A 4-year-old male came to clinic with a 1 week history of daytime enuresis. He was toilet trained for urine during the day for 9 months and used diapers at night. Over the past week his babysitter and family noticed that he would be playing, then ran for the bathroom but often would have urinary incontinence. He denied dysuria. Parents denied constipation, but did say that he was urinating more frequently and seemed to be drinking more for the past 3 weeks. The past medical history showed a healthy male. The family history was positive for type 2 diabetes mellitus and hypothyroidism. The social history revealed that his mother had recently returned from a military deployment. The review of systems showed no weight loss, nausea, emesis, or fever. The family denied concerns of abuse.
The pertinent physical exam showed a well appearing male with normal vital signs. His growth parameters were 50-75%. His weight was 16.4 kilograms which was the same as 6 months previously. His mucous membranes appeared slightly dry. The work-up showed a urine dipstick with large ketones and glucose. His glucometer reading was 434 mg/dl and a true glucose was later 612 mg/dl and his hemoglobin A1c was 8.1 %. Thyroid studies were eventually normal. The diagnosis of new onset type 1 diabetes mellitus was made. The patient’s clinical course had him admitted to the hospital where he was started on an insulin drip, and he was later changed to insulin injections and scheduled meals and snacks. His parents and grandparents were educated regarding daily management including common problems such as toddler/preschoolers refusing to eat, management during intercurrent illnesses and emergency treatment for hypoglycemia.
Type 1 diabetes mellitus or insulin-dependent diabetes mellitus (DM) is a chronic metabolic disorder caused by the lack of insulin. Langerhans cells in the pancreas make insulin and congenital absence or destruction of the cells produces DM where patients are dependent on exogenous insulin. An estimated 3/1000 children develop DM by age 20. Overall there is an incidence of 15/100,000 annually for DM.
Insulin and diet treatment is necessary but needs to be tailored to the individual. Intercurrent illnesses also require special treatment so patients do not progress to ketoacidosis. To read more about intercurrent illness treatment click here. Patients can also have long-term side effects of their diabetes including other endocrinopathies/autoimmune diseases, growth problems and retinopathy. Endocrinopathies are generally screened for yearly and growth is monitored closely during regular diabetes and well-child care follow-up. Yearly retinopathy screening generally starts ~5 years after diagnosis.
Primary nocturnal enuresis is a common developmental problem in children that improves overtime. Although organic causes can present with primary nocturnal enuresis, these more commonly present with diurnal or daytime enuresis. Secondary diurnal enuresis should raise the clinicians suspicion for further history, careful physical examination, evaluation and management.
Primary enuresis is defined as a child who has never gained urinary control, and secondary enuresis is a child who has gained control and how does not have control. Click on the links to learn more about bladder dysfunction and primary nocturnal enuresis.
The causes of diurnal enuresis include:
- Increased urine output
- Excessive water intake
- Diabetes mellitus
- Diabetes insipidus
- Sickle cell anemia
- Structural problems
- Ectopic ureter
- Vesicle sphincter dyssynergy
- Labial adhesions
- Vaginal reflux
- Meatal stenosis
- Posterior urethral valves
- Bladder instability or decreased size
- Bladder spasm
- Urinary tract infection
- Neurological problems
- Spinal cord abnormalities
- Sphincter weakness
- Sexual abuse
- Central nervous system or developmental anomalies
- Foreign body
- Food sensitivities
- Irritation – i.e. soaps, bubble bath, tight undergarments
- Inattention to normal voiding signals – i.e. not paying attention to need to void until too late to void in toilet
- Stress incontinence (often associated with large bladder capacity)
Questions for Further Discussion
1. What treatments are available for primary nocturnal enuresis?
2. What multiple endocrinopathy syndromes is diabetes associated with?
3. What are the indications for a urology consultation for diurnal enuresis?
4. What workup should be considered for diurnal enuresis?
- Disease: Diurnal Enuresis | Toilet Training and Bedwetting | Juvenile Diabetes
- Symptom/Presentation: Enuresis and Urinary Incontinence | Failure to Thrive and Lack of Normal Physiologic Growth
- Specialty: Endocrinology | General Pediatrics | Nephrology / Urology
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Type 1 Diabetes and Bedwetting.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Cooper CS, Nepple KG, Hellerstein S, Glassock EL. Voiding Dysfunction. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/1016198-overview (rev. 6/24/08, cited 1/5/10).
Lui P. Urinary Incontinance. Merck Manual.
Available from the Internet at http://www.merck.com/mmpe/sec17/ch228/ch228b.html#sec17-ch228-ch228b-344 (rev. 3/08, cited 1/5/10).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital