A 6-year-old boy is brought to the office for chronic bedwetting. He was fully toilet trained for daytime by age 4 but has never consistently stayed dry overnight. In the past 6 months, his parents have tried several behavioral modifications, with fluid intake restricted for 2 hours prior to bedtime and the patient voiding prior to going to sleep. His parents also implemented a reward system, but he still wets the bed frequently. The patient says, "I feel really embarrassed. I want to go to a sleep-away camp next year but my parents won't let me." The boy has regular soft bowel movements without stooling accidents. He has no other medical problems and takes no medication. Vital signs are appropriate for age. Physical examination and urinalysis are unremarkable. His mother says, "I'm really tired of washing the sheets every other day. What else do you suggest?" Which of the following is the most appropriate advice regarding this patient's condition?

Question

A 6-year-old boy is brought to the office for chronic bedwetting.  He was fully toilet trained for daytime by age 4 but has never consistently stayed dry overnight.  In the past 6 months, his parents have tried several behavioral modifications, with fluid intake restricted for 2 hours prior to bedtime and the patient voiding prior to going to sleep.  His parents also implemented a reward system, but he still wets the bed frequently.  The patient says, "I feel really embarrassed.  I want to go to a sleep-away camp next year but my parents won't let me."  The boy has regular soft bowel movements without stooling accidents.  He has no other medical problems and takes no medication.  Vital signs are appropriate for age.  Physical examination and urinalysis are unremarkable.  His mother says, "I'm really tired of washing the sheets every other day.  What else do you suggest?"  Which of the following is the most appropriate advice regarding this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c090_fb1a_8f63_816c00409fd5_MD0005_00 Primary nocturnal enuresis is the inability to achieve nighttime dryness in healthy patients age >5 without additional urinary tract symptoms (eg, dysuria, daytime incontinence). Management of nocturnal enuresis begins with behavior modifications (eg, limiting fluid intake before bedtime) and motivational therapy (eg, reward system). Continued enuresis after institution of these measures for 3-6 months warrants enuresis alarm therapy, a first-line treatment that has the best long-term outcome and a low risk of relapse. An enuresis alarm is activated when a sensor in the patient's underwear or bed pad detects moisture and triggers an auditory or vibratory alarm that wakes the patient, thereby inhibiting further bladder emptying. With consistent use, the alarm conditions the child to wake prior to voiding. Patient adherence and motivation are required as the child is responsible for responding to the alarm. (Choice A) Having the parent periodically wake the child is not recommended as a long-term solution. The child becomes reliant on the parent's intervention to void rather than on physiologic cues (eg, bladder fullness). (Choice B) Desmopressin, an antidiuretic, is an alternate first-line treatment of primary nocturnal enuresis but has a high rate of relapse after discontinuation. Desmopressin is recommended for families seeking a short-term solution (eg, sleep-away camp) or who have failed/refused enuresis alarm therapy. Adverse effects are rare but include hyponatremia if taken with excessive oral fluids. (Choice D) Tricyclic antidepressants (eg, imipramine) are not first-line therapy for enuresis but can be considered for refractory cases. Efficacy results from the anticholinergic effect of urinary retention; tricyclic antidepressants are not used to treat anxiety in patients with enuresis. (Choice E) If motivational therapy results in significant improvement of enuresis, or if the parents/child can tolerate breakthrough episodes, continued motivational therapy is reasonable. This family has instituted changes for 6 months without success and should be offered alarm therapy. Educational objective: If behavioral modifications (eg, limiting evening fluid intake) and motivational therapy for primary nocturnal enuresis are unsuccessful, first-line treatment includes enuresis alarms and desmopressin. Enuresis alarms provide the best long-term outcome (ie, low rate of relapse). References: Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the International Children's Continence Society. (http://www.ncbi.nlm.nih.gov/pubmed/20006865) Advances in the management of primary monosymptomatic nocturnal enuresis in children. (http://www.ncbi.nlm.nih.gov/pubmed/25936863)

A 6-Year-Old Boy Is Brought to the Office for Chronic