Which one of the following treatments for childhood nocturnal enuresis has both the highest cure rates and the lowest relapse rates?
Correct Answer A: Treatments available for childhood nocturnal enuresis include nonpharmacologic and pharmacologic treatments. Compared to other techniques and pharmacologic treatments, the bed-wetting alarm has a higher success rate (75%) and a lower relapse rate (41%).
A 5-year-old male is brought in by his parents for advice about primary nocturnal enuresis. The father had similar problems until age 11. The parents are not overly concerned, but want to know what should be done. The child seems to understand his situation, is in charge of cleaning his bed, and seems unconcerned about the problem.
After a thorough examination and discussion of the options, the most appropriate recommendation in this case would be:
Correct Answer E: Primary nocturnal enuresis is a common condition for which there are many options. Treatment depends on the motivation of the parents and the child. Many times, parents and children just need reassurance that the condition is benign and that nothing needs to be done, especially for children under the age of 7.
As the child gets older and expresses an interest in tackling the problem, treatment should be initiated. Options include motivational training, bladder training, fluid management, use of an alarm clock 2-3 hours after going to bed, enuresis alarms, and desmopressin spray or pills. Research indicates that all of these options are effective. However, the enuresis alarms have been shown to be the most successful treatment in the long run. Desmopressin has also been successful, but relapses are frequent when it is discontinued.
A 6-year-old boy comes to your office for a well-child checkup. He has been healthy and doing well in school, but his mother is concerned about his bedwetting. He has never had a prolonged period of nighttime dryness, and he currently wets every night, about 2-3 hours after going to sleep. The patient's father had enuresis until age 9, but he outgrew the problem without any treatment. The mother has tried restricting fluids prior to bed, but this has not helped. His urinalysis results are normal.
What step in management would you do next?
Correct Answer D:
Enuresis is a common problem that is usually self-limited, but treatment with buzzer alarm conditioning devices has been shown to be effective in about 70% of cases.
→ Unless there is a history of urinary tract infection or an abnormal urinary stream, cultures and radiographic studies (choice A) are not necessary.
→ Intervention (choice B), when enuresis persists beyond 7-8 years of age, may decrease stress and embarrassment.
→ While medications (choice C) may work initially, most children start wetting again as soon as the medication is stopped. Since desmopressin is very expensive and imipramine may cause serious side effects if overdosed, medications should probably not be used as initial treatment.
→ Punishment and restriction of fluid (choice E) have not been shown to be effective treatments for enuresis.
A very concerned mother tells you that her 5-year-old son is still wetting the bed at night.
The most appropriate next step is to:
Primary nocturnal enuresis or bed-wetting during sleep is relatively common in children under the age of 6. Reassuring the parents is appropriate, as many cases of enuresis will spontaneously resolve. Further investigation is required if the bed-wetting continues beyond 6 years of age, the child experiences dysuria, the enuresis becomes diurnal or if the enuresis appears after the child has sustained a period of bladder control (secondary enuresis).
First line management includes behaviour modification: limiting nighttime fluids, voiding prior to sleep and positive reinforcement. Medications and psychosocial therapies are second line.
Anatomic abnormalities should be considered in cases of diurnal enuresis along with UTI, constipation and CNS disorders. If the child exhibits secondary enuresis, screening for diabetes, UTI, diabetes insipidus and psychosocial stresses may be warranted.
PEARL: Nocturnal enuresis is considered normal until the age of 6.
A 3-year-old boy, known to have sickle cell anemia, presents to the emergency room with sudden onset of severe pallor. Clinical examination reveals massive splenomegaly. On an earlier clinic visit 2 weeks before this boy had splenomegaly of only 2 cm.
Which one of the following is the most likely explanation for this acute deterioration?
Correct Answer E:
The spleen filters out abnormal red blood cells and helps the body's immune system fight infection. Sometimes, as in the case of sickle cell disease, red blood cells can be trapped in the spleen, a condition known as splenic sequestration. The body reacts as if it were bleeding internally because the blood trapped in the spleen cannot circulate to the heart or brain. This condition can range from mild to life threatening, depending on how much of the body's red blood cells are sequestered.
When red blood cells are trapped, the spleen grows tender and becomes enlarged enough to feel in the upper left part of the abdomen. Doctors detect splenic sequestration by feeling for this enlarged spleen and testing for low red-blood cell counts.
The child will look pale. In darker-skinned people, this may be easier to detect by looking at the lips, the inner eyelids, and the fingernail beds. Usually these areas are red or dark pink, but if they look light pink or white, then the child is pale.
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