Nocturnal Enuresis & Cryptorchidism: MSRA High-Yield
- examiner mla
- Jul 9
- 3 min read
🔷 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
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