A 5-year-old boy comes to the office with his parents due to bed-wetting. He had difficulty toilet training for urination as a toddler and has never achieved consistent dryness during the day or night. The patient has a soft stool every day and has had no episodes of fecal incontinence. Compared to other children his age, he tires easily, requiring a nap after playing outside. The patient was adopted from an overseas orphanage 2 months ago, and medical history is significant for frequent urinary tract infections. Temperature is 37.5 C (99.5 F), blood pressure is 130/80 mm Hg, pulse is 80/min, and respirations are 16/min. Height and weight are at the 25th and 5th percentiles, respectively. Physical examination shows no abnormalities. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 5-year-old boy comes to the office with his parents due to bed-wetting.  He had difficulty toilet training for urination as a toddler and has never achieved consistent dryness during the day or night.  The patient has a soft stool every day and has had no episodes of fecal incontinence.  Compared to other children his age, he tires easily, requiring a nap after playing outside.  The patient was adopted from an overseas orphanage 2 months ago, and medical history is significant for frequent urinary tract infections.  Temperature is 37.5 C (99.5 F), blood pressure is 130/80 mm Hg, pulse is 80/min, and respirations are 16/min.  Height and weight are at the 25th and 5th percentiles, respectively.  Physical examination shows no abnormalities.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d608_cae8_bc81_59fa81055b28_MD0003_00 This patient with a history of frequent urinary tract infections (UTIs) has fatigue, hypertension, and proteinuria in addition to daytime and nighttime enuresis. These findings are concerning for chronic kidney disease (CKD). CKD in children is most commonly due to a congenital urinary tract abnormality such as posterior urethral valves (PUV). PUV is an obstructive uropathy that prevents the outflow of urine from the bladder, causing symptoms of bladder dysfunction such as urinary incontinence (during the day and night) and a weak stream. Urinary stasis and associated vesicoureteral reflux from the distended bladder into the ureters can cause damage to the kidneys and predispose patients to recurrent UTIs, which further contribute to renal scarring. posterior urethral valves Fatigue, poor growth, and hypertension in a child, in addition to urinary symptoms, should also raise suspicion for CKD. Proteinuria (and/or hematuria) on urinalysis may be present and cause edema if in the nephrotic range (typically ≥3+). The next step in evaluation of CKD is to check a serum creatinine level as an indicator of renal function. Imaging with renal ultrasound and voiding cystourethrogram may also be considered. (Choice B) Elevated serum osmolality and low urine osmolality are suggestive of diabetes insipidus, which is characterized by free water loss. Patients can experience nocturnal enuresis but typically also have polyuria, polydipsia, and low urine specific gravity, none of which are seen here. (Choice C) Nephrolithiasis can occur with chronic hypercalcemia and cause voiding problems. However, kidney stones are uncommon in young children and typically associated with pain (eg, abdominal, flank) and/or hematuria. (Choice D) Reassurance is appropriate for isolated nocturnal enuresis in a young child. However, this patient's daytime symptoms, hypertension, proteinuria, and history of UTIs require evaluation for underlying renal disease. (Choice E) Trauma-focused psychotherapy can be considered in a child with a history of suspected trauma or maltreatment. Although psychological stressors can worsen enuresis, they do not explain this patient's other findings (eg, proteinuria). Educational objective: Chronic kidney disease is a cause of daytime and nighttime urinary incontinence and should be suspected in a child with fatigue, hypertension, proteinuria, and/or a history of urinary tract infections. Evaluation includes obtaining a serum creatinine level and renal imaging. References: Signs and symptoms of developmental abnormalities of the genitourinary tract. (http://www.ncbi.nlm.nih.gov/pubmed/26994452)

A 5-Year-Old Boy Comes to the Office with His Parents