Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

3. Cardiopulmonary

4. GI

5. GU
--UTIs and Vesicoureteral Reflux
--Practice Parameter for UTI under age 2 years
--Nocturnal Enuresis

Daytime Enuresis

Definition: Enuresis that occurs either during daytime only or both during day and night.

Differential Diagnosis of Daytime Enuresis:

1. Urinary Tract Infection: Not always associated with dysuria, frequency etc. Seen more often with cystitis (bacterial, viral) than with upper tract involvement.

2. Emotional Issues: most often seen in our clinics, these issues are often quite apparent.  In practice the causes of emotional turmoil may need to be sought. Often can be a regression symptom (new sibling born, recent death, move etc)

3. Urethritis without UTI: Seen in both males and females: Differential dx must include:

1. bubble bath or soap
2. self-instrumentation
3. *pinworms: can occur with no other symptoms of rectal itching, vaginal discharge, abdominal pain.
4. dietary issues: some think that carbonated drinks an issue.
5. “non-specific urethritis?”: organism may be related to this entity.

4. Habit: waiting too long to go to the bathroom, being unaware of need to go, etc.

5. Neurological disorder: differential to include:

1. spina bifida, tethered cord, urorectal abnormalities
2. neurodynamic problem to the bladder (requires urology workup)

6. Polyuria: seen mostly with increased intake of fluid, but also can be seen in diabetes.  Not usually associated with enuresis.          

Workup of daytime enuresis:

1. UA and urine culture on all children no matter which of above causes apparent
2. If vaginitis: treat condition and possible predisposing condition (eg pinworms)
3. If treatment doesn’t work, or if underlying neurological disorder, must refer to urologist for urodynamic studies.

Treatment of daytime enuresis:

1. Behavioral approach: star charts, positive reward systems
   Approach: try to get to go longer between bathroom trips-?  bladder training
2. If above fails, can consider anticholinergic meds (eg oxybutynin, terodiline); however, usually need urodynamic studies by urologist first. Useful in children with small bladder capacity.
3. Treat UTI, pinworm, etc if find the cause.
4. Alarm can be used in the daytime as well if necessary
5. If no cause and symptoms persist, consider psychol. referral.

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004