A 7-year-old boy comes to the office with his parents due to bed-wetting. He achieved daytime dryness at age 4 but has never stayed dry overnight for more than 3 consecutive nights. His urinary stream is strong, and there is no dribbling, straining, or urgency. The child is irritable and inattentive, often interrupting his teacher and disrupting his classmates at school. His mother and father both achieved nighttime dryness at age 5. Height and weight are tracking along the 75th and 25th percentiles, respectively. Blood pressure is at the 90th percentile. On examination, the tympanic membranes are clear, and the tonsils are symmetrically enlarged. Cardiopulmonary, abdominal, and genital examinations are normal. Urinalysis and serum creatinine are normal. Which of the following is the best next step in management of this patient?
Medical conditions causing enuresis | ||
Etiology | Symptoms | Findings |
Constipation* |
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Bladder dysfunction* |
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Urinary tract infection |
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Chronic kidney disease |
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Diabetes mellitus |
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Diabetes insipidus |
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Obstructive sleep apnea |
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*Often a clinical diagnosis. | ||
Nocturnal enuresis, or nighttime urinary incontinence at age ≥5, is a common childhood condition, particularly in boys. In an otherwise asymptomatic child, enuresis is typically genetic (most have ≥1 parents affected during childhood) and developmental, with self-resolution expected as bladder control matures. However, an underlying medical condition should be suspected when other signs or symptoms are present, as in this case.
In addition to wetting the bed, this child is irritable and inattentive with tonsillar hypertrophy. These findings are concerning for obstructive sleep apnea (OSA) as the underlying cause of his enuresis. Enuresis may reflect apnea effects on arousal response (eg, effects on bladder pressure, urinary hormone secretion) or difficulties awakening in response to a full bladder. Instead of daytime somnolence seen in adults with OSA, behavioral concerns (eg, inattention, impulsivity) and mood changes (eg, emotional lability) are common manifestations of sleep disturbance in children. OSA is also associated with increased blood pressure (as seen here); chronic symptoms can result in poor growth (decreased nocturnal growth hormone secretion) and cardiovascular complications (eg, cor pulmonale).
Evaluation of OSA is with nocturnal polysomnography (ie, sleep study), which detects and quantifies respiratory pauses and desaturations during sleep. Treatment of OSA (eg, adenotonsillectomy, positive airway pressure) can lead to resolution of associated enuresis.
(Choice A) A trial of methylphenidate may be indicated for attention deficit hyperactivity disorder (ADHD), which can also present with irritability and inattention and has association with enuresis. However, ADHD would not explain this child's tonsillar hypertrophy.
(Choice C) Urodynamic testing can be considered in a patient with findings concerning for bladder dysfunction, such as daytime incontinence, weak stream, dribbling, straining, or urgency, none of which is present in this patient.
(Choice D) Imipramine is a tricyclic antidepressant that can be considered for nocturnal enuresis that is not due to an underlying medical problem and is refractory to first-line management (eg, desmopressin, bed-wetting alarm). Evaluation and management of coexisting conditions, such as OSA, should be prioritized before initiating pharmacotherapy for enuresis.
(Choice E) Reassurance and follow-up are appropriate for normal bed-wetting behaviors in an otherwise asymptomatic child age <5. This patient with behavioral concerns, enlarged tonsils, and hypertension requires further workup for his enuresis.
Educational objective:
Nocturnal enuresis secondary to obstructive sleep apnea should be considered in a child who has bed-wetting in addition to inattention, behavioral concerns, hypertension, and/or tonsillar hypertrophy. Evaluation is with nocturnal polysomnography.