What is the next step in management for a 9-year-old boy with primary monosymptomatic nocturnal enuresis occurring three times per week, normal urinalysis and culture, and an unremarkable physical exam?

Management of Primary Monosymptomatic Nocturnal Enuresis in a 9-Year-Old Boy

The next step is behavioral interventions combined with supportive measures, as this represents uncomplicated primary monosymptomatic nocturnal enuresis (PMNE) with no red flags requiring imaging or specialist referral. 1

Why Behavioral Changes Are First-Line

• This child has classic PMNE: nighttime-only wetting, never been dry (primary), normal urinalysis and culture, and unremarkable physical exam with no red flags 1
• Behavioral interventions should be tried first-line before any alarm therapy or medications, as they carry no risk or expense and establish the foundation for all subsequent treatments 1
• The American Academy of Child and Adolescent Psychiatry recommends starting with general supportive measures including establishing regular voiding schedules, restricting evening fluid intake, and using reward systems 2

Specific Behavioral Interventions to Implement

• Restrict fluid intake 2 hours before bedtime to decrease nocturnal urine volume 1
• Establish a regular voiding schedule with mandatory voiding immediately before bed 1, 2
• Implement a reward system using a sticker chart to track dry nights and reinforce positive changes 1
• Awaken the child once during the night to void, which generally does not cause significant sleep disruption given enuretic children's sound sleeping ability 1
• Keep a 2-week frequency-volume chart to document wet/dry nights and identify patterns, which will guide whether alarm therapy or desmopressin is more appropriate if behavioral measures fail 1, 2

Why Other Options Are Incorrect

MRI Lumbar (Option A) - Not Indicated

• MRI is only indicated when red flags are present, such as sacral dimple, abnormal neurological exam, combined day and night enuresis, or signs of spinal dysraphism 3
• This child has an unremarkable physical exam with isolated nighttime wetting, making structural spinal pathology extremely unlikely 3

Urology Referral (Option B) - Premature

• Specialist referral is reserved for therapy-resistant cases who fail both first-line treatments (alarm and desmopressin) or have concerning physical findings 1
• The International Children's Continence Society guidelines specify that children with severe/continuous incontinence or anatomic abnormalities require immediate specialist referral, none of which apply here 3
• This child hasn't yet tried any treatment, making referral premature 1

Reassurance Alone (Option D) - Insufficient

• While spontaneous resolution occurs in 15% annually, active intervention is warranted given the psychological impact on the child and the availability of effective treatments 1, 4
• Enuretic children experience social isolation and low self-esteem, and self-esteem improves with management even if cure is not achieved 5
• At age 9 with 3 wet nights weekly, this represents significant PMNE requiring active management beyond reassurance 1

Next Steps If Behavioral Interventions Fail

• After 3-4 weeks of behavioral interventions, if no improvement occurs, proceed to first-line therapies 1
• Two evidence-based first-line options exist: enuresis alarm (66% initial success rate with best long-term efficacy) or desmopressin 1
• The frequency-volume chart will guide which to choose: alarm therapy is best for children with low voided volumes, while desmopressin is best for documented nocturnal polyuria with normal bladder capacity 1
• Schedule follow-up appointments at least every 3 weeks to monitor progress and maintain motivation 1, 2

Common Pitfalls to Avoid

• Don't skip behavioral interventions and jump directly to medications or alarm therapy, as establishing good voiding habits is essential for treatment success 1, 2
• Don't order imaging without red flags, as this wastes resources and causes unnecessary anxiety 3
• Don't dismiss constipation as a comorbidity - assess bowel movement frequency and consistency, as constipation is present in 44% of PMNE cases and must be treated concurrently 2, 6
• Don't present this as purely psychological - PMNE has concrete organic causes including nocturnal polyuria (21%), detrusor overactivity (55%), or both (13%), not mental/behavioral issues 7