more tolerable, and ultimately more effective than aversion-based methods and medications.
Urology Times: “The Ultimate Bedwetting Survival Guide” emphasizes a multidisciplinary approach. Could you elaborate on specific scenarios where you’ve found collaboration with pediatricians, psychologists, or even dietitians to be particularly crucial in achieving successful outcomes for patients with recalcitrant enuresis?
Kirsch: As urologists, most of our patients are referred to us, usually by general pediatricians who identify the problem early but refer late—often when the child is 9 or 10 years old. That surprised me, because guidelines recommend starting treatment at age 5 or 6, and if behavioral therapy hasn’t worked within 4 to 6 months, moving on to interventional therapies such as medications or bedwetting alarms. Given that pediatricians don’t always feel comfortable prescribing these options, we would expect referrals at an earlier age. This reflects a significant gap in education—something we’ve tried to address by working with the American Academy of Pediatrics in Georgia to survey pediatricians about when they prescribe medications or use alarms. What we found confirms that treatment is often delayed.
I don’t blame the referring physicians, because these therapies only have about a 50% success rate. That’s why, once patients reach a specialist, we often proceed with interventional therapies more directly. We also collaborate with nephrologists, who see these patients as well. In general, nephrologists are reluctant to prescribe DDAVP because of the risk of water intoxication—hyponatremia that can lead to seizures, lethargy, and other serious complications. Although I’ve never personally seen this in my practice, it’s an important issue to educate families about so that we can avoid problems.
There’s also sometimes a role for dietitians and psychologists. While diet alone won’t resolve enuresis, dietitians can be valuable in addressing contributing factors such as constipation, excessive caffeine intake in adolescents, or poor hydration habits. Psychologists, on the other hand, can play a key role when there are secondary emotional issues—such as shame, frustration, or family stress—that often accompany bedwetting. Their support helps normalize the condition for the child and family, reduces anxiety, and improves adherence to treatment. In both cases, the roles are supportive, complementing but not replacing targeted medical or neuromodulation therapies.
Urology Times: Beyond the practical advice for families, what novel insights or perhaps underappreciated aspects of the pathophysiology of nocturnal enuresis did you aim to highlight in your book that might be particularly relevant to a urologist’s understanding and treatment strategies?
Kirsch: Bedwetting isn’t caused by just one thing—it’s multifactorial. Some kids make too much urine at night because their vasopressin doesn’t rise when it should, others simply don’t wake up to the bladder signal, and many have small bladder capacity or overactivity, often tied to constipation. Desmopressin helps a subset, but the success rate is only about 30–50%, so it doesn’t cover most cases.
As urologists, it’s important to separate primary enuresis—where the child has never been dry for at least six months—from secondary cases, which should push us to look for things like diabetes, infection, sleep apnea, neurologic conditions, or stress. At the heart of it, this is a brain–bladder signaling issue during sleep, and poor sleep quality only makes it harder to treat.
What I try to stress to colleagues is that matching therapy to the child’s phenotype makes all the difference. Alarms work best when arousal is the issue, desmopressin when it’s nocturnal polyuria, bladder training or antimuscarinics for small capacity, and constipation always needs to be managed. For those who don’t respond, neuromodulation may be an option on the horizon. A tailored, often combined approach gives us the best chance at long-term success.
Urology Times: Given the emotional and psychological impact of bedwetting, how do you approach counseling families on managing expectations and maintaining motivation throughout what can often be a prolonged treatment journey, especially when initial interventions aren’t immediately successful?
Kirsch: I start by reassuring families that they’re not alone—bedwetting is common, and it’s not their child’s fault. In our survey, fewer than half of parents even knew that multiple treatments exist, which shows how much education is still needed, even among referring pediatricians. Part of my role is to explain those options, set realistic expectations, and remind them that progress usually comes step by step rather than overnight.
I emphasize that while it can take time, we have effective strategies, and families shouldn’t lose hope. Just as importantly, I share that new technologies, such as neuromodulation, are on the horizon and may expand what we can offer beyond the traditional approaches. Being able to tell families that innovation is coming—that we’re not standing still—often gives them optimism and motivation to stay engaged in the treatment process.
Urology Times: Your book provides a “survival guide” for families. From a urologist’s standpoint, what are the key indicators or “red flags” that, despite following your guide’s recommendations for initial management, should prompt a more intensive work-up or referral for specialized investigations?
Kirsch: The red flags are usually the kids who don’t respond to standard therapies, or those with secondary enuresis where something else is driving the problem—such as psychiatric, neurologic, or endocrine issues. In those cases, bedwetting may just be one of several symptoms, and it’s important to involve the appropriate specialists. Another group that requires closer attention are children with daytime symptoms—urgency, frequency, incontinence, or constipation. That broader picture suggests bowel–bladder dysfunction, which we approach very differently than isolated nocturnal enuresis. In general, we always address the daytime problems first, and if the child continues to have nighttime wetting, we treat that afterward. Published reports show that treating children with ADHD is more challenging , since their attention and arousal difficulties make standard therapy less effective.Fortunately, most children simply have primary nocturnal enuresis, but when red flags are present, more testing and targeted referrals are warranted.