First Step in Managing New Onset Nocturnal Enuresis
The first step is obtaining a thorough case history focused on voiding patterns and daytime symptoms, followed immediately by a urine dipstick test to exclude underlying medical conditions like diabetes mellitus or kidney disease. 1
Initial History Taking
The cornerstone of evaluation is a detailed history that specifically addresses:
- Voiding habits during the day: Ask specifically about urgency, holding maneuvers (standing on tiptoe, pressing heel into perineum), interrupted micturition, weak stream, and need to use abdominal pressure to void 1
- Current or previous daytime incontinence: If present, determine frequency and situations when it occurs—this distinguishes monosymptomatic from non-monosymptomatic enuresis 1
- Bowel habits: Constipation must be identified as it significantly impacts treatment success; ask about frequency (every second day or less suggests constipation), stool consistency, and fecal incontinence 1
- Fluid intake patterns: Estimate daily fluid consumption to detect polydipsia (which makes desmopressin dangerous) and identify children with polyuria from diabetes or kidney disease 1
- Previous treatment attempts: Document what strategies have been tried and whether they were implemented correctly 1
- General health screening: Ask about recent fatigue or weight loss to detect diabetes or kidney disease 1
- Sleep patterns: Heavy snoring or sleep apnea may be relevant, as some children become dry after upper airway obstruction is relieved 1
Mandatory Initial Testing
The sole obligatory laboratory test is a urine dipstick test. 1, 2
- Glycosuria requires immediate diabetes mellitus exclusion 1
- Proteinuria in repeat samples warrants kidney disease investigation 1
- A urine culture is often sent simultaneously due to logistic difficulties of obtaining culture after the office visit and because no rapid urinalysis method can exclude infection with 100% certainty 2
- First-morning urine specific gravity may help predict desmopressin response (specific gravity <1.015 suggests nocturnal polyuria) 2
Essential Physical Examination
Physical examination focuses on detecting alarming features:
- Rapid examination of the back and external genitals is mandatory in all children with history of UTI or non-monosymptomatic enuresis 1
- Rectal palpation is useful if constipation is suspected—formed feces in the rectal ampulla strongly supports the diagnosis 1
- Thorough somatic examination is required for alarming symptoms like weak stream or severe/continuous incontinence 1
Frequency-Volume Chart
Completion of a frequency-volume chart for at least 2 days (with symptom tracking for 1 week) is recommended as it: 1
- Provides objective data supporting the history
- Helps detect non-monosymptomatic enuresis
- Provides prognostic information
- Detects children requiring extra evaluation
- Identifies polydipsia
- Assesses family adherence to instructions
Critical Distinctions to Make
Distinguish between monosymptomatic (nighttime only) and non-monosymptomatic enuresis (daytime symptoms present), as this fundamentally changes the diagnostic and treatment approach 1, 3, 4
Common Pitfalls to Avoid
- Do not skip urinalysis—this is the only mandatory test and missing it could overlook treatable causes like UTI or diabetes 2
- Do not order routine blood tests or renal ultrasound unless specific indications are present (history of UTI, abnormal voiding pattern, continuous wetting, or abnormal urinalysis) 1, 2
- Do not overlook constipation—if not treated first, achieving dryness becomes difficult 1
- Avoid punitive approaches—ensure parents understand enuresis is non-volitional 5, 2