Toilet training and elimination behaviour — branching viva

Stem

You are in clinic with a 7-year-old and parents. They report frequent night wetting, stained underwear and large hard stools. They want to punish wet nights and ask for a tablet before camp. ^{[1] [11]}

Examiner: How do you open this consultation? ^[1]

Strong answer: Without blame. Name that wetting and soiling are common and usually involuntary. Stop punishment first, then assess phenotype, constipation and red flags. ^{[1] [13]}

Examiner: Classify the likely continence phenotype. ^{[2] [3]}

Strong answer: Primary nocturnal enuresis — if no significant daytime LUTS this is MNE by ICCS language — plus retentive encopresis with constipation and overflow. Age thresholds are met (enuresis ≥5, encopresis ≥4). ^{[2] [3] [11]}

Examiner: What is the enuresis triad? ^[13]

Strong answer: Nocturnal polyuria, reduced nocturnal bladder capacity or overactivity, and impaired arousal from sleep. Children load differently on these factors. ^{[2] [13]}

Examiner: Why treat the bowel before or with the bedwetting plan? ^[9]

Strong answer: Rectal loading drives overflow soiling and can compress the bladder (bowel–bladder axis). Clearing constipation often improves urinary symptoms and treatment adherence. ^{[9] [11]}

Examiner: Alarm versus desmopressin — when each? ^{[4] [5] [6]}

Strong answer: Alarm for durable cure when family is ready. Desmopressin for short-term dryness (camp/sleepover) or when alarm is unsuitable, failed or refused. Desmopressin usually works only while taken. ^{[4] [5] [6]}