A 13-year-old boy comes to the office with his mother because of bed-wetting. The boy was toilet trained for urine during the day and night by age 3. Over the past 2 weeks, he has been wetting his bed every night. His mother has asked him to not drink juice just before bedtime, but he has ignored her. In the past few days, he also has refused to help with household chores and participate in gym class. The patient is developmentally appropriate for age and does not take any medication. Medical history includes oppositional defiant disorder, which is managed with behavioral counseling. Compared to 6 months ago, his height has increased along the 50th percentile, but his weight has remained stable at 44 kg (97 lb). Vital signs are normal. Examination is unremarkable. Which of the following is the best next step in management of this patient?

Question

A 13-year-old boy comes to the office with his mother because of bed-wetting.  The boy was toilet trained for urine during the day and night by age 3.  Over the past 2 weeks, he has been wetting his bed every night.  His mother has asked him to not drink juice just before bedtime, but he has ignored her.  In the past few days, he also has refused to help with household chores and participate in gym class.  The patient is developmentally appropriate for age and does not take any medication.  Medical history includes oppositional defiant disorder, which is managed with behavioral counseling.  Compared to 6 months ago, his height has increased along the 50th percentile, but his weight has remained stable at 44 kg (97 lb).  Vital signs are normal.  Examination is unremarkable.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c092_339c_8f63_b7fccdd0bf6c_MD0005_00 This patient has secondary nocturnal enuresis, which is defined as new-onset bed-wetting in a child age ≥5 who had previously achieved overnight dryness for a prolonged period (≥6 months). Although primary enuresis (in which nighttime urinary continence has never been established) is a common and generally self-resolving condition in childhood, secondary enuresis in an adolescent should raise suspicion for a psychological stressor (eg, parents' divorce) or an underlying medical condition. Enuresis may be a sign of polyuria and the presenting feature of diabetes mellitus, particularly in a patient with poor weight gain, as in this boy who has grown taller but has not gained weight over the past 6 months. Other findings may be subtle but can include lethargy (eg, refusal to participate in gym class or perform chores) and polydipsia (eg, insistence on drinking juice at bedtime). The first step in evaluation of a child with nocturnal enuresis is urinalysis to exclude medical causes (eg, urinary tract infection); glucosuria supports the diagnosis of diabetes mellitus. Enuresis concerning for diabetes mellitus also warrants checking serum chemistries; elevated blood glucose (ie, ≥200 mg/dL on random testing or ≥126 mg/dL if fasting) suggests the diagnosis. Electrolyte derangements associated with hyperglycemia may also be identified and include hyponatremia and hypokalemia. (Choices B and E) Patients with isolated primary nocturnal enuresis may benefit from enuresis alarm therapy, which conditions the brain to prevent enuresis by waking the patient after bed-wetting. These patients also are often instructed to keep a voiding diary to identify modifiable behavioral habits (eg, evening fluid intake). In contrast, this patient has secondary enuresis with poor weight gain, findings requiring workup for a medical cause. (Choices C and D) In addition to cognitive-behavioral therapy, treatment for oppositional defiant disorder (ODD) can include parent management training (eg, how to provide consistent consequences). A selective serotonin reuptake inhibitor may also be considered for ODD with comorbid anxiety or depression. However, ODD does not explain this patient's enuresis or poor weight gain. His new defiant behaviors (eg, refusing to do chores) may be due to underlying fatigue associated with new-onset diabetes. Educational objective: An underlying medical condition such as diabetes mellitus should be suspected in a child with secondary enuresis (ie, bed-wetting after establishing a prolonged period of nighttime dryness) and poor weight gain. Evaluation includes urinalysis and serum chemistries. References: Primary and secondary enuresis: pathophysiology, diagnosis, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28888814)

A 13-Year-Old Boy Comes to the Office with His Mother