A 4-year-old boy is brought to the office due to bedwetting. Toilet-training was initiated at age 2 when he learned the words "pee" and "poop." His parents are concerned that the boy still urinates in his bed at least 1 night a week despite avoiding fluid intake 2 hours prior to bedtime. The patient's older sisters were toilet-trained during the day and night by age 3. He has a soft bowel movement in the toilet every day. The boy is active and plays outside for at least an hour a day. He has no medical problems and takes no medications. Physical examination shows a well-nourished, talkative boy. There is no sacral dimple or hair tuft. Testes are descended bilaterally, and the urethral meatus is at the tip of the glans. He can hop on each foot for a few seconds. He identifies the colors of "pee" and "poop" as yellow and brown, respectively. What is the best next step in management of this patient?

Question

A 4-year-old boy is brought to the office due to bedwetting.  Toilet-training was initiated at age 2 when he learned the words "pee" and "poop."  His parents are concerned that the boy still urinates in his bed at least 1 night a week despite avoiding fluid intake 2 hours prior to bedtime.  The patient's older sisters were toilet-trained during the day and night by age 3.  He has a soft bowel movement in the toilet every day.  The boy is active and plays outside for at least an hour a day.  He has no medical problems and takes no medications.  Physical examination shows a well-nourished, talkative boy.  There is no sacral dimple or hair tuft.  Testes are descended bilaterally, and the urethral meatus is at the tip of the glans.  He can hop on each foot for a few seconds.  He identifies the colors of "pee" and "poop" as yellow and brown, respectively.  What is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient is a developmentally normal child who has not yet achieved complete urinary continence. Most children are ready to begin toilet-training at age 2-4 years with the acquisition of the following skills: Walking Imitating others' actions (eg, sitting on toilet) Following 2-step commands Removing pants Communicating the need to urinate and stool Voluntarily controlling sphincters Premature initiation of toilet-training can prolong the duration of training. Once developmentally ready, most children master daytime continence within months, but nighttime continence can sometimes take years to accomplish. Parents should be reassured that bedwetting is normal before age 5. Also, boys generally complete toilet-training later than girls. Most cases even beyond age 5 resolve spontaneously but often require intervention due to family and child frustration or embarrassment. (Choices A and D) Enuresis alarm therapy and initiation of desmopressin are considered first-line therapies in patients seeking treatment for nocturnal enuresis, defined by urinary incontinence in children age ≥5. These interventions are unnecessary in a 4-year-old with occasional episodes of incontinence. (Choice B) When incontinence persists beyond age 4, urinalysis should be performed to screen for urinary tract infection, diabetes mellitus, and diabetes insipidus. These comorbidities are unlikely in an otherwise asymptomatic young child who is gradually achieving complete continence. (Choice C) Bladder ultrasound can help identify bladder dysfunction, which can present with enuresis. However, other expected symptoms include daytime incontinence, weak stream, or hesitancy. This child's isolated, occasional nocturnal enuresis does not warrant imaging. (Choice F) Secondary enuresis, or return of incontinence after ≥6 months of dryness, can be caused by social stressors (eg, divorce, new school) and may improve by addressing such stressors in therapy. This boy has no identifiable stressors and has primary nocturnal enuresis. (Choice G) Punishment (eg, restriction of activities, corporal punishment) can lead to increased stress and anxiety, resulting in prolonged bedwetting. Encouragement and positive reinforcement should be provided when the child demonstrates readiness and succeeds in staying dry. Educational objective: Bedwetting is normal before age 5. Mastery of nighttime continence can take months to years, and boys generally achieve this milestone later than girls. References: Toilet training. (http://www.ncbi.nlm.nih.gov/pubmed/19007052) Primary nocturnal enuresis: a review (http://www.ncbi.nlm.nih.gov/pubmed/27703953)

A 4-Year-Old Boy Is Brought to the Office Due to Bedwetting