Question

A 7-year-old boy is brought to the office by his mother because of a 1-month history of urinary incontinence. During this time, he also has passed occasional hard, painful stools. He has not had pain with urination or changes in appetite. He has had occasional episodes of daytime enuresis at school since he was toilet trained at the age of 4 years; until last month, these episodes were rare. He has wet the bed four times weekly during the past month. His mother cannot identify any new stressors at home. He has no history of serious illness and receives no medications. Vaccinations are up-to-date. He receives grades of A's in school. He is at the 25th percentile for height and weight and 35th percentile for BMI. Vital signs are within normal limits. Examination shows no abnormalities. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

A) Administration of an osmotic laxative

B) Desmopressin therapy

C) Recommendation for use of a bed-wetting alarm

D) Renal ultrasonography

E) Reassurance that this is normal behavior

Correct Answer 🧠 Administration of an osmotic laxative (e.g., polyethylene glycol):

• Relieves rectal distension, decompresses bladder, and restores normal bladder function.

Clinical Scenario:

• 7-year-old boy with recent urinary incontinence

• Hard, painful stools → Constipation🧠

🧠 Chronic constipation (↓ stool frequency, hard stools)
⬇️
Rectal distension due to stool impaction
⬇️
Compression of bladder neck & urethra
⬇️
🧠 Incomplete bladder emptying
⬇️
Urinary stasis → overflow incontinence (daytime enuresis, nocturnal bedwetting)
⬇️
↑ Bladder pressure → detrusor instability
⬇️
Urinary urgency, frequency, or additional leakage

Explanation of Other Answers

Option B: Desmopressin Therapy

• Not indicated as primary treatment since enuresis is likely secondary to constipation rather than primary nocturnal enuresis.

• 🧠 Desmopressin is typically for enuresis unrelated to bladder pressure or constipation.

Option C: Bed-wetting Alarm

• Used for primary nocturnal enuresis; doesn’t address constipation-induced bladder pressure.

• Ineffective if incontinence is due to functional constipation.

Option D: Renal Ultrasonography

• Not required without signs of renal or anatomical abnormalities.

• Urinalysis is normal, ruling out urinary infection or structural issue.

Option E: Reassurance

• While this could address mild enuresis, it does not treat the underlying constipation.

Flashcards

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