What is the next step in managing a 3-year-old girl with intermittent nocturnal enuresis and normal urinalysis?

From the Guidelines

The most appropriate next step in management for this 3-year-old girl with intermittent bed-wetting is reassurance only (option D). This case represents primary nocturnal enuresis, which is common in children who have been recently toilet-trained. The child has normal physical examination findings, normal development, and a normal urinalysis with no signs of infection or other urinary tract abnormalities. Primary nocturnal enuresis typically resolves spontaneously with age as bladder control matures, and at age 3, this condition is considered developmentally normal. Approximately 15% of 5-year-olds still experience bed-wetting, with the percentage decreasing as children get older. Reassurance to the parents about the benign and self-limiting nature of this condition is appropriate at this stage, rather than medications like desmopressin or invasive procedures like cystoscopy or voiding cystourethrography, which would be reserved for cases with concerning features such as daytime incontinence, urinary tract infections, or abnormal urinalysis results. According to the most recent and highest quality study 1, children with monosymptomatic nocturnal enuresis could primarily be treated by a primary care physician or an adequately educated nurse, and the mainstays of primary therapy are bladder advice, the enuresis alarm and/or desmopressin, but in this case, reassurance is the most appropriate initial approach.

Some key points to consider in the management of this condition include:

• The importance of a proper history and physical examination to rule out underlying conditions that may be contributing to the enuresis, as noted in the study by 1.
• The use of supportive approaches such as education, demystification, and ensuring that parents do not punish the child for enuretic episodes, as recommended by 1.
• The potential for spontaneous resolution of the condition with age, as the child's bladder control matures.
• The need for reassurance and support for the child and their family, rather than immediate initiation of medical therapy or invasive procedures.

In terms of specific management strategies, the study by 1 suggests that bladder advice, the enuresis alarm, and/or desmopressin may be considered as primary therapies for monosymptomatic nocturnal enuresis, but in this case, reassurance and supportive approaches are the most appropriate initial steps.

From the Research

Patient Assessment

The patient is a 3-year-old girl experiencing intermittent bed-wetting at night since being toilet-trained at age 2½ years. She has no history of serious illness, receives no medications, and has normal growth and development. Vital signs are within normal limits, and abdominal examination shows no abnormalities.

Urinalysis Results

The urinalysis of a clean-catch specimen shows:

• Color: clear yellow
• Specific gravity: 1.015 (within normal range)
• Protein: negative
• Glucose: negative
• Nitrite: negative
• WBCs: 1-2/hpf
• Bacteria: negative

Management Options

Considering the patient's age and symptoms, the most appropriate next step in management can be determined based on the following options:

• A) Desmopressin therapy: Desmopressin is most effective in children with nocturnal polyuria and normal bladder capacity 2, 3, 4, 5. However, the patient's age and lack of indication for nocturnal polyuria make this option less likely.
• B) Endoscopic cystoscopy: This option is not indicated unless there is suspicion of a urologic disease, which is not present in this case 2.
• C) Voiding cystourethrography: This option is also not indicated unless there is suspicion of a urologic disease, which is not present in this case 2.
• D) Reassurance only: Given the patient's age and normal urinalysis results, reassurance is an appropriate option. Primary nocturnal enuresis almost always resolves spontaneously over time, and treatment should be delayed until the child is able and willing to adhere to the treatment program 2. Reassurance therapy can be effective in patients with benign disease or symptoms not explained by disease 6.

Next Steps

Based on the evidence, the most appropriate next step in management is:

• Reassurance only, as the patient's symptoms are likely due to primary nocturnal enuresis, which often resolves spontaneously over time. Parents should be reassured about their child's physical and emotional health and counseled about eliminating guilt, shame, and punishment 2, 6.