Approach
When approaching a child for the first time who presents with enuresis, it is vital to determine that both the patient and the family are in agreement that there is a problem and they are all committed to a treatment plan. If the child shows little interest or does not recognise it as a problem, then it is wise to delay treatment until that time arrives. Likewise, parents must be educated that treatment will require their involvement and patience. If the parents do not demonstrate a willingness to be involved, or are relying on shame to motivate the child, the physician must do some groundwork with the parents to ensure their support through diagnosis and treatment.
Clinical assessment
It is important to diagnose the appropriate pathophysiological subtype of enuresis, as management and treatment differ accordingly. Review of systems should focus on the patient's sleeping habits, bowel function, and enquiry about symptoms or signs of upper airway obstruction.
A thorough evaluation should be done, including a detailed neurological and genitourinary examination to rule out neurological disorders or anatomical abnormalities leading to voiding dysfunction.
Voiding or elimination diary
The diary, with questionnaire and frequency-volume chart, should be sent to the family to record the child's voiding, starting 2 weeks before the appointment.[27] All information such as records of wet days and nights and timing of fluid intake and voiding is recorded. A frequency-volume chart details functional bladder capacity, which is assumed as being the largest micturition recorded during this period. Estimating bladder capacity can also be performed using the Koff formula of (age in years + 2) x 30 mL.[28] Night-time voided volume can be calculated by weighing the nappy. By recording stool frequency and consistency, patients with unrecognised constipation may be identified. The physician or nurse specialist should talk with the family to explain exactly how to complete the chart. The diary assists in obtaining an accurate history and provides a baseline as the treatment progresses.
It should be determined whether the patient takes in large amounts of fluids, specifically caffeinated beverages, late at night. By asking the child, family, and possibly school teachers, it is common to find that the patient does not drink an adequate amount of fluids while at school in order to avoid trips to the toilet. Thus, most of their fluid intake is in the evening, which leads to increased night-time voiding.[29]
Investigations
On the initial visit, urinalysis (U/A) should be done to help rule out infection or new-onset diabetes. If the child complains of frequency both day and night and on occasion also suffers from enuresis, it is important to rule out diabetes as the cause before embarking on any further investigation. One study supports ultrasound to evaluate bladder wall thickness, as it correlates well with baseline voiding dysfunction, which could be responsible for the enuresis.[30] In practice, renal ultrasound may be reserved for children in whom treatment has failed, or where there are complaints of other symptoms or signs of voiding dysfunction.
After completing a thorough history and physical examination, reviewing the voiding diary, and performing the U/A, it should be possible to rule out other causes for enuresis and start empirical treatment.
Further urological evaluation is necessary in children who cannot reliably empty the bladder or must use secondary manoeuvres to do so. These children, by definition, do not have primary monosymptomatic nocturnal enuresis, and investigations are required to determine the presence of bladder-sphincter dyssynergia, or an anatomical or neurological disorder in the lower urinary tract. A child with primary monosymptomatic nocturnal enuresis should be able to void to completion in one attempt, whether that void be at night or during the day.
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