The Toddler/Preschool Child
Case 3.2 Bedwetting
64 The Toddler/Preschool Child
Family m edical h istory: J ’ Quan ’ s mother (26 years old) and father (26 years old) are healthy and have no history of chronic medical conditions. His mother has sickle cell trait. His maternal grand- mother (age 48 years old) has a history of heart disease. His maternal grandfather (50 years old) has a history of liver disease. J ’ Quan ’ s paternal grandfather (51 years old) has a history of vertigo. His paternal grandmother (50 years old) has a history of high cholesterol.
Medications: J ’ Quan is currently taking no over - the - counter, prescription, or herbal medications. He has no known allergies to medication, food, or the environment. He is up to date for required immunizations.
OBJECTIVE
J ’ Quan ’ s vital signs are taken, and his weight in the offi ce is 20 kg. His temperature is within the normal range at 36.7 ° C (temporal). When observing J ’ Quan ’ s general appearance, he is alert, pleas- ant, and interactive. He appears well hydrated and well nourished.
Skin: His skin is clear of lesions. There is no cyanosis of his skin, lips, or nails. There is no diaphoresis noted, and J ’ Quan has good skin turgor on examination.
HEENT : J ’ Quan ’ s head is normocephalic. His red refl exes are present bilaterally; and his pupils are equal, round, and reactive to light. There is no ocular discharge noted. J ’ Quan ’ s external ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examination, the tympanic membranes are gray bilaterally, in normal position with positive light refl exes. Bony landmarks are visible, and there is no fl uid noted behind the tympanic membranes.
Both nostrils are patent. There is no nasal discharge, and there is no nasal fl aring. J ’ Quan ’ s mucous membranes are noted to be moist. He has 16 teeth present. There are no lesions present in the oral cavity.
Neck: J ’ Quan ’ s neck is supple and able to move in all directions without resistance. There is no cervi- cal lymphadenopathy present.
Respiratory: J ’ Quan ’ s respiratory rate is 20 breaths per minute, and his lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted.
Cardiovascular: J ’ Quan ’ s heart rate is 96 beats per minute with a regular rhythm. There is no murmur noted upon auscultation.
Abdomen: Normoactive bowel sounds are present throughout, and J ’ Quan ’ s abdomen is soft and nontender. J ’ Quan has shotty nodes present in his inguinal area bilaterally. These nodes are mobile, nontender, and nonerythematous. There is no evidence of hepatosplenomegaly.
Genitourinary: Normal circumcised male genitalia without erythema or lesions. His testes are descended bilaterally.
Neuromusculoskeletal: Good tone and full range of motion in all extremities; extremities are warm and well perfused. Capillary refi ll is less than 2 seconds, and his spine is straight.
CRITICAL THINKING
What laboratory tests or diagnostic imaging studies should be ordered as part of a workup for bedwetting?
What is the most likely differential diagnosis and why?
What is the plan of treatment, referral, and follow - up care?
Does this patient ’ s psychosocial history affect how you might treat this case?
Bedwetting 65
What if the patient lived in a rural setting?
Are there any demographic characteristics that might affect this case?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t esting: A urine dipstick will provide information on hydration, infection, diabetes insipi- dus, or diabetes mellitus by measuring the urine specifi c gravity, nitrites, glucose, and ketones. A urine culture can be done if infection is suspected to identify the organism. In preschool - aged children with enuresis and a urinary tract infection ( UTI ), consider a renal and bladder ultrasound. If abnor- malities are found on the ultrasound, a voiding cystourethrography ( VCUG ) to identify structural abnormalities and measure bladder fi lling can be obtained. An X - ray of the kidney, ureters, and bladder can be done if constipation or abnormalities of the spine are suspected. Urodynamic studies measure the fl ow of urine qualitatively and quantitatively and may be used if a neurological disorder is suspected or in children with daytime wetting who do not respond to traditional therapies.
What is the most likely differential diagnosis and why?
Enuresis:
Bedwetting, or enuresis, has many etiologies. Enuresis refers to involuntary urinary incontinence beyond the expected age of 4 years for daytime dryness and 5 years for night dryness. It may involve genetic factors, changes in vasopressin secretion, sleep factors, structural abnormalities, infection, or pyschological factors. Primary nocturnal enuresis ( PNE ) is defi ned as a child > 5 years who is incon- tinent at night with no previous history of dryness at night for an extended period of time. Secondary enuresis refers to episodes of bedwetting after a period of dryness > 6 months and can be precipitated by a stressful event in the child ’ s life.
The most common differentials for enuresis are urinary tract infection, diabetes mellitus, diabetes insipidus, structural abnormalities of the genitourinary tract, constipation, excessive caffeine, spinal cord injury, or psychological stress. A UTI may be the source when there is dysuria, urinary frequency, and a positive urine culture. High glucose or ketones in the urine dip would indicate diabetes mel- litus, and a low specifi c gravity would indicate diabetes insipidus. Abdominal palpation of stool or stool visible on a KUB (kidneys, ureters, and bladders) x - ray would indicate constipation. Abnormal physical exams of the spine or refl exes can indicate an underlying neurologic disorder or spinal cord injury. Structural abnormalities are identifi ed with a renal and bladder ultrasound, VCUG, or urody- namic studies. In the absence of clinical evidence for enuresis, a thorough history should review psychological stressors, abuse, or dietary patterns that include caffeine or liquids before bed.
J ’ Quan ’ s mother states he has “ never been dry at night but has been toilet trained during the daytime for 2 years. ” Because enuresis refers to involuntary urinary incontinence beyond the expected age of 4 years for daytime dryness and 5 years for night dryness, J ’ Quan is within the normal age range for his bedwetting to be considered nonpathologic.
What is the plan of treatment, referral, and follow - up care?
The plan of treatment would be to provide counseling and reassurance for the family after ruling out any other physiologic, psychologic, or organic causes of bedwetting. You can reassure the family that J ’ Quan is developmentally appropriate for his age. Bedwetting is more frequent in boys than girls, and 5% – 10% of children have primary nocturnal enuresis (PNE) at age 5. It is important to emphasize that J ’ Quan might be experiencing stress and embarrassment related to his bedwetting and that this is exacerbated by teasing from his sister, being spanked for wetting the bed by his father, and seeing his mother ’ s frustration. Parents should avoid punishment and criticism of a child ’ s bedwetting and provide positive reinforcement when the child has a night without wetting the bed.
The health care provider may recommend children ’ s books on bedwetting or making a sticker chart to keep track of dry nights. J ’ Quan ’ s mother should be reminded to limit nighttime fl uids to 2 hours before bed. She can also ensure that J ’ Quan has easy access to the toilet. The family can be helped to set a goal for J ’ Quan to use the toilet when he has to go to the bathroom at night, rather
66 The Toddler/Preschool Child
than staying dry all night. Based on history and physical exam, J ’ Quan does not need a referral at this time. Telephone followup can be conducted with J ’ Quan ’ s family to monitor progress over the course of the next year until his 5 - year - old, well - child visit. His family should be encouraged to come to the offi ce sooner as needed for signs and symptoms of illness.
For children with true enuresis, there are several options that can be used in the treatment of this condition, such as bedwetting alarms or medications. Bedwetting alarms work best with children 7 years or older and can be very effective. The alarm conditions the child to get up to use the toilet in order to avoid the alarm going off. They must be used every night for 3 – 4 months, the family must be counseled on proper use, and the family must wake the child if the child does not awaken to the noise of the alarm.
Medications can also help to manage enuresis. First - line treatment is desmopressin acetate vaso- pressin ( DDVAP ) in children ages 6 years and older to reduce the volume of urine produced at night.
In patients with nocturnal enuresis and daytime incontinence or those who fail with DDVAP alone, adding anticholinergic agents such as oxybutynin chloride or imipramine, a tricyclic antidepressant, in children age 5 years and older can be helpful in reducing uninhibited bladder contractions.
Children older than 5 years may also benefi t from complementary medicine including acupuncture/
acupressure, hypnosis, and biofeedback although there is limited evidence for the success of these interventions.
Daytime wetting can also be a stressful issue for children. Its origin can be neurologic, anatomic, muscular, or functional which results in problems with storage or emptying of the bladder. Similar to nocturnal enuresis, a full workup should be done to determine the cause. Daytime enuresis is treated with the same medications and behavioral strategies as nighttime enuresis.
Does this patient ’ s psychosocial history affect how you might treat this case?
In J ’ Quan ’ s situation, the health care provider should reinforce with the parents and sibling that J ’ Quan should not be teased or punished for bedwetting.
What if the patient lived in a rural setting?
If this patient lived in a rural setting, it might not be convenient for them to return to clinic for a follow - up visit. Telephone followup with the family to discuss J ’ Quan ’ s bedwetting and to evaluate any strategies the family has tried may be more feasible for families living in a rural setting.
Are there any demographic characteristics that might affect this case?
There is no racial or ethnic predisposition regarding the development of enuresis. In relation to gender, males are affected more than females. The incidence of enuresis decreases as children age.
J ’ Quan ’ s mother reports frustration with having to wash sheets frequently and buy new mattresses because of bedwetting. Considering the socioeconomic status of the parents, it is possible that this is causing additional fi nancial strain for the family. As the provider, you can suggest plastic coverings for the mattress or plastic reusable underpads to protect the mattress from getting wet, as well as absorbent briefs for J ’ Quan to wear at night.
Are there any standardized guidelines that you should use to assess or treat this case?
Guidelines for the treatment of enuresis are available from the International Children ’ s Continence Society (Neveus, et al., 2010 ).
REFERENCES AND RESOURCES
Gim , C. , Lillystone , D. , & Caldwell , P. ( 2009 ). Effi cacy of the bell and pad alarm therapy for nocturnal enuresis . Journal of Paediatrics and Child Health , 45 , 405 – 408 .
Glazener , C. , Evans , J. , & Cheuk , D. ( 2005 ). Complementary and miscellaneous interventions for nocturnal enuresis in children . Cochrane Database of Systematic Reviews , ( 2 ), CD005230.
Neveus , T. , Eggert , P. , Evans , J. , Macedo , A. , Rittig , S. , Tekgul , S. International Children ’ s Continence Society . ( 2010 ). Evaluation of and treatment for monosymptomatic enuresis: A standardization document from the International Children ’ s Continence Society. Journal of Urology , 183 , 441 – 447 .