Nocturnal Enuresis & Cryptorchidism: MSRA High-Yield

Practice a case with the AI patient 🤖

🔷 Nocturnal Enuresis (Bedwetting)

Definition

• Enuresis: Involuntary urination by day or night in a child ≥5 years, without congenital or acquired defects of the nervous system or urinary tract.

Classification

✅ Primary enuresis

• Never been dry before.

✅ Secondary enuresis

• Relapse after ≥6 months of dryness.

Primary Enuresis Without Daytime Symptoms (Most Common)

🔑 Mechanisms:

• Sleep arousal difficulties

• Nocturnal polyuria (↓ADH secretion)

• Bladder dysfunction (small capacity or overactivity; significant dysfunction usually causes daytime symptoms too).

Primary Enuresis With Daytime Symptoms

• Urgency, frequency (overactive bladder)

• UTI

• Constipation

• Structural abnormalities (e.g. ectopic ureter)

• Neurological disorders (e.g. neurogenic bladder, spinal dysraphism)

🔷 Secondary Enuresis Causes

✅ Emotional upset / child abuse

✅ UTI

✅ Diabetes Mellitus (polyuria, polydipsia, weight loss)

✅ Constipation

✅ Threadworm infestation

🔷 Management Summary (NICE Guidelines)

If WITH Daytime Symptoms

• Refer to secondary care / enuresis clinic for assessment.

If WITHOUT Daytime Symptoms

✅ <5 years

• Reassure (continence often develops with age).

✅ ≥5 years

• Infrequent (<2 times/week): Reassure.

• Frequent (≥2 times/week):

  • First-line (long-term): Enuresis alarm + reward system.

  • Short-term control (e.g. camps) or >7 years: Desmopressin.

🔴 Persistent enuresis after 2 complete treatment courses (alarm + desmopressin): Refer to secondary care.

Additional Key Points

✔ Alarm therapy course = up to 3 months or until 14 consecutive dry nights.

✔ Desmopressin course = ~3 months, then trial off to assess recurrence.

✔ Reward systems: Reward behaviour (e.g. toilet use before bed), not merely dry nights.

🔑 MSRA Clinchers for Nocturnal Enuresis

✔ Primary = never dry

✔ Secondary = dry ≥6 months then relapse

✔ Alarm = first-line long-term control

✔ Desmopressin = first-line short-term control or >7 years

✔ New enuresis + polydipsia + weight loss = check glucose urgently (DM)

✔ Constipation = common hidden cause

🔷 Cryptorchidism (Undescended Testis)

Definition

• Failure of one or both testes to descend into the scrotum.

Incidence

• ~3% term males, up to 30% preterm males (prematurity = major risk factor).

🔷 Types

✅ True undescended testis: Along normal path (inguinal canal, abdomen).

✅ Ectopic testis: Deviates from descent path (perineum, femoral).

✅ Retractile testis: Normal testis pulled up by cremasteric reflex; not true cryptorchidism, no surgery needed but monitor annually.

🔷 Risk Factors

✔ Family history

✔ Low birth weight / SGA

✔ Prematurity

✔ Associated genetic abnormalities (e.g. hypospadias, androgen insensitivity syndrome)

🔷 Complications

✅ Testicular cancer (↑ risk, especially seminoma)

✅ Infertility (due to germ cell damage)

✅ Testicular torsion

✅ Inguinal hernia

✅ Surgical complications (vascular injury)

🔷 Screening (UK Guidelines)

✔ Initial check within 72 hours of birth

✔ Recheck at 6-8 weeks baby check

🔷 Management

Unilateral Undescended Testis

• Re-examine at 4-5 months.

• If still undescended by 6 months:

  • Refer to paediatric surgery/urology for orchidopexy, ideally by 12 months (max by 18 months).

Bilateral Undescended Testes or Hypospadias (Suspected DSD)

• Urgent referral within 24 hours to paediatrics/endocrinology/genetics for DSD evaluation.

🔷 Hormonal Therapy

🔴 Not recommended in UK (e.g. hCG therapy is ineffective)

🔷 Advice & Follow-Up

✔ Testicular self-examination post-puberty (cancer surveillance)

✔ Counselling for parents/carers

🔑 MSRA Clinchers for Cryptorchidism

✔ Prematurity = major risk factor

✔ Retractile testis = no surgery, annual monitoring

✔ Bilateral undescended + hypospadias = urgent DSD evaluation within 24 hours

✔ Orchidopexy ideally between 6-12 months (max by 18 months)

✔ Cancer risk remains increased post-orchidopexy

✔ No role for hormonal therapy (hCG) in UK guidelines

🔷 What is DSD?

✅ DSD = Disorders (Differences) of Sexual Development

• Congenital conditions with atypical chromosomal, gonadal, or anatomical sex development.

✔ Examples:

• Androgen insensitivity syndrome (46,XY)

• Congenital adrenal hyperplasia (46,XX)

• 5-alpha reductase deficiency

📝 Final Tips for MSRA

✅ Memorise definitions, first-line treatments, and urgent referral criteria.

✅ Practice scenario-based questions focusing on management steps and underlying causes.

✅ Understand timing of referrals and surgeries for cryptorchidism.

📌 Rapid Recall

✔ Enuresis alarm = long-term control

✔ Desmopressin = short-term control / >7 years

✔ Orchidopexy by 12 months

✔ Bilateral undescended testes + hypospadias → urgent DSD evaluation

✔ Prematurity = strongest risk factor for cryptorchidism

📚 References

• https://www.nice.org.uk/guidance/cg111

• https://patient.info/childrens-health/bedwetting-nocturnal-enuresis

• https://www.nhs.uk/symptoms/bedwetting/

• https://www.nhs.uk/conditions/undescended-testicles/

• https://www.auanet.org/guidelines-and-quality/guidelines/cryptorchidism-guideline