nocturnal enuresis
Doctor Information
Isabelle Jacobs, age 4
PMH
nil
DH
nil
No allergies
PMH
nil
DH
nil
No allergies
Patient Information
Isabelle Jacobs age 4
You are Mitchell Jacobs, Isabelle’s father. Izzy has started wetting herself at night for the last few months. It is strange because she was potty trained when she was three, and was dry in the day and night. She is wetting the bed most nights in the week, and then she comes to your room crying and you have to get up and sort it out. She is fine in the day, you asked nursery and she has not had any problems there. You just can’t understand how she could have been fine and now it seems she is going backwards.
If asked only: Izzy is a healthy little girl. She has always been ahead - she walked when she was 10 months old, first words at 12 months. She has a twin brother Isaac who developed things much later. But even he is dry day and night. There are no problems with her bowels, and she has not complained of burning or pain on passing urine, or abdominal pain. There is no leg weakness and can keep up with other children. She has not been losing weight or having excessive thirst.
Izzy drinks lots of squash throughout the day. She has warm milk with her brother before bed.
You work as a bookkeeper from home. Your wife is a nurse who mostly works night, so it is you that looks after the kids most of the time. When Izzy wakes you up, you reluctantly go and change her sheets and put her back to bed. You did shout at her once but felt really bad and gave her a treat the next day. As far as you can see, Izzy is a happy kid. She started nursery with Isaac 2 months ago and seems to be happy there. There are no problems at home at you have noticed, and there is no family history of bed wetting.
Ideas: You have no idea why this has happened
Concerns: You don’t know where to turn for help, or whether you should be more worried about this - is it normal for this to happen? Does it mean there is something serious wrong?
Expectations: Does Izzy need a referral to a specialist?
If nocturnal enuresis is explained to you, along with possible causes, you start to feel reassured. If the doctor takes the time to explain measures such as start charts, fluid management and screening for infection and diabetes, you will be happy with this and offer to try these things. If you feel that an adequate plan has not been given, you will continue to ask for a referral.
You are Mitchell Jacobs, Isabelle’s father. Izzy has started wetting herself at night for the last few months. It is strange because she was potty trained when she was three, and was dry in the day and night. She is wetting the bed most nights in the week, and then she comes to your room crying and you have to get up and sort it out. She is fine in the day, you asked nursery and she has not had any problems there. You just can’t understand how she could have been fine and now it seems she is going backwards.
If asked only: Izzy is a healthy little girl. She has always been ahead - she walked when she was 10 months old, first words at 12 months. She has a twin brother Isaac who developed things much later. But even he is dry day and night. There are no problems with her bowels, and she has not complained of burning or pain on passing urine, or abdominal pain. There is no leg weakness and can keep up with other children. She has not been losing weight or having excessive thirst.
Izzy drinks lots of squash throughout the day. She has warm milk with her brother before bed.
You work as a bookkeeper from home. Your wife is a nurse who mostly works night, so it is you that looks after the kids most of the time. When Izzy wakes you up, you reluctantly go and change her sheets and put her back to bed. You did shout at her once but felt really bad and gave her a treat the next day. As far as you can see, Izzy is a happy kid. She started nursery with Isaac 2 months ago and seems to be happy there. There are no problems at home at you have noticed, and there is no family history of bed wetting.
Ideas: You have no idea why this has happened
Concerns: You don’t know where to turn for help, or whether you should be more worried about this - is it normal for this to happen? Does it mean there is something serious wrong?
Expectations: Does Izzy need a referral to a specialist?
If nocturnal enuresis is explained to you, along with possible causes, you start to feel reassured. If the doctor takes the time to explain measures such as start charts, fluid management and screening for infection and diabetes, you will be happy with this and offer to try these things. If you feel that an adequate plan has not been given, you will continue to ask for a referral.
