Station 36
Adam Leatherhead
Age: 6 years old male
Full Case
Patient’s Data
Patient’s name: Adam Leatherhead
Age: 6-year-old-male
Past medical history
- Bronchiolitis at 1 year of age
Drug and Allergy History
- No known drug allergy
- Movicol – 2 sachets daily for constipation (Acute prescription)
Alerts and QOFs
- Up to date with immunization
Recent notes/consultation
Seen by Mrs Penelope Brinkman (Nurse Access role) 6 months ago
Presenting Complaint: Mother reports constipation in patient
Examination: Abdomen soft, non-tender and no masses. Heart rate: 109bpm, Temp 36.5
Plan: trial of Movicol-2 sachets daily. Encourage fibre diet, Worsening advice given
Mother, Ruby Leatherhead, has booked a telephone appointment to discuss concerns regarding
Patient's Story (Role player’s brief)
Patient’s Story
You are Ruby Leatherhead, the mother of 6-year-old Adam, and you’re calling today because you’ve noticed that Adam has started wetting the bed over the past 3 months.
If asked for more detail:
- Adam wets the bed almost every night, typically 3–4 times a week, and this has been going on for the last 3 months.
- He had been fully dry at night since the age of 4, so this change is causing you some concern.
Only disclose the following information if specifically asked:
Adam sometimes wakes up after wetting the bed, but not always. He has had constipation for the last 6 months and was prescribed Movicol (2 sachets daily), which he still takes. Despite this, he still strains occasionally and passes hard stools.
His diet is poor, with frequent junk food (e.g. McDonald’s) and fizzy drinks. You’ve tried to encourage healthier eating, but he strongly prefers these foods.
Adam passes urine normally during the day. No daytime wetting, pain, or blood in the urine. He is fully toilet trained. You have not noticed any weight changes
Social History: Adam lives at home with you (his mother), his father, and his older brother. He shares a bedroom with his 10-year-old brother, but they sleep in separate bunk beds. The bedroom is close to the bathroom. No issues at school or home, and no concerns about bullying. Adam is generally happy, active, and plays well. You don’t blame him, but you suspect something may be wrong.
Birth and developmental history are unremarkable: normal pregnancy, vaginal delivery, and up to date with immunisations.
Idea/Concern: If asked what you think might be causing the bedwetting, you are worried it could be diabetes, especially since Adam’s father was diagnosed with Type 1 diabetes as a child with similar symptoms.
Expectation: You would like the doctor to test Adam for diabetes.
Say NO to any other questions/symptoms asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Special Instructions for Role Player:
If the doctor offers an enuresis alarm, ask: “How does that work?”
Then mention: “He shares a room with his older brother, wouldn’t that also disturb the brother’s sleep?
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
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.