A 7-year-old girl comes to the office with her mother due to "wetting her bed" for the past week. The patient has been dry at night for the past year but has woken up about once a night for the past week because she urinated in the bed. She has no fever, dysuria, hematuria, or changes in bowel movements. There have been no changes in the patient's diet or fluid intake; the family eats dinner at 6:00 PM, with which she has her last glass of milk or juice for the day. The patient goes to bed at 8:30 PM. The patient has no medical conditions and takes no daily medications. Her parents divorced six months ago, and she lives with her mother and older sister. Temperature is 36.7 C (98.1 F), blood pressure is 96/57 mm Hg, and pulse is 70/min. Height and weight are at the 40th percentile. Cardiopulmonary examination is unremarkable. The abdomen is soft and nontender. The external genitalia appear normal with no rashes or excoriations. Which of the following is the best next step in management of this patient?
Nocturnal enuresis in children | ||
Primary | Secondary | |
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UTI = urinary tract infection. | ||
This patient has secondary nocturnal enuresis, defined as new-onset nighttime wetting after achieving urinary continence for ≥6 months. In contrast to primary nocturnal enuresis, which is often developmental and resolves with time, secondary nocturnal enuresis is more likely to be due to a medical condition (eg, urinary tract infection [UTI], diabetes mellitus) or psychological stressor (eg, parents' divorce).
After a careful history and physical examination, the first step in evaluation of all patients with nocturnal enuresis (both primary and secondary) is a urinalysis (UA). A UA is a simple test that can assess for medical causes of enuresis; treatment of the underlying condition typically leads to resolution of enuresis.
For example, a UTI can present in children with new-onset incontinence, even without typical symptoms of dysuria or abdominal pain, and leukocytes and/or nitrites on UA are supportive of the diagnosis. Treatment with antibiotics for a culture-confirmed infection typically leads to resolution of enuresis. Similarly, in a patient with secondary enuresis plus polyuria and polydipsia, low specific gravity on UA may be indicative of diabetes insipidus, and glucosuria suggests diabetes mellitus. Furthermore, the presence of hematuria or proteinuria may require further workup for chronic kidney disease (eg, metabolic panel, renal ultrasound).
(Choices B, C, and D) In an otherwise asymptomatic child with a normal blood pressure and examination, as with this patient, reassurance may be provided if the UA is negative. Further evaluation of emotional stressors (eg, parental discord) should also be considered. In addition, similar to the management of primary enuresis, behavioral modifications (eg, restricting evening fluids, avoiding caffeine) and a diary to better understand the patient's voiding patterns may be suggested. However, prior to these interventions, a UA is first required to exclude a secondary medical condition.
(Choice E) An enuresis alarm, which conditions a child to wake prior to nighttime voiding, is often indicated for persistent, primary nocturnal enuresis despite behavioral modifications. Arousal devices are not typically required for patients who have previously achieved nighttime dryness.
Educational objective:
Secondary enuresis, or new-onset nighttime wetting after a ≥6-month period of urinary continence, may be caused by an underlying medical condition (eg, urinary tract infection) or a psychological stressor. The first step in evaluation is urinalysis.