Examination Findings
Pulse 88
Alert and interactive
Capillary refill < 2 secs
No pallor, does not look underweight
Height 95cm, weight 17kg
Abdomen soft non tender
Normal tone and power in legs
Urine dip negative
Alert and interactive
Capillary refill < 2 secs
No pallor, does not look underweight
Height 95cm, weight 17kg
Abdomen soft non tender
Normal tone and power in legs
Urine dip negative
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation. Excludes red flag symptoms Identifies abnormal findings or results and/or recognises their implications. Asks about physical and psychological aspects of enuresis Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Discusses possible causes of enuresis and simple strategies to treat symptoms initially. Discusses plans and strategies should initial treatments fail Makes appropriate prescribing decisions Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Inappropriately influences patient interaction through own views/values Quick to judge |
Management
Explanation: Bedwetting at night is very common, and although most parents expect their children to be dry by age 3, it is still considered normal under the age of 5. Sometimes there is no obvious reason why it happens, but common factors include any form of stress, excess fluids especially caffeine or fizzy drinks, and constipation. The vast majority of children will become dry by the age of 5, and there is a lot of help and advice to encourage them. As a parent, it is important to remember it is not your child’s fault, and to give them plenty of reassurance.
Nocturnal enuresis actually refers to involuntary bed wetting at least twice a week, in a child older than 5. However it is generally used to describe bed wetting at any age. In your history, it is crucial to establish whether it is primary (the child has never had night time continence) or secondary (a previously continent child). In addition to the causes described above, children sometimes do not wake to the sensation of a full bladder. It can run in families. Try and find the pattern of bedwetting, the daily fluid intake, and what happens at night (is the child punished?). Sometimes a diary is useful to monitor what is happening with these factors. Look for stressors - things like changes in the family unit, school problems, bullying etc.
You should carry out urinalysis to exclude infection and glycosuria, with subsequent tests as necessary. A lot of the management involves behavioural therapy - are the family willing to try this? Offer some general advice about fluid intake, reassurance, and lifting and waking at night. Reward systems are very useful but often misunderstood - in a child who wets the bed regularly, there is little point offering a reward for a dry night. Start with rewards for having the recommended amount of fluid in the day, or going to the toilet before bed, or waking up and helping to change the sheets - basically make it achievable so you are actually giving the child encouragement.
Enuresis alarms are considered first line if the child is over 7 - the child sleeps on a sensor pad which sounds if the pad becomes wet. Alarms can be bought for between £50 and £100, or borrowed from Education and Resources for Improving Childhood Continence, telephone 0845 370 8008, www.eric.org.uk. Alternatively if you are referring to an enuresis clinic or service, they can usually be obtained there.
In primary care, desmopressin should be used with caution and for short term events, like a sleepover or holiday. It works by reducing urine production at night, so starting with a low dose, take before bed and ensure sips of fluid only from one hour before to 8 hours after. This avoids the potentially serious problem of hyponatraemia.
Primary and secondary nocturnal enuresis can be initially managed the same way in general practice. Refer if you suspect an underlying cause such as UTI or diabetes, or even psychological problems and failure of conservative measures.
Nocturnal enuresis actually refers to involuntary bed wetting at least twice a week, in a child older than 5. However it is generally used to describe bed wetting at any age. In your history, it is crucial to establish whether it is primary (the child has never had night time continence) or secondary (a previously continent child). In addition to the causes described above, children sometimes do not wake to the sensation of a full bladder. It can run in families. Try and find the pattern of bedwetting, the daily fluid intake, and what happens at night (is the child punished?). Sometimes a diary is useful to monitor what is happening with these factors. Look for stressors - things like changes in the family unit, school problems, bullying etc.
You should carry out urinalysis to exclude infection and glycosuria, with subsequent tests as necessary. A lot of the management involves behavioural therapy - are the family willing to try this? Offer some general advice about fluid intake, reassurance, and lifting and waking at night. Reward systems are very useful but often misunderstood - in a child who wets the bed regularly, there is little point offering a reward for a dry night. Start with rewards for having the recommended amount of fluid in the day, or going to the toilet before bed, or waking up and helping to change the sheets - basically make it achievable so you are actually giving the child encouragement.
Enuresis alarms are considered first line if the child is over 7 - the child sleeps on a sensor pad which sounds if the pad becomes wet. Alarms can be bought for between £50 and £100, or borrowed from Education and Resources for Improving Childhood Continence, telephone 0845 370 8008, www.eric.org.uk. Alternatively if you are referring to an enuresis clinic or service, they can usually be obtained there.
In primary care, desmopressin should be used with caution and for short term events, like a sleepover or holiday. It works by reducing urine production at night, so starting with a low dose, take before bed and ensure sips of fluid only from one hour before to 8 hours after. This avoids the potentially serious problem of hyponatraemia.
Primary and secondary nocturnal enuresis can be initially managed the same way in general practice. Refer if you suspect an underlying cause such as UTI or diabetes, or even psychological problems and failure of conservative measures.