Station 36

Adam Leatherhead

Age: 6 years old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis 

  • Ask if the child has ever been dry at night and clarify the onset of bedwetting (e.g. new onset or ongoing since infancy. Note that secondary bedwetting refers to the return of nighttime wetting after a child has been dry at night for more than six months). 
  • Ask about the frequency of bedwetting, including whether it occurs every night or only some nights, and whether the child wakes up after wetting the bed.
  • Ask if the child has any daytime urinary symptoms and explore the following: Daytime wetting or urgency – may suggest urinary tract infection (UTI) or bladder overactivity. Increased frequency of urination – could indicate diabetes or UTI. Infrequent urination (fewer than four times a day) – may suggest urinary retention or obstruction
  • Ask about symptoms suggestive of diabetes, including excessive thirst (polydipsia), increased hunger (polyphagia), and weight loss or weight gain.
  • Ask if the child is toilet trained; if not, explore the reasons why.
  • Ask about fluid intake, including whether the parents restrict fluids in an attempt to manage bedwetting, and explore consumption of fizzy drinks or caffeine-containing beverages.
  • Ask about bowel habits, specifically constipation, as this can contribute to urinary incontinence.
  • Ask about psychological or emotional factors, such as any recent changes in circumstances (e.g. change of school, house move, bereavement, divorce of parents), or concerns about bullying or stress.
  • Ask about the home environment, including whether the child sleeps alone or shares a room, and if there is easy access to the toilet during the night.
  • Ask about any family history of bedwetting.
  • Ask how the bedwetting has affected the child’s confidence and emotional well-being, and how it has impacted the family as a whole.
  • Ask about symptoms of PBIND (Pregnancy, Birth, Immunization, Nutrition and Development) 
  • Make a diagnosis of Secondary Enuresis 

Example of explanation to patient​

Mrs Leatherhead, from everything you’ve described and what we know so far, it sounds like Adam has a condition called enuresis, which is the medical term for bedwetting. In Adam’s case, this is called secondary enuresis because he had previously been dry at night for some time and has now started wetting the bed again.

I want to reassure you that this is not Adam’s fault. Bedwetting happens because the amount of urine produced during the night can sometimes exceed what the bladder can hold, and in some children, the sensation of a full bladder doesn’t fully wake them up in time to get to the toilet.

One important factor in Adam’s case is his constipation. When a child has a build-up of stool in the bowel, it can press on the bladder, which makes it harder to control urine — especially at night. So, in many children, treating the constipation can significantly help reduce or even stop the bedwetting.

You mentioned diabetes, and that’s a very valid concern — you’re absolutely right that diabetes can cause children to urinate more frequently, which in turn can contribute to bedwetting. However, based on what you’ve told me, Adam doesn’t seem to have some of the typical symptoms of diabetes, such as frequent daytime urination, weight loss or gain, or increased appetite.

That said, I think it would be a good idea to see him face-to-face, so I can examine his tummy, and also check a urine sample to look for any signs of infection or sugar, which might suggest a concern like diabetes. If you’re happy to, we can also do a simple blood test to check his blood sugar levels for extra reassurance.

Management

  • Offer a face-to-face appointment to examine the child’s abdomen, assess for signs of constipation or faecal impaction, and evaluate general wellbeing.
  • Arrange investigations, including urinalysis to check for signs of urinary tract infection or the presence of glucose, which may suggest diabetes.
  • You may also offer a blood glucose test to assess for possible underlying diabetes, especially in light of parental concern and family history.
  • Advise the parent to keep a 2-week diary recording the child’s fluid intake, toileting habits, and bedwetting episodes, to help identify patterns and monitor progress.
  • Continue managing constipation, which may include increasing the dose of Movicol to achieve regular, soft, formed stools. Provide dietary advice to increase fibre and fluid intake, and advise to limit fizzy drinks, as they may irritate the bladder and worsen symptoms.
  • Offer an enuresis alarm as a treatment for bedwetting, explaining that it works by waking the child as soon as they begin to urinate, helping to retrain the brain to respond to a full bladder at night. Alarms come in various formats, including a sensor attached to the underwear that triggers a sound when moisture is detected or a sensor pad placed under the bedsheet connected to a noise box, and vibrating alarms, which are suitable for children who share a room or have hearing difficulties.
  • Advise using a positive reward system, tailored to the child’s age, to encourage engagement with bedwetting management. Rewards can be given for behaviours such as having dry nights, drinking appropriate amounts of fluid during the day, using the toilet before bed, or taking part in management tasks (e.g. taking medication, helping to change sheets). Emphasise that punishable approaches or removing earned rewards are not recommended, as they can negatively impact the child’s self-esteem.
  • Inform the parent that enuresis alarms can be borrowed through the ERIC charity website
  • Provide a leaflet on bedwetting, including reliable online resources such as the ERIC website
  • Offer follow-up in 2–3 weeks to review progress with constipation management, assess the effectiveness of any behavioural strategies or enuresis alarm use, and discuss results of any completed investigations.

Learning point from this station: ​

Bedwetting (enuresis) can be classified into three main types, each with different underlying causes and management considerations:

  • Primary bedwetting without daytime symptoms: The child has never achieved sustained nighttime dryness and has no daytime urinary symptoms. This is commonly related to sleep arousal difficulties, night-time polyuria, or bladder dysfunction.
  • Primary bedwetting with daytime symptoms: The child has never been dry at night and also has daytime urinary symptoms, such as wetting, urgency, or frequency. Potential causes include an overactive bladder, chronic constipation, UTI, neurological conditions, or congenital abnormalities.
  • Secondary bedwetting: The child previously achieved dryness at night for at least 6 months but has relapsed. This is typically due to an underlying trigger such as diabetes, UTI, constipation, emotional or psychological distress, or family-related stressors.

It is essential to identify and address any underlying cause where possible. Many cases can be safely managed in primary care, particularly if there are no red flags.

Although bedwetting is generally considered normal in children under the age of five, children over 2 years old who are beginning to show awareness of toileting behaviours but are still struggling with both daytime and nighttime wetting may require further assessment and investigation to rule out an underlying medical condition.

Further reading