A 7-year-old boy is brought to the office due to persistent bedwetting. Since age 3, he has been able to stay dry during the day but continues to have "accidents" 3 nights a week. The child drinks fluids primarily in the morning and early afternoon and does not drink juice or caffeinated beverages. For the past 4 months, his parents have tried enuresis alarms and awarded "gold stars" for dry nights without improvement in the frequency of bedwetting. His parents are frustrated, and the patient is sad about missing activities such as summer camp. He was recently invited to a sleepover party but is nervous about wetting the bed. He has otherwise been in good health, has met all other developmental milestones, and takes no medications. The father had a history of nocturnal enuresis until age 8. Physical examination and urinalysis are normal. Which of the following is the best next step in management of this patient?

Question

A 7-year-old boy is brought to the office due to persistent bedwetting.  Since age 3, he has been able to stay dry during the day but continues to have "accidents" 3 nights a week.  The child drinks fluids primarily in the morning and early afternoon and does not drink juice or caffeinated beverages.  For the past 4 months, his parents have tried enuresis alarms and awarded "gold stars" for dry nights without improvement in the frequency of bedwetting.  His parents are frustrated, and the patient is sad about missing activities such as summer camp.  He was recently invited to a sleepover party but is nervous about wetting the bed.  He has otherwise been in good health, has met all other developmental milestones, and takes no medications.  The father had a history of nocturnal enuresis until age 8.  Physical examination and urinalysis are normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d2b0_c5df_bc81_ef5b4401bd9d_MD0003_00 Primary nocturnal enuresis is defined by urinary incontinence in children age ≥5 who have never achieved nighttime dryness and have no underlying medical condition explaining enuresis. Boys with a family history of delayed bladder control, as in this case, are predisposed to prolonged bedwetting. Although enuresis has a high rate of spontaneous resolution over time, many families seek active intervention to improve quality of life due to embarrassment or anxiety. Initial steps in management include behavioral modifications such as voiding before bedtime and minimizing evening fluid intake. For children who do not respond to lifestyle changes, enuresis alarms are the most effective long-term intervention but can take 3-4 months to be effective. Pharmacotherapy with desmopressin is also considered first-line therapy for those who desire immediate improvement. Oral desmopressin, an antidiuretic hormone analogue, decreases urine production during sleep. Patients should be counseled on minimizing fluid intake in the evening to prevent hyponatremia with therapy. In addition, the rate of relapse on discontinuation of desmopressin therapy is high. (Choice B) Tricyclic antidepressants (eg, imipramine) are as effective as desmopressin. However, they are reserved for patients who do not respond to desmopressin due to their rare, but serious, side effects (eg, increased suicidality, cardiotoxicity). (Choice C) Oxybutynin is an anticholinergic medication that causes urinary retention. In children with nighttime and daytime incontinence, it can be used in conjunction with desmopressin to increase bladder capacity. This child has only nocturnal enuresis. (Choice D) Polyuria and enuresis are symptoms of diabetes mellitus. Screening for diabetes mellitus includes urinalysis for glucosuria or serum glucose for hyperglycemia. This patient's urinalysis is normal, and no further testing is required. (Choice E) Urine culture should be considered in a patient with signs of a urinary tract infection (eg, dysuria, hematuria) or an abnormal urinalysis (eg, positive nitrites). (Choice F) A voiding cystourethrogram is used to diagnose vesicoureteral reflux, which can present with recurrent urinary tract infections. This patient has isolated nocturnal enuresis with no history of infection. Educational objective: Desmopressin is the first-line pharmacotherapy for nocturnal enuresis. It can provide immediate improvement when behavioral modifications and alarm therapy have failed. When used as monotherapy, it has a high rate of relapse on discontinuation of therapy. 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) Nocturnal enuresis: an approach to assessment and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25086164)

A 7-Year-Old Boy Is Brought to the Office Due to Persistent