Management of Secondary Nocturnal Enuresis in a 5-Year-Old
For this 5-year-old girl with new-onset bedwetting after her sibling's birth, provide reassurance and education to the family, implement simple behavioral interventions with a reward system, but defer active treatment until age 6 unless the family is highly motivated. 1, 2
Initial Assessment and Family Education
Reassure the parents that this is secondary enuresis (previously dry, now wet after a major family event) and is extremely common, affecting 15-20% of 5-year-olds, with a 14% spontaneous remission rate per year. 2, 3 The timing coinciding with the new baby's arrival is significant—when secondary enuresis occurs, asking whether the recurrence coincided with any major family event is essential. 1
Emphasize that bedwetting is not the child's fault and avoid any punitive responses, as punishment, shaming, or control struggles can worsen the situation and create psychological distress. 2, 4
Diagnostic Workup
Perform a urinalysis (urine dipstick test) to rule out diabetes mellitus (glycosuria), urinary tract infection, or kidney disease (proteinuria). 1, 2 This is the only obligatory laboratory test for monosymptomatic enuresis. 1
Complete a frequency-volume chart or bladder diary for at least 1 week, measuring fluid intake and voided volumes for at least 2 days, and noting enuresis episodes, daytime incontinence, and bowel movements. 1, 2 This helps detect whether this is truly monosymptomatic (nighttime only) versus non-monosymptomatic enuresis (day and night symptoms). 1
Screen for constipation by asking about bowel movement frequency (every second day or less is concerning) and stool consistency. 1 If constipation is present, treat it first with dietary changes and polyethylene glycol if needed, as this alone can resolve enuresis. 1, 4
Behavioral Interventions at Age 5
Since active treatment should usually not be started before age 6 years 1, focus on supportive behavioral measures:
Implement a reward system (sticker chart) for dry nights to increase motivation and awareness, which has an independent therapeutic effect. 1, 2
Establish regular daytime voiding schedules: morning, at least twice during school, after school, at dinner time, and just before turning out the lights. 1, 2
Minimize evening fluid and solute intake while ensuring liberal water intake during the morning and early afternoon hours. 1, 2
Encourage the child to void at bedtime and on awakening. 1
Involve the child in changing wet bedding to raise awareness (not as punishment). 2, 4
Important Caveats
If parents are waking the child at night to void, inform them this is allowed but not necessary and only helps for that specific night, if at all. 1, 2 This does not provide long-term benefit.
Keep a calendar of dry and wet nights, as this provides a baseline to judge therapeutic interventions and has an independent therapeutic effect. 1
Schedule monthly follow-up appointments with realistic goals to sustain motivation and improve outcomes. 1, 4
Treatment After Age 6
If bedwetting persists beyond age 6, enuresis alarm therapy becomes first-line treatment with approximately 66% success rates. 2 Desmopressin can be considered as second-line therapy, particularly if nocturnal polyuria is documented (by weighing diapers), with 30% full response and 40% partial response rates. 2, 4
When to Refer
Children with severe/continuous incontinence, weak urinary stream, or non-monosymptomatic enuresis (day and night symptoms) must be sent to a specialized center without delay. 1, 5 However, this child's presentation with isolated nighttime wetting after a major family stressor does not warrant immediate referral.