What is the most appropriate next step for a 6-year-old patient with nocturnal and diurnal enuresis, chronic constipation, and a sacral dimple?

Immediate Spinal Imaging is Mandatory

This 6-year-old with combined day/night enuresis, chronic constipation, and a sacral dimple requires urgent MRI of the spine to rule out spinal dysraphism with tethered cord before any other intervention. 1

Why This Takes Absolute Priority

The constellation of symptoms—both diurnal and nocturnal enuresis combined with chronic constipation and a sacral dimple—is a classic red flag triad for occult spinal cord pathology. 1 This is not simple monosymptomatic enuresis that can be managed conservatively.

Critical Red Flags Present in This Case

• Sacral dimple is a cutaneous marker that alerts clinicians to potential underlying spinal cord abnormalities, particularly when associated with urologic and bowel dysfunction 1
• Combined day and night wetting (non-monosymptomatic enuresis) suggests neurogenic bladder dysfunction rather than simple developmental delay 1
• Chronic constipation occurring with enuresis raises concern for sacral spinal cord involvement affecting both bladder and bowel innervation 1
• The combination of urinary incontinence with fecal soiling/constipation is the most common presentation of tethered cord in toilet-trained children 1

What Spinal Dysraphism Means for This Patient

Between 10-52% of children with anorectal malformations (including chronic constipation) have associated dysraphic malformations. 1 The physical examination finding of a sacral dimple specifically suggests possible:

• Tethered spinal cord causing progressive neurologic deterioration 1
• Spinal lipoma or other occult spinal cord anomalies 1
• Lower motor neuron dysfunction manifesting as detrusor underactivity with denervation of the external urethral sphincter 1

The Diagnostic Algorithm

Step 1: Immediate Neurologic Assessment

• Perform thorough neurologic examination focusing on lower extremity strength, reflexes, gait abnormalities, and sensory deficits 1
• Examine the back carefully for the sacral dimple characteristics (depth, location, associated findings like hair tufts or skin discoloration) 1
• Assess for orthopedic deformities including leg length discrepancy, foot deformities, or scoliosis that occur in 75% of patients with spinal dysraphism 1

Step 2: Obtain MRI of Entire Spine

• MRI is the definitive imaging modality to visualize spinal cord tethering, lipomas, or other dysraphic lesions 1
• This must be done before initiating any enuresis treatment, as the underlying pathology determines the entire treatment approach 1
• Plain radiographs may show bony abnormalities but are insufficient to rule out soft tissue spinal cord pathology 1

Step 3: Concurrent Basic Evaluation (While Awaiting MRI)

• Urinalysis and urine culture to exclude urinary tract infection 1, 2
• Abdominal examination for bladder distention and fecal impaction 1
• Renal ultrasound may reveal hydronephrosis or bladder wall thickening suggesting neurogenic bladder 1, 3

Why Standard Enuresis Treatment Would Be Harmful Here

Common Pitfall to Avoid

Never treat this as simple monosymptomatic enuresis with behavioral therapy, alarms, or desmopressin without first ruling out spinal pathology. 1, 2 Doing so would:

• Delay diagnosis of a progressive neurologic condition 1
• Miss the window for surgical intervention that can prevent permanent neurologic damage 1
• Allow continued deterioration of bladder and bowel function 1
• Risk permanent orthopedic deformities that won't improve even after tethered cord release 1

The Evidence on Timing

Long-standing or severe neurologic dysfunction from untreated tethered cord is unlikely to improve even with surgical correction, though surgery effectively arrests progression. 1 Early detection through recognition of cutaneous markers and associated symptoms provides the best opportunity to prevent deterioration. 1

If Spinal Imaging is Normal: Then Address Constipation First

Only after spinal dysraphism is definitively ruled out should you proceed with standard management:

Aggressive Constipation Treatment is Paramount

• Disimpaction and bowel regimen must precede enuresis therapy 1
• Mechanical pressure from fecal impaction on the bladder commonly causes or perpetuates enuresis 1
• Use polyethylene glycol for stool softening with goal of daily soft bowel movements 1
• However, note that fecal disimpaction alone will not cure nocturnal enuresis even when constipation is present—it simply removes a contributing factor 4

Subsequent Enuresis Management (Only After Above Steps)

• Behavioral modifications including regular daytime voiding schedule, evening fluid restriction, and pre-sleep voiding 1, 2
• Enuresis alarm as first-line therapy for motivated families (66% initial success rate) 1
• Desmopressin as alternative if alarm fails or family cannot comply 1

Urologic Referral Indications

Refer to pediatric urology if: 1

• Abnormal voiding patterns (straining, poor stream, unusual posturing)
• Recurrent urinary tract infections
• Abnormal genital examination
• Hydronephrosis or bladder wall thickening on ultrasound
• Spinal imaging reveals dysraphism requiring urodynamic evaluation before surgery 1

The bottom line: A sacral dimple with combined day/night enuresis and constipation is spinal dysraphism until proven otherwise—obtain MRI immediately. 1