Phone call

You are speaking to Mrs. Green (mother)

Personal Details:

Name: Tom Green

Age: 6

Medical Record:

Past medical history:

No significant past medical history.

Up-to-date with immunizations.

Regular medication: None.

Allergies: None known.

Opening Sentence:

“Doctor, my son, Tom, has started wetting the bed again, and I don’t know what to do”

Open History (to give freely):

Was reliably dry at night from the age of 4. However, about 3 months ago, he started having accidents again, and now it’s almost every other night.

She’s tried limiting fluids before bed, waking him up to go to the toilet, and even star charts, but nothing seems to work.

Cues to give:

Cue to give “It’s been a big adjustment for him” (if this was picked up or if asked about changes at home): “Well, we did move house about 4 months ago, and he started a new school at the same time. It’s been a big adjustment for him.”

ICE:

Ideas:  You don’t understand why he started wetting the bed again

Concerns: I’m worried about him going to sleepovers, and it’s affecting his confidence. I also worry if there’s something medically wrong with him.

She’s worried about the impact on his self-esteem and the practicalities of constantly changing bedding. Tom himself might be a bit withdrawn and embarrassed.

Expectation: I was hoping you could give him some advice, or maybe some medication to stop it. I just want it to stop.”

How to Act:

Mrs. Green should be tired and frustrated, but loving towards her son.

More History (only if asked):

·       He has been dry since he was 4 years old, but started wetting his bed again in the last three months, nearly every other night.

·       Daytime symptoms: He didn’t have any accidents during the day, but he sometimes rushes to the toilet during the day, and occasionally has a little dribble if he leaves it too long, but he’s generally dry during the day.

·       He loves juice and fizzy drinks, and I probably let him have too much sometimes, especially after school.

·       He always had constipation, but he used to open his bowels every day. However, in the last 2-3 months, he has only opened his bowels once every other day on average.

·       He is very fussy with food. Doesn’t like green or vegetables.  

·       He is growing well, eating well.

·       No polyuria/polydipsia (drinking more than usual and passing urine more than usual), no dysuria (painful urination).

Social History:

School: Started a new school 3 months ago.

Home situation: Recently moved house.

Family: Lives with both parents and a younger sister.

Questions to ask:

“Does he need blood tests or a scan?”

“Is there a medication he can take?”

EXAMPLE CONSULTATION SCRIPT

Explain the situation, the likely diagnosis or DD, and manage ICE:

I understand how frustrating and worrying this must be for both of you, especially since Tom was dry for so long. I know it could be embarrassing, but it’s really common for children your age to start wetting the bed again, and it’s definitely not his fault.

It’s called secondary nocturnal enuresis, and it means he was dry for at least six months and has now started wetting again.

It’s very unlikely to be a serious medical problem as he’s generally well and doesn’t have any other concerning symptoms that would suggest something serious. Often, it’s a combination of factors. Moving house and starting a new school are big changes, and stress can definitely play a part.

Also, sometimes children just haven’t fully developed the ability to wake up when their bladder is full, or their bladder might be a bit overactive at night. We also need to consider if constipation is playing a role, as a full bowel can press on the bladder.

Next Steps:

Would it be possible for me to see him in the clinic to examine him?  I’d like to check a urine sample to rule out a urinary tract infection, as that can sometimes cause bedwetting. I would also book him for a finger-prick test with one of the nurses to check his blood sugar.

Self-help measure:

There are things which you and Tom can do to help improve his bladder control.

·       Fluid intake: Encourage Tom to drink plenty of fluids in the morning and throughout the day, but try to reduce drinks, especially fizzy ones, in the hour or two before bedtime, and don’t restrict fluids during the day.

·       Regular toilet habits: Make sure Tom goes to the toilet regularly during the day, about 5-7 times, and always just before bed. Ensure he empties his bladder fully each time.

·       Constipation: From what you have said, I don’t think that this is a major factor, but it may be contributing a bit. Trying to increase the amount of vegetables and roughage he eats is important- there is lots of advice on the internet around ‘hiding’ vegetables in other recipes for fussy eaters. If he is really struggling with this, we could trial a specific medication to help his bowels at a future date.

·       Avoid punishment: It’s really important not to punish or blame Tom for wetting the bed. It’s not his fault, and it can make him feel worse and delay progress.

·       Star charts/rewards: Continue with a positive reward system for dry nights, or for following the steps (e.g., going to the toilet before bed).

·       Practical measures: Use waterproof mattress protectors. Involve Tom in changing wet bedding, but in a supportive, non-punitive way.

·       Stress management: Talk to Tom about any worries he might have about the new school or house. Reassure him that it’s okay to feel a bit anxious and that these feelings can sometimes affect his body.

Other treatment options.

Given the recent move and new school, stress may be a significant factor. We need to be patient and supportive. If these initial measures don’t work after a few weeks, we can consider other options, such as a bedwetting alarm, which can be very effective in teaching the brain to wake up to a full bladder. If he shares a room with his younger sister, he can use a vibrating alarm which only wakes him up without disturbing anyone else in the room. I can send information about a charity called Eric, which can support you to hire one for a period of time.

Medication is usually a last resort, which could be considered if we are not getting this better, or if he has an important event coming like a school trip. It is called desmopressin, which works by reducing the amount of urine produced overnight. He can take it in the evening, and he should stop fluid intake one hour before it till the next morning. He can start using it now to make sure it is working before his planned school trip date. 

Any other management:

I’ll provide you with some patient information leaflets on bedwetting and a bladder diary to complete for a few days. This will help us understand his fluid intake and toilet habits better. We’ll review you in about 4-6 weeks to see how things are progressing. Please come back sooner if you have any new concerns, or if Tom develops any pain when passing urine, or starts wetting himself during the day.

Management objective

Important areas in data gathering:

·       Onset of enuresis: Primary (never dry) vs. secondary (previously dry for >6 months). Frequency and volume of wetting. Daytime symptoms: Urgency, frequency, daytime wetting, dysuria, straining, holding manoeuvres.

·       Fluid intake: Type and volume, especially evening intake.

·       Bowel habits: Constipation (frequency, consistency, pain with defecation).

·       Psychosocial factors: Recent stressors (house move, new school, family changes, bullying).

·       Developmental history.

·       Family history of enuresis.

·       Red flags: Polyuria/polydipsia, recurrent UTIs, weak stream, neurological symptoms, faecal soiling.

Management highlights

·       This scenario is testing the candidate's ability to differentiate primary from secondary enuresis: Understand the significance of a child who was previously dry starting to wet the bed again.

·       Rule out underlying medical causes: Systematically inquire about red flag symptoms for UTIs, diabetes, constipation, and other organic causes.

·       Provide sensitive and supportive communication: Address the child’s embarrassment and the parent’s frustration without blame.

·       Educate on common causes: Explain the multifactorial nature of bedwetting, including stress and developmental factors.

·       Implement initial conservative management: Advise on fluid management, regular toileting, and addressing constipation.

·       Follow-up: Arrange a review to monitor progress and discuss further options (e.g., alarms) if needed.

·       Safety netting: Advise on when to seek further medical attention or if new symptoms develop.

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