What is the most appropriate advice for a 4-year-old with primary nocturnal enuresis who has never been dry at night?

Reassurance is the Most Appropriate Advice

For a 4-year-old with primary nocturnal enuresis who has never been dry at night, reassurance is the most reasonable advice. At this age, bedwetting is developmentally normal and does not warrant active treatment or specialist referral. 1, 2, 3

Why Reassurance is Appropriate at Age 4

Developmental Context

• Primary nocturnal enuresis affects 15-20% of 5-year-olds, making it extremely common in this age group, and the spontaneous remission rate is approximately 14% per year. 4, 1, 2
• At age 4, the child is still within the normal developmental window for achieving nighttime bladder control, and most children will naturally outgrow bedwetting without any intervention. 1, 3
• The condition is nonvolitional—the child cannot control it—so parental anxiety should be addressed by explaining this is a maturational issue, not a behavioral problem. 4, 2

What Reassurance Should Include

Education for the mother should emphasize:

• Bedwetting at age 4 is not abnormal and does not indicate any underlying medical or psychological problem in most cases. 1, 2
• The child should never be punished, shamed, or made to feel guilty, as this worsens psychological distress without improving the condition. 4, 1, 2
• Simple supportive measures can be implemented at home without formal treatment, including reward systems (sticker charts for dry nights), regular daytime voiding schedules, and minimizing evening fluid intake. 1, 2, 3

When Active Treatment Becomes Appropriate

Active interventions are typically reserved for children aged 6 years and older:

• Enuresis alarm therapy becomes first-line treatment after age 6, with approximately 66% initial success rates. 4, 1, 3
• Desmopressin may be considered for children 6 years and older with documented nocturnal polyuria. 1, 2
• Before age 6, watchful waiting with supportive behavioral measures is the standard approach after ruling out underlying conditions. 1, 3

Essential Screening Before Reassurance

While reassurance is appropriate, basic screening should still be performed:

• Urinalysis (dipstick) is the only mandatory test to rule out diabetes mellitus, urinary tract infection, or kidney disease. 4, 1
• Ask about bowel habits to screen for constipation, as treating constipation can resolve urinary symptoms in up to 63% of cases. 4, 1
• Ensure the child has no daytime symptoms (urgency, frequency, weak stream, or continuous incontinence), which would indicate non-monosymptomatic enuresis requiring specialist referral. 4, 1

When NOT to Reassure (Red Flags Requiring Referral)

Immediate referral to pediatric urology is necessary if the child has:

• Weak urinary stream or need to use abdominal pressure to void. 4, 1
• Severe or continuous daytime incontinence. 4, 1
• Daytime urgency with moderate to severe intermittent incontinence. 4
• History of recurrent urinary tract infections. 1

Common Pitfalls to Avoid

• Do not refer to behavioral therapy for simple primary nocturnal enuresis at age 4—this is not a behavioral or psychological problem in the vast majority of cases. 4, 1
• Do not refer to urology unless red flags are present—routine urologic evaluation and imaging are not indicated for uncomplicated primary monosymptomatic enuresis. 4, 1
• Do not start pharmacologic treatment (desmopressin or anticholinergics) at age 4—these are reserved for children 6 years and older who have failed behavioral interventions. 1, 2, 3
• Avoid creating control struggles by pressuring the child or implementing punitive measures, as this increases psychological harm without therapeutic benefit. 4, 1, 2

Answer: C - Reassure