A 6-year-old boy is brought to the office for the first time for a well-child checkup. The family recently moved to the area, and the boy has been adjusting well and making friends. He started first grade a month ago and soccer last week. The patient is a picky eater and his meals consist of fruit, pasta, crackers, and milk. When asked about his sleep pattern, his mother says, "He sleeps straight through wetting the bed at least twice a week. We tried to potty train him when he was 3 years old, but he's dry only during the day. Our last doctor recommended a few behavioral changes. We have tried avoiding fluids before bedtime and other changes, but nothing seems to help." The patient has no dysuria or constipation. He has seasonal allergies for which he takes cetirizine. He is allergic to shellfish and has an epinephrine injector. Immunizations are up to date. Growth is along the 30th percentile for both height and weight. Blood pressure is 96/62 mm Hg. The abdomen is soft, nontender, and nondistended. External genitalia are Tanner stage I with a circumcised penis, normal urethral meatus, and descended testicles bilaterally. The skin is clear with no rashes. Which of the following is the best next step in management of this patient?

Question

A 6-year-old boy is brought to the office for the first time for a well-child checkup.  The family recently moved to the area, and the boy has been adjusting well and making friends.  He started first grade a month ago and soccer last week.  The patient is a picky eater and his meals consist of fruit, pasta, crackers, and milk.  When asked about his sleep pattern, his mother says, "He sleeps straight through wetting the bed at least twice a week.  We tried to potty train him when he was 3 years old, but he's dry only during the day.  Our last doctor recommended a few behavioral changes.  We have tried avoiding fluids before bedtime and other changes, but nothing seems to help."  The patient has no dysuria or constipation.  He has seasonal allergies for which he takes cetirizine.  He is allergic to shellfish and has an epinephrine injector.  Immunizations are up to date.  Growth is along the 30th percentile for both height and weight.  Blood pressure is 96/62 mm Hg.  The abdomen is soft, nontender, and nondistended.  External genitalia are Tanner stage I with a circumcised penis, normal urethral meatus, and descended testicles bilaterally.  The skin is clear with no rashes.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c091_be6b_8f63_154ddb3d8668_MD0005_00 Enuresis is defined as urinary incontinence at age >5 and is most commonly due to primary nocturnal enuresis, the inability to have ever achieved nighttime dryness. Nocturnal enuresis, which is more common in boys, affects 15% of 5-year-olds and has a declining prevalence to 1% in adolescence. Although secondary causes are unlikely in a patient who has never achieved nighttime dryness, a urinalysis is indicated to exclude more urgent diagnoses. For example, glucosuria is suggestive of diabetes mellitus, which can present with polyuria and polydipsia. Diabetes insipidus can present with enuresis and a low specific gravity on first morning void. Finally, occult infection can present with enuresis in addition to leukocytes and nitrites on urinalysis. A normal urinalysis is reassuring that the diagnosis is likely primary nocturnal enuresis and spontaneous resolution is expected. For motivated families, such as this family, modification of evening behavior, such as limiting fluid intake and voiding before bedtime, is initial management. (Choices A and C) A renal and bladder ultrasound is indicated for children with nocturnal enuresis who have additional urinary symptoms, such as daytime incontinence or weak urinary stream. Evaluation of renal function with a serum creatinine level would be indicated in patients with concomitant signs of renal disease (eg, hypertension). Imaging and laboratory evaluation are not warranted in healthy patients with isolated, primary nocturnal enuresis. (Choice B) An elevated fingerstick glucose level could be suggestive of diabetes mellitus, a potential cause of enuresis. A urinalysis, however, can screen for additional secondary causes of enuresis (eg, diabetes insipidus) as well and is noninvasive. (Choice E) A urine culture is appropriate if screening urinalysis is suggestive of infection (eg, leukocytes, nitrites) or history includes symptoms of dysuria or hematuria. This patient has no other symptoms and does not warrant a urine culture. Educational objective: Primary nocturnal enuresis is the lack of nighttime dryness in children age >5 and resolves spontaneously over time. A screening urinalysis is recommended to exclude underlying etiologies such as diabetes mellitus or insipidus. 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)

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