What should be checked in a 7-year-old child with nocturnal enuresis (bedwetting)?

Evaluation of Nocturnal Enuresis in a 7-Year-Old Child

The essential evaluation requires only three components: a detailed history focusing on voiding patterns and associated symptoms, a physical examination targeting specific anatomical areas, and a urinalysis—more invasive testing is not indicated unless red flags are identified. 1

History Taking

Core Voiding Information

• Document the pattern of bedwetting: frequency per week, whether the child has ever been consistently dry for 6+ months (distinguishing primary from secondary enuresis), and volume of urine passed at night 1
• Screen for daytime symptoms: urgency, frequency, daytime incontinence, unusual voiding postures, straining, weak stream, or discomfort during urination—these indicate non-monosymptomatic enuresis requiring different management 1
• Assess fluid intake patterns: timing and volume of drinks, particularly evening consumption, and whether the child has excessive thirst or polydipsia (red flag for diabetes or kidney disease) 1, 2

Associated Conditions to Identify

• Bowel habits: Ask specifically about stool frequency (less than every 2 days is concerning), hard stools, straining, or fecal soiling—constipation is present in a significant proportion of enuretic children and mechanical pressure from fecal impaction can cause or worsen enuresis 1, 3
• Sleep-related symptoms: Heavy snoring, witnessed apneas, or mouth breathing suggest obstructive sleep apnea, which can cause enuresis and may resolve after treatment of upper airway obstruction 1
• Urinary tract infections: History of dysuria, fever, or previous documented UTIs 1
• Psychosocial stressors: For secondary enuresis, identify major life events (parental divorce, school trauma, abuse, hospitalization) that coincided with recurrence of wetting 1

Motivation Assessment

• Gauge the child's perception: Ask the child directly whether bedwetting bothers them—children who are not bothered may not comply with treatment 1
• Assess family motivation: Determine if parents and child are willing to commit to treatment interventions 1

Physical Examination

Focus on specific anatomical regions rather than a general examination: 1

• Oropharynx: Examine for enlarged tonsils and adenoids; assess nasal patency and voice quality for adenoid hypertrophy 1
• Abdomen: Palpate for bladder distention and fecal masses in the lower abdomen—palpable formed feces strongly support constipation diagnosis 1
• External genitalia: Look for meatal abnormalities, epispadias, phimosis, or other structural anomalies (examination should only proceed when child and family are comfortable) 1
• Back examination: Inspect for sacral dimple, hair tuft, or other signs suggesting spinal cord anomaly 1
• Neurologic assessment: Perform a thorough neurologic exam to detect subtle dysfunction, particularly lower extremity reflexes and perineal sensation 1
• Rectal examination: Consider only if constipation is suspected and family is comfortable—formed feces in rectal ampulla confirms diagnosis 1

Laboratory and Diagnostic Testing

Mandatory Testing

• Urinalysis by dipstick is the only obligatory test: Check for glycosuria (mandates immediate diabetes mellitus exclusion), proteinuria (investigate for kidney disease if persistent on repeat samples), leukocyte esterase, and nitrites 1, 2
• Negative dipstick for leukocyte esterase and nitrites has 95-98% negative predictive value for UTI, making it highly reliable for ruling out infection 1, 2

Conditional Testing

• Urine culture: Only send if urinalysis suggests infection or clinical suspicion remains high despite negative screening 1, 2
• First-morning urine specific gravity: May help predict desmopressin response (specific gravity <1.015 suggests nocturnal polyuria and better desmopressin response), though not routinely required 1

Testing NOT Indicated

• Renal ultrasound and upper urinary tract imaging are not warranted for uncomplicated monosymptomatic enuresis 1
• Blood tests are not indicated unless urinalysis reveals glycosuria or proteinuria 1
• Urodynamic studies, voiding cystourethrogram, and cystoscopy are only pursued with specific red flags: continuous wetting, abnormal voiding pattern, recurrent UTIs, weak urinary stream, or structural abnormalities on examination 1

Frequency-Volume Chart

Have the family complete a bladder diary for at least 2 days of measured fluid intake and voided volumes, plus 1 week of tracking wet/dry nights, daytime incontinence, and bowel movements. 1 This serves multiple purposes:

• Provides objective data supporting the history 1
• Detects children with non-monosymptomatic enuresis who were missed on history 1
• Identifies nocturnal polyuria (by weighing nighttime diapers), which predicts desmopressin success 1
• Reveals polydipsia requiring metabolic investigation 1, 2
• Assesses family adherence to instructions 1

Critical Red Flags Requiring Specialist Referral

Refer to pediatric urology without delay if: 1

• Weak or poor urinary stream 1
• Severe or continuous incontinence 1
• Structural genital or spinal abnormalities on examination 1
• Abnormal neurologic findings 1
• Recurrent urinary tract infections 1
• Persistent proteinuria or hematuria suggesting kidney disease 1, 2, 4

Common Pitfalls to Avoid

• Do not attribute bedwetting to behavioral causes when polydipsia and excessive thirst are present—these are red flags requiring metabolic investigation for diabetes mellitus or diabetes insipidus 2
• Do not start treatment before age 6 years unless specifically indicated 1
• Do not overlook constipation—it commonly coexists and contributes to enuresis; treating constipation resolves nocturnal incontinence in 63% of cases 1, 3
• Do not perform invasive testing (imaging, urodynamics) in uncomplicated monosymptomatic enuresis—history, examination, and urinalysis are sufficient 1