What is the next step for a 6-year-old patient with primary nocturnal enuresis (bedwetting) and a family history of the condition?

Next Step: Reassurance and Behavioral Interventions

For a 6-year-old child with primary nocturnal enuresis and a positive family history, the next step is to provide reassurance and education to the family, along with implementing supportive behavioral interventions, before considering alarm therapy or medications. 1, 2

Why Reassurance is the Appropriate Next Step at Age 6

At exactly 6 years of age, this child is at the threshold where active treatment becomes appropriate, but initial management should still focus on education and behavioral approaches:

• Bedwetting affects 15-20% of 5-year-olds with a spontaneous remission rate of approximately 14% per year, making reassurance about the commonality and natural resolution essential to reduce parental guilt and prevent punitive responses 1, 2

• The family history of enuresis is significant - this is a familial condition with complex inheritance patterns, and educating parents that this is not the child's fault helps prevent psychological distress 3, 2

• Active treatment should generally not be started before age 6 years, with the focus instead on general lifestyle advice and supportive behavioral interventions 4

Initial Management Algorithm

Step 1: Assessment and Education

• Perform urinalysis to rule out diabetes mellitus, urinary tract infection, or kidney disease 1, 2
• Assess for constipation, as treating it can resolve urinary symptoms in up to 63% of cases with nocturnal enuresis 1, 4
• Complete a frequency-volume chart or bladder diary for at least 1 week to establish baseline patterns 1, 2

Step 2: Behavioral Interventions (First-Line at Age 6)

• Implement a reward system (sticker chart) for dry nights to increase motivation and awareness 1, 2
• Establish regular daytime voiding schedules (morning, at least twice during school, after school, dinner time, and bedtime) 1, 2
• Minimize evening fluid intake, particularly caffeinated beverages, while ensuring adequate hydration earlier in the day 1, 2
• Address constipation aggressively with polyethylene glycol if needed 1
• Involve the child in changing wet bedding to raise awareness (not as punishment) 1, 2

Step 3: When to Escalate to Alarm or Medications

Alarm therapy becomes first-line active treatment after behavioral interventions, with success rates of approximately 66% and is considered the most effective intervention for nocturnal enuresis 2, 5:

• Requires written instructions, establishing a contract, and scheduling frequent monitoring appointments 1
• Treatment should continue for at least 2-3 months before attempting to wean 1
• The urine alarm is supported as the most effective intervention when used with proper instruction and family cooperation 6, 5

Desmopressin is considered when alarm therapy has failed or is unlikely to be successful, particularly for children with nocturnal polyuria 1:

• Typical oral dose is 0.2 to 0.4 mg tablets taken 1 hour before bedtime 1
• Provides immediate anti-enuretic effect with approximately 30% full response and 40% partial response rates 1, 2
• Critical safety consideration: Limit fluid intake to 200 ml (6 ounces) or less in the evening and no drinking until morning to prevent hyponatremia 1

Common Pitfalls to Avoid

• Never punish, shame, or create control struggles around bedwetting - this worsens the situation and creates psychological distress 1, 2
• Do not skip the assessment for constipation - this is a frequently missed treatable cause 1, 4
• Avoid starting with medications before trying behavioral interventions and alarm therapy - conditioning with alarm therapy has better long-term success rates than medications alone 6, 5
• Schedule monthly follow-up appointments to sustain motivation and assess treatment response 1, 2

Answer to Multiple Choice Question

The answer is A - reassure, as this is the appropriate first step at age 6 with primary nocturnal enuresis and family history. However, reassurance should be coupled with behavioral interventions as outlined above. Alarm therapy (option D) would be the next escalation if behavioral measures fail after 1-2 months of consistent implementation 1, 2.