Evaluation of Enuresis with Red Flags

Critical Red Flags Present

The presence of a sacral dimple in a child with both day and night enuresis plus chronic constipation mandates immediate MRI of the lumbar spine to rule out occult spinal dysraphism, as recommended by the American Academy of Child and Adolescent Psychiatry 1
Combined day and night enuresis represents non-monosymptomatic enuresis, which requires more thorough evaluation than simple bedwetting, according to the American Urological Association 2

Examination of the back is mandatory in all children with non-monosymptomatic enuresis or history of urinary tract infection, and any suggestion of vertebral or spinal cord anomaly requires immediate investigation, as stated by the American Academy of Child and Adolescent Psychiatry and the American Urological Association 1, 3
Children with severe/continuous incontinence or concerning physical findings must be sent to a specialized center without delay, as recommended by the American Urological Association 2

When evaluating a child with enuresis, first identify red flags requiring immediate specialized evaluation, including weak urinary stream, severe/continuous incontinence, anatomic abnormalities, and combined day and night symptoms, as recommended by the American Urological Association 2, 4
If red flags are present, immediate imaging and specialist referral are necessary, as stated by the American Academy of Child and Adolescent Psychiatry and the American Urological Association 1, 2, 3