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

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

The appropriate next step is behavioral interventions (Option C), including fluid restriction before bedtime, scheduled voiding, reward systems, and maintaining a voiding diary. 1

Why Behavioral Changes Are the Correct First Step

Behavioral interventions are the recommended initial therapeutic approach for primary monosymptomatic nocturnal enuresis (PMNE) when the urinalysis is normal and physical examination is unremarkable. 2, 1 This 9-year-old boy meets the criteria for uncomplicated PMNE: nighttime-only wetting, never been dry (primary), normal urine studies, and unremarkable physical exam. 1

Specific Behavioral Measures to Implement

• Limit fluid intake for at least 2 hours before bedtime to reduce nocturnal urine production. 1
• Institute a regular daytime voiding schedule with a mandatory void immediately before sleep. 1
• Use a simple reward system (e.g., sticker chart) to reinforce dry nights. 1
• Consider gently awakening the child once during the night to void, which does not markedly disrupt sleep in enuretic children. 1
• Maintain a 2-week frequency-volume chart to record wet/dry nights and identify patterns that will guide subsequent therapy selection (alarm vs. desmopressin). 1

Why Other Options Are Incorrect

MRI Lumbar (Option A) - Not Indicated

Lumbar MRI is not indicated unless red-flag features are present. 1 Red flags include sacral dimple, abnormal neurological exam, combined day-and-night enuresis, or signs of spinal dysraphism. 3 This child has an unremarkable physical examination, making imaging unnecessary and wasteful. 1

Referral to Urology (Option B) - Premature

Urologic referral is reserved for children who fail both first-line behavioral measures and subsequent alarm or desmopressin therapy. 1 Referral is also appropriate for severe/continuous incontinence or identifiable anatomic abnormalities, neither of which are present in this case. 1 Jumping directly to specialist referral bypasses evidence-based first-line management. 2

Reassurance Alone (Option D) - Inadequate

While spontaneous resolution occurs in approximately 15% of children annually, active intervention is recommended because untreated enuresis impairs psychosocial wellbeing. 1 At age 9 with three wet nights per week, this condition is clinically significant and warrants active management beyond reassurance. 1

Treatment Escalation Algorithm

If no improvement occurs after 3-4 weeks of behavioral interventions, proceed to one of two evidence-based first-line options: 1

• Enuresis alarm (initial success ≈66% with best long-term efficacy) - favored when the voiding chart shows low voided volumes. 1
• Desmopressin - favored when documented nocturnal polyuria with normal bladder capacity is present. 1

Follow-up appointments should be scheduled at least every 3 weeks to assess progress, reinforce behavioral strategies, and adjust treatment as needed. 1

Critical Pitfalls to Avoid

• Do not bypass behavioral interventions and jump directly to medication or alarm therapy; establishing good voiding habits enhances overall treatment success. 1
• Do not order imaging studies in the absence of red-flag signs, as this wastes resources and causes unnecessary anxiety. 1
• Assess and treat constipation concurrently, since it co-occurs in roughly 44% of children with PMNE and can impede treatment response. 1 Constipation is significantly more prevalent in primary nocturnal enuresis. 4