What is the evaluation and treatment approach for a 10-year-old child with nocturnal enuresis (bedwetting) and proteinuria (protein in the urine) detected in a clean catch urinalysis (UA)?

Evaluation and Treatment of a 10-Year-Old with Bedwetting and Proteinuria

A 10-year-old child with nocturnal enuresis and proteinuria detected in a clean catch urinalysis requires thorough evaluation for underlying kidney disease before addressing the bedwetting. 1

Initial Evaluation

Mandatory Tests

• Urinalysis is the sole obligatory laboratory test for children with nocturnal enuresis, but proteinuria in repeat samples should prompt investigations for kidney disease 1
• Urine culture should be performed simultaneously with urinalysis to rule out urinary tract infection with certainty (95-98% negative predictive value) 1
• Repeat urinalysis to confirm persistent proteinuria, as transient proteinuria is common in children 2

Physical Examination

• Examine the abdomen for bladder distention or fecal impaction 1
• Examine external genitalia for abnormalities of the meatus, epispadias, or phimosis 1
• Examine the back for sacral dimple or other signs of vertebral/spinal cord anomalies 1
• Perform thorough neurological examination to rule out subtle dysfunction 1

History Taking

• Document frequency and pattern of bedwetting (primary vs. secondary, frequency per week) 1
• Assess for daytime symptoms (urgency, frequency, incontinence, weak stream) 1
• Evaluate bowel habits, as constipation is common and may contribute to enuresis 1, 3
• Assess fluid intake patterns and screen for polydipsia 1
• Inquire about snoring or sleep apnea, which may contribute to enuresis 1
• Ask about weight loss or increased fatigue, which could suggest kidney disease or diabetes 1

Management Algorithm

Step 1: Address Proteinuria First

• Proteinuria in a child with enuresis requires evaluation for underlying renal disease before treating the enuresis 1, 2
• Refer to pediatric nephrology if proteinuria is persistent on repeat testing, especially with active urinary sediment, hypertension, or reduced glomerular filtration rate 2

Step 2: If Proteinuria is Transient or Ruled Out as Benign

• Complete a frequency-volume chart for at least 2 days to assess bladder capacity and rule out polydipsia 1, 3
• Treat any identified constipation aggressively with polyethylene glycol to optimize bowel emptying 1, 3
• Implement behavioral modifications:
  • Regular daytime voiding schedule (morning, twice during school, after school, dinner time, bedtime) 1, 3
  • Proper voiding posture with relaxed pelvic floor muscles 1
  • Restrict evening fluid intake while ensuring adequate hydration earlier in the day 1, 3
  • Maintain a calendar of dry and wet nights 1, 3

Step 3: Active Treatment (if child is bothered by bedwetting)

• Enuresis alarm therapy is first-line treatment with superior long-term success rates 3, 4

  • Provide written instructions and establish a contract with the child 3
  • Schedule monthly follow-up appointments to sustain motivation 1, 3
  • Continue for at least 2-3 months before attempting to wean 3

• Desmopressin is an alternative, particularly for children with nocturnal polyuria 1, 3

  • Approximately 30% full response rate and 40% partial response 1
  • More effective in children with normal bladder capacity but increased nighttime urine production 1
  • Monitor for water intoxication, especially during illness 3

Special Considerations

For Non-Monosymptomatic Enuresis (with daytime symptoms)

• If daytime symptoms persist and suggest detrusor overactivity, consider anticholinergic medication 3
• Refer to a specialized center without delay if the child voids with a weak stream, must use abdominal pressure, or has continuous incontinence 1

For Resistant Cases

• Consider combining alarm therapy with desmopressin 3
• If no improvement occurs after 1-2 months of consistent therapy, reassess diagnosis and consider referral to a specialist 3

Common Pitfalls to Avoid

• Failing to investigate persistent proteinuria, which may indicate serious kidney disease 1, 2
• Treating enuresis before addressing underlying medical conditions like constipation or sleep disorders 3
• Discontinuing treatment too early before establishing long-term success 3
• Using desmopressin without proper fluid restriction in the evening, increasing hyponatremia risk 3
• Punishing the child for wet episodes, which worsens psychological impact 3