128 A.M. Behr

12.1.5.4  Food Sensitivity

Diet may also play a role in enuresis. Although scientific evidence showing a relationship between diet and nighttime wetting is lacking, anecdotal data demonstrate that avoiding certain foods and beverages can decrease wetting. For instance, dairy products like milk or ice cream contain tryptophan, the amino acid that produces serotonin, which slows down nerve traffic in the brain and may lead to decreased sleep arousal. Other foods may stimulate urine production, like carbonated and caffeinated beverages, citrus fruits and drinks, melons, licorice and Vitamin C. Bladder irritants, like spicy foods, can cause the bladder to contract more often, signaling the need to void. Therefore, the presence of these foods in a child’s diet may cause more bladder contractions that can lead to nocturia or enuresis.

12.2  Investigations

12.2.1  History

A thorough history is essential in the evaluation of enuresis. Most school-aged children can give a good school-day history of voiding. For those families who are not reliably accurate, a more objective measure is the voiding diary. The voiding diary is a tool kept by the parents to assess the time and volume of voids and their association with certain events, such as incontinence episodes, urgency, bowel movements, and play or distraction activities. The history should also include screening for symptoms like cystitis and constipation, since both are associated with reduced bladder capacity. Parents are often unaware of their child’s bowel habits once they reach school age and children should be directly interviewed about the amount and consistency of stool, the frequency of bowel movements, and any pain or soiling.

A history of soaking undergarments and sheets suggests nocturnal polyuria. A daily diet and fluid intake can be

helpful in this instance. Many children do not get adequate amounts of fluid during the school day and some purposefully dehydrate themselves to prevent daytime incontinence episodes. These children will compensate once they arrive home and through the evening, which leads to a higher nighttime production of urine.

12.2.2  Physical Examination

The physical examination should focus on the bladder and bowel and include assessment of the genital and neurological systems. The abdomen should be palpated for stool and bladder distention. The spine should be examined for any cutaneous defects, including sacral dimples off the midline or above the gluteal cleft, hair tufts or pigmentation. Genitals should be evaluated for abnormalities (ie., urethral position, meatal stenosis, adhesions, and signs of abuse or trauma). The urine stream should be observed if it sounds abnormal by history. A digital rectal exam could be performed if the history is consistent with encopresis or constipation, although this is very rarely needed, as the history is usually sufficient. The anus should be evaluated for sphincteric reflex. Assessment of strength, tone, reflexes and sensation should be performed for possibility of neurogenic bladder.

12.2.3  Laboratory Tests

A urinalysis should be conducted in every child with enuresis. This study will help to evaluate for glycosuria in clinical diabetes mellitus. Specific gravity should be assessed to rule out diabetes insipidus or low fluid intake. If symptoms of UTI are present or if the urine is malodorous, a urine culture should also be performed, especially if the urinalysis contains nitrites, leukocyte esterase, or the patient has a history of UTI.