Management of Primary Monosymptomatic Nocturnal Enuresis
The best next step is behavioral changes (Option C), which should include implementing a voiding schedule, evening fluid restriction, treating any constipation, and using a calendar to track wet/dry nights, with consideration for enuresis alarm therapy as definitive first-line treatment if the child and family are motivated. 1, 2
Why Behavioral Interventions Are the Correct Next Step
This boy has primary monosymptomatic nocturnal enuresis (MNE) - he has never been dry (primary), wets only at night (nocturnal), and has no daytime symptoms, normal urinalysis, and unremarkable physical exam (monosymptomatic). 1 The International Children's Continence Society guidelines explicitly state that the primary care provider should be able to "start adequate first-line treatment" after excluding underlying medical conditions and comorbidities through history and physical examination alone. 1
What Behavioral Changes Should Include:
- Implement a calendar system to track wet and dry nights - this provides baseline data and has independent therapeutic effect (Grade Ib evidence) 1
- Establish regular daytime voiding schedule: morning, twice during school, after school, dinner time, and immediately before sleep 1
- Evening fluid and solute restriction while maintaining liberal intake during morning/early afternoon 1
- Screen and aggressively treat constipation if present (bowel movements less than every other day or hard consistency) - this is paramount as constipation is a major cause of treatment resistance 1, 2
- Educate family that bedwetting is involuntary, not the child's fault, and treatment should not be punitive 1, 2
Why Other Options Are Incorrect
MRI Lumbar (Option A) is not indicated. Imaging is only needed when there are red flags: continuous wetting (day and night), abnormal voiding pattern, weak stream requiring abdominal pressure, recurrent UTIs, or abnormal physical findings like sacral dimple with neurological signs. 2, 3 This child has normal PE and only nighttime wetting.
Referral to Urology (Option B) is premature. The International Children's Continence Society states that "any adequately educated nurse or physician" can manage uncomplicated MNE, and specialty referral is reserved for children with daytime symptoms suggesting non-monosymptomatic enuresis, particularly those with weak stream or continuous incontinence requiring "specialized center without delay." 1, 4
Reassurance Alone (Option D) is inadequate and potentially harmful. While enuresis has some spontaneous resolution rate, the psychological impact "may be severe" and "makes treatment not only justified but mandatory." 1 Children develop shame and guilt that threatens self-esteem at a critical developmental period. 5 The expectant "wait and see" approach is outdated - more than 5% of 7-year-olds and 0.5% of adults continue bedwetting if untreated. 5
Definitive First-Line Treatment Options After Behavioral Modifications
Once behavioral interventions are established, two evidence-based first-line therapies exist:
Enuresis Alarm (Preferred for Long-Term Cure)
- 66% initial success rate with over 50% achieving long-term cure - the highest cure rate of any intervention 1, 2, 4
- Requires motivated family and child, written contract, thorough instructions, and frequent (every 3 weeks) monitoring 1
- Parents must commit to waking child when alarm sounds to finish voiding in toilet 1
- Success followed by "overlearning" (using alarm every other day before discontinuation) 1
Desmopressin (For Rapid/Short-Term Response)
- 30% full response, 40% partial response but high relapse rate 1
- Best for children with nocturnal polyuria and normal bladder capacity 1, 2
- Dose: 0.2-0.4 mg tablets taken 1 hour before sleep 1
- Critical safety concern: Risk of hyponatremia with excessive fluid intake - limit evening intake to ≤200 mL and no drinking until morning 1, 6
- Contraindicated with polydipsia, loop diuretics, or glucocorticoids 6
Critical Pitfalls to Avoid
- Missing constipation - this is the most common cause of treatment resistance and must be addressed first 1, 2
- Inadequate treatment duration - minimum 2-3 months required before declaring failure 2
- Punitive parental response - reinforces that bedwetting is involuntary, not behavioral 2, 4
- Insufficient alarm monitoring - requires frequent follow-up and parental commitment to wake child 1, 2
- Excessive fluid intake on desmopressin - increases hyponatremia risk 1, 2, 6
When to Escalate Care
Refer to urology if: daytime symptoms emerge, weak urinary stream develops, continuous incontinence occurs, recurrent UTIs develop, or first-line therapies fail after proper implementation. 2, 4 For therapy-resistant cases after both alarm and desmopressin failure, anticholinergics (if constipation excluded) or combination therapy may be considered. 1, 4