What is the first step in evaluating and managing a patient with enuresis (bedwetting)?

Enuresis Rule Out: Initial Evaluation Approach

Begin with a comprehensive history, physical examination, and screening urinalysis—these three components form the essential foundation for ruling out secondary causes of enuresis before initiating treatment. 1

History Taking: Key Elements to Assess

Urinary symptom characterization:

• Document frequency, timing, and pattern of wetting episodes (every night vs. sporadic) 1
• Distinguish primary (never been dry) from secondary enuresis (dry for ≥6 months then recurred) 2
• Identify monosymptomatic (nighttime only) vs. non-monosymptomatic enuresis by specifically asking about daytime urgency, holding maneuvers, interrupted micturition, weak stream, and daytime incontinence 2
• Assess for dribbling, dysuria, frequency, and urgency which suggest underlying bladder dysfunction 1

Critical comorbidities to screen:

• Constipation/fecal impaction (paramount cause of treatment resistance that must be aggressively treated) 2
• Sleep apnea symptoms: snoring, witnessed apneas, upper airway obstruction, daytime sleepiness 1, 2
• ADHD, diabetes mellitus, diabetes insipidus, chronic kidney disease 2, 3
• Developmental delays or subtle neurologic symptoms 1

Psychosocial factors:

• Screen for previous or ongoing inappropriate sexual contact 1
• Assess environmental stressors, especially in secondary enuresis 2
• Evaluate child's motivation and family's response (non-punitive approach essential) 1
• Obtain family history (one or both parents affected increases risk) 1, 2

Medication review:

• Identify drugs that may cause enuresis: lithium, valproic acid, clozapine, theophylline 2

Physical Examination: Focused Assessment

Every enuretic child requires physical examination before treatment initiation 1:

• Nasal/pharyngeal: assess nasal patency, voice quality, enlarged adenoids/tonsils (sleep apnea indicators) 1
• Abdominal: palpate for bladder distention and fecal impaction 1, 2
• Genitalia: examine for meatal abnormalities, epispadias, phimosis 1, 2
• Back: inspect for sacral dimple or vertebral anomalies suggesting spinal cord issues 1, 2
• Neurologic: complete exam to rule out subtle dysfunction 1, 2

Laboratory Workup: Essential Testing

Urinalysis and urine culture are mandatory for all patients 4, 2:

• Screen for urinary tract infection, diabetes, and kidney disease 4, 2
• Clear urine with negative dipstick (leukocyte esterase and nitrite) has 95-98% negative predictive value for UTI 1
• Send both urinalysis and culture simultaneously due to logistic difficulty of obtaining culture after the visit 4
• Consider first-morning urine specific gravity (<1.015 suggests poor concentration and may predict desmopressin response) 4

Imaging is NOT routinely needed unless 4, 2:

• History reveals continuous wetting, abnormal voiding pattern, or recurrent UTIs
• Physical examination findings are concerning
• Urinalysis/culture results are positive
• Daytime wetting or evidence of anatomical abnormalities present

Baseline Monitoring Strategy

Obtain a 2-week baseline record of wet/dry nights before the initial evaluation visit 1, 4:

• This monitoring alone frequently produces dramatic improvement 1
• Serves as standard for gauging success of subsequent interventions 1, 4

Common Pitfalls to Avoid

• Underinvestigation: Failing to perform even basic urinalysis could miss treatable causes like UTI 4
• Overinvestigation: Routine imaging beyond urinalysis is unnecessary without specific indications 4
• Missing constipation: The most frequent cause of treatment resistance 2
• Overlooking sleep apnea: Must specifically ask about snoring and witnessed apneas 2
• Ignoring medication side effects: Review all current medications 4
• Punitive approaches: Parents must understand the non-volitional nature of enuresis 4, 2
• Starting treatment without physical examination: Never acceptable 1

When to Refer to Pediatric Urology

Urgent specialty referral indicated for 2:

• Weak urinary stream or use of abdominal pressure to void
• Continuous incontinence
• Refractory cases after standard and combination therapies
• Suspected urinary tract malformations or neurologic disorders 3