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PUID: 62 || PLAB 2 Mock 5 :: Challenging Parenting 5: Primary Nocturnal Enuresis


Summary

  • A parent presents worried about their 3-year-old’s bedwetting. This is primary nocturnal enuresis (PNE)—a normal developmental stage where nighttime bladder control has not yet been attained; most children achieve dryness by about age 5. Your role is to normalise, screen briefly for red flags, and offer behavioural conditioning strategies first (alarms/reward charts), with follow-up.



Key Points


Definitions & Classification

  • Primary nocturnal enuresis (PNE): Child has never achieved a sustained period of nighttime dryness.

  • Secondary enuresis: Child had a period of dryness and then relapsed → prompts broader search for causes (e.g., UTI, constipation, psychosocial stressors, diabetes symptoms).

  • In this station, with a 3-year-old, PNE is most likely and usually physiological (developmental).


Normal Development & Parental Concerns

  • Typical milestone for consistent night dryness is around 5 years; at 3, persistent bedwetting is expected.

  • Normalize differences between siblings—children develop at different rates. Reassure but remain patient-centred and avoid amplifying anxiety with unnecessary pathology lists.


History: What to Cover (Focused, child-appropriate)

  • Pattern: Frequency, timing (only at night vs. naps/any sleep), volume, any dry nights.

  • Daytime symptoms: Frequency/urgency, daytime wetting, holding behaviours.

  • Bowel habits: Constipation (painful/infrequent stools) = common contributor.

  • Red flags: Fever/dysuria, polydipsia/polyuria/weight loss (diabetes), lethargy, secondary onset after dryness, sleep apnoea symptoms, neuro/renal history.

  • Psychosocial context: Recent changes (house move, nursery), stressors.

  • What’s been tried: Toileting routines, fluid timing, rewards/alarms.

  • Developmental milestones: Broadly on track; concern here is nocturnal control which matures later.


Examination (if child present) & Basics

  • General observation; abdomen for palpable bladder/masses; signs of constipation.

  • Consider if feasible in the station; if not, state you would examine and why, then proceed efficiently (PLAB 2 rewards logical, relevant action over rote lists).



Important Considerations (for PLAB 2 performance)

  • Keep the consultation logical, organised and focused; avoid stock phrases and irrelevant lists.

  • Interact naturally; show empathy without sounding rehearsed.

  • Use clear explanations, check understanding, and work in partnership with the parent.

  • Document who you spoke to (e.g., mother/caregiver), and the child’s name/age—good record-keeping is part of professional standards.



Diagnostic Approach


Step 1 — Clarify the Scenario

  • Confirm age (3), never dry at night → PNE likely. Clarify daytime continence, nap-time wetting, and presence/absence of dry nights.


Step 2 — Focused Screening for Red Flags / Differentials

  • Ask for UTI symptoms, constipation, diabetes features (polyuria, polydipsia, weight loss), secondary onset, behavioural regression or stressors.


Step 3 — Minimal Tests (only if indicated or parental anxiety is high)

  • Urinalysis to screen for infection or glycosuria when history raises concern or to support reassurance when the parent is very anxious.

  • Broader blood tests are not routine in straightforward PNE, but may be considered if secondary enuresis suspected or specific concerns persist (explain judicious test use; PLAB examiners discourage unfocused investigations).


Step 4 — Examination (if child present)

  • Abdominal exam (constipation/bladder fullness), general assessment.


Step 5 — Diagnose & Explain

  • Provide a plain-language diagnosis: “Primary nocturnal enuresis—a normal part of development; most children gain night control by about five.” Use clear, jargon-free language and check understanding.



Management


First-Line: Normalise + Behavioural Strategies

  • Reassure: Common and usually resolves with time.

  • Fluid guidance: Encourage good daytime fluids, reduce fluids in the last 1–2 hours before bed, avoid caffeinated/sugary drinks late.

  • Toileting routine: Regular daytime voids; always before bed.

  • Positive reinforcement: Reward chart/stickers for helpful behaviours (e.g., using the toilet before bed, waking parent to go, helping change bedding), not only for dry nights—avoid blame/shame.

  • Sleep hygiene: Consistent bedtime routine; address constipation proactively (diet/fluids/stool softeners if indicated).


Enuresis Alarm (Conditioning Technique)

  • Best for older children or after basic measures; explain simply: the moisture-sensing alarm triggers on wetting; over weeks it conditions the child’s brain–bladder link to wake before a full void. Parents support the child to wake, finish in the toilet, and reset. (Use as part of a structured plan; set expectations for gradual improvement.)

  • Reinforce that the alarm is a tool for conditioning, paired with positive reinforcement and routines.


Second-Line (Age ≥5 or Special Situations)

  • Desmopressin: Consider short-term use if alarms/behavioural strategies fail or for time-limited needs (e.g., sleepovers/camps). Explain risks/benefits and that it manages symptoms, it doesn’t “cure” enuresis. Use clinician guidance and safety netting; prescribe appropriately and document clearly (professional standards for prescribing).


Follow-Up & Referral

  • Arrange follow-up to review progress, adherence, and red flags.

  • Consider referral (e.g., enuresis clinic/continence services) if ≥5 years with persistent symptoms despite first-line measures, or if secondary enuresis/complexity is suspected.

  • Provide patient information leaflets; ensure shared plan. (PLAB 2 values continuity, clear plans, and resource-sensible care.)



Communication Skills (what examiners reward)

  • Elicit ICE early: What does the parent think is happening? Concerns (e.g., sibling dry at 3), expectations (want a “cure” now).

  • Normalise sensitively, avoid unnecessary medicalising; don’t over-promise (“we’ll address every concern today”)—be precise and realistic.

  • Avoid stock phrases; speak naturally and clearly; check understanding and invite questions.

  • Structure the encounter: signpost sections, keep it relevant and time-efficient; don’t dump differential lists at the parent.



Ethical Considerations

  • Partnership & respect: Treat parent and child with kindness; tailor explanations and avoid blame.

  • Clear, accurate information; shared decisions; check understanding; meet communication needs. 

  • Good record-keeping: Who attended, concerns raised, advice given, safety netting, and follow-up plan.



Additional Resources

  • GMC Examiner Top Tips – PLAB 2: interaction over stock phrases; logical, organised consultations; relevant actions.

  • Understanding Your Results (PLAB 2): how domains are scored; common feedback statements (time, rapport, language, management).

  • Good Medical Practice (2024): patients, partnership & communication; clear information; shared decisions; continuity and documentation.

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