What is the next step for a patient with nocturnal enuresis (nighttime urinary incontinence) who has never achieved dryness, has normal urine culture (urine CX) and analysis, and an unremarkable physical examination (PE)?

Management of Primary Nocturnal Enuresis with Normal Workup

The next step is behavioral changes (Option C), as this patient has uncomplicated primary monosymptomatic nocturnal enuresis with a normal evaluation, and behavioral interventions are the recommended first-line approach before considering alarm therapy or medications. 1

Clinical Reasoning

This patient presents with:

• Primary nocturnal enuresis (never been dry) occurring 3 times per week
• Normal urinalysis and urine culture (ruling out infection)
• Unremarkable physical examination (excluding anatomic abnormalities, neurologic issues, constipation)
• No red flags requiring specialist referral 1

When history, physical examination, and urinalysis are completely normal, this represents uncomplicated monosymptomatic primary nocturnal enuresis that should be treated with nonspecific supportive approaches initially. 1

Why Not the Other Options?

MRI Lumbar (Option A) - Not Indicated

• Imaging is only pursued with specific indications from history or physical examination 1
• Spinal imaging would only be warranted if there were signs of spinal cord anomaly (sacral dimple, neurologic deficits, abnormal gait) 1
• This patient has an unremarkable physical examination 1

Referral to Urology (Option B) - Premature

• Urologic referral is indicated for: daytime wetting, abnormal voiding patterns, recurrent urinary tract infections, genital abnormalities, or refractory cases 1, 2
• This patient has none of these features 1
• Referral should be reserved for children with primary enuresis refractory to standard therapies 2, 3

Reassurance Alone (Option D) - Insufficient

• While education and reassurance are important components, they should be combined with active behavioral interventions 1
• Not all children require treatment, but when families seek help, supportive approaches should include more than reassurance alone 1

Recommended Behavioral Interventions

Supportive approaches should always include: 1

• Education about prevalence and high spontaneous cure rate (14% annual resolution) 1, 3
• Demystification emphasizing the nonvolitional nature of the symptom 1
• Ensuring parents do not punish the child for enuretic episodes 1

Specific behavioral modifications include: 1

• Journal keeping or dry bed chart by the child for consciousness raising 1
• Involving the child in changing the bed 1
• Fluid restriction, especially caffeinated beverages before bedtime 1
• Night awakening to void (though evidence for efficacy is limited) 1
• Reward systems such as star charts for dry nights 4

Treatment Progression Algorithm

1. First-line: Behavioral modifications (as described above) 1, 2
2. Second-line: Enuresis alarm therapy if behavioral methods fail and family is cooperative and motivated 1, 5
   • Most effective long-term treatment with lower relapse rates 5
   • Requires high parental involvement and time commitment 5
3. Third-line: Medications (desmopressin or imipramine) if alarm therapy fails or is not feasible 1, 2
   • Desmopressin provides faster symptom relief but higher relapse rates 3
   • Consider first-morning urine specific gravity (<1.015) to predict desmopressin response 1

Common Pitfalls to Avoid

• Overinvestigation: More invasive tests beyond urinalysis are not routinely needed without specific indications 1, 6
• Premature specialist referral: Reserve urology referral for refractory cases or specific red flags 1, 2
• Punitive approaches: Parents must understand bedwetting is not volitional 1, 3
• Skipping behavioral interventions: These should be attempted before more demanding treatments like alarms or medications 1, 4