A Case Of Nocturnal Enuresis

A 5-year-old male presents to your clinic with his mother with a complaint of enuresis. Evidently, this
child has never been completely continent at night, wetting his bed several times per week. This has become somewhat of a problem for him now that his friends are having sleepover birthday parties. Plus, his mother confides that she’s tired of paying for pull-ups and cleaning sheets. His incontinence is mono symptomatic (meaning no overactive bladder symptoms or daytime wetting).
Because he has had no period of nocturnal dryness, this patient has primary enuresis.

Q 1. Which of the following is likely to be part of this child’s history?
A) A family history of enuresis.
B) A stressful event in the family such as the birth of a new child or parental divorce.
C) Increased fluid intake over the past 2 months.
D) History of urinary tract infections.

Answer And Discussion

The correct answer is “A.” A family history of enuresis.

 Enuresis is divided into primary and secondary enuresis.
Primary enuresis occurs in cases where there is never a consistent period of dryness at night. Secondary enuresis occurs when there is a period of dryness (by convention, 6 months) before the patient develops enuresis. “B,” “C,” and “D” would more likely be seen in children with secondary
enuresis. Primary enuresis tends to be a familial trait.

Q 2. This patient’s exam is essentially normal including neurologic evaluation. Further evaluation of this patient should include all of the following EXCEPT:
A) Asking about a history of bowel problems.
B) Assessment of growth and development.
C) Investigation into family history of nocturnal enuresis.
D) Spine MRI to rule out pathologic lesion.
E) Urinalysis.

Answer And Discussion
The correct answer is “D.”

Patients with enuresis who have an otherwise normal neurologic exam need not have an MRI done. If on exam this child had neurologic findings, an MRI would be indicated. All of the remaining options are part of a thorough evaluation of nocturnal enuresis. Of particular note is the assessment of growth and development (is this child neurologically delayed leading to enuresis?). Attention to bowel problems is also important. Fecal impaction can lead to incontinence. Asking about snoring can help
to identify obstructive sleep apnea, which can be associated with enuresis.

Q 3. You find no indication of an underlying cause, and you decide that this is primary enuresis. The parents are desperate for some sort of intervention to fix the problem, since it is becoming a major source of anxiety in the home and of teasing at school. Which of the following should constitute INITIAL treatment of this patient’s primary enuresis?
A) Patient education and motivational training (e.g., rewards for staying dry).
B) Over-learning.
C) Enuresis alarm.
D) Nasal desmopressin (DDAVP).
E) Oral desipramine.

Answer And Discussion; The correct answer is “A.” All of the above have been found to be useful in the treatment of enuresis; however, the best initial approach includes education. Patients and parents should be informed of how common this condition is, how to reduce fluid intake in the evening without getting dehydrated, and how to schedule voiding. Motivational training plays a role as well. The other interventions are secondary.
“B,” over-learning, is thought to help prevent relapses in patients who have been successful with an enuresis alarm. Once continence is achieved with the alarm, the child drinks a set amount of fluid before bedtime. The amount is successively increased once dryness is achieved until a maximum is reached. The idea is that the patient is conditioned to respond to his increasing bladder capacity.
“C,” an enuresis alarm, is an effective treatment but relatively expensive and requires significant motivation on the part of the family. The enuresis alarm increases success of the other options when used in combination and has shown the best long-term results.
“D” and “E” are incorrect in this scenario although they are used to treat enuresis. Relapse is more common when pharmacologic therapy is discontinued than with the other modalities. However,
medications are effective as a short-term treatment option but are felt to be second tier to be used when the urine alarm fails or is impractical (think sleepover or summer camp). Of note, “D” is wrong for another reason: nasal DDAVP is no longer approved for nocturnal enuresis due to problems with hyponatremia. Oral DDAVP still carries the enuresis indication, but it can cause hyponatremia as well—it just occurs less often.