A thorough de-identification has been done to secure the privacy of the patient and a well informed consent has been obtained from the informant ( since the patient is a minor )
INTRODUCTION :
This is a story of an 8 year old boy, residing with his family , somewhere in the hilly East India .
CHIEF COMPLAINT:
Informant is the Mother who complains of frequent urination in her otherwise bubbling child since 4 months.
HISTORY OF PRESENTING ILLNESS
Elaborating on the frequency,she mentions that the problem began about 4 months back when she noticed that her son would urinate around 25 times in a day( in other words ,he urinates every 10-15 minutes) she specifically remembers a chilly ,rainy day when her son had rushed to the washroom 29 times which rang a bell and she seeked medical help.
She has also maintained a chart regarding the volume and frequency of micturition
Whereby she reports that the volume of the first urine after night is about 30 ml and then throughout the day it's an average of about 7 ml.
No frothing or thickened consistency of urine has been noticed by the mother.
There is no association with
Flank pain
Lower abdominal pain
Burning sensation while micturating
Fever
Malaise
No history of falls
No history of spinal cord trauma
No spinal defects.
PERSONAL HISTORY
Body weight :19 kg
Height : 127 cm
The young boy has good appetite
Sleeps well ,does not wake up to urinate
Has had zero episodes on bed wetting.
Few more points regarding the traits of the child is that , according to the mother , the boy is excessively hyperactive, impulsive,does not have proper social etiquettes as is expected of his age, too active to pay any attention at school, talk so fast that even comprehending sentences becomes quite difficult.
He was addicted to the smartphone ( as is the problem with most others ) but the mother has completely stopped him from even going near the smartphone since the last four months.
PAST HISTORY :
History of constipation which has been almost resolved by diet modification and mild purgatives
PAST MEDICAL AND SURGICAL H/O :
Occasional use of purgatives.
No use of antibiotics lately ( mentioned to rule out sterile pyuria after culture )
He has had a inguinal hernia repair surgery at the age of 2;
No similar complaints in the past
A general look at the child with a clinical eye :
REPORTS :
The routine urine examination reports are normal.
Also note : When he was taken up for ultrasonogram a couple of months back( dated 27.02.2021 ) as an investigation regarding this increased frequency issue
He couldn't hold urine even after trying for the umpteenth time, so a proper lower abdomen study couldn't be done.
Radiologist upon ultrasonography has commented about " multiple subcentimetric mesenteric lymph nodes "
The urine examination report :
Serum Electrolytes :
Few Differentials :
1. Although the cell counts in the urine examination, and there are no microorganisms after urine culture , still due to the presence of some mildly enlarged mesenteric lymph nodes, there still remains suspicion of an infective etiology, including cox bacilli.
2. Since the child does not get the urgency to urinate when he is asleep, there can be a chance of the manifestation being psychosomatic, or as a result of an undiagnosed anxiety disorder , or a stressor triggering this manifestation.
3.From the history of excessive hyperactivity , impulsiveness , lacking of attentivity , a though goes towards Attention Deficit Hyperactivity Disorder (ADHD) and in turn towards the association urination disorders.
Discussion : The case had been posted in several online portals and here are a few discussion threads that came up regarding the patient. All participants in the discussion have been de-identified.
[ VHP : Veteran Health Professional ]
VHP 1 : I will be interested to know examination findings and the basic blood parameters FBC, U&E, glucose, urine MCS, Micturation Cysto Urethrogram was done and the results please to start with.
VHP 1 : Also interested to know what history taker is trying to elicit from consistency of urine
Moderator : The data was collected by our student half an hour back after twenty minutes of telephonic conversation with the mother who approached our CBBLE (case based blended learning ecosystem) that provides clinical decision support CDSS (clinical decision support system).
They are from a remote corner without any other nearby medical support.
I guess many medical students have a habit of checking for frothy urine in the history to rule in Nephrotic syndrome.
VHP 1 : Ok thanks. So you don’t have results of any blood tests and MCUG hasn’t been done? USS Kidney urethra bladder? Has anyone examined the child?
Moderator: Yes none. No examination yet other than the students video call
VHP1 : What do you plan to advice?
VHP2 : Just skimmed over...
I think the key is no nocturnal enuresis or nighttime waking to urinate.
Overactive bladder during the day...? Psycho somatic?
Since everything else seems normal, behavior training or if that fails trial of Ditropan...?
VHP1 : Key is no nocturnal enuresis?
VHP3: If all the investigations come back normal....it's OCD....I do have similar patients in my practice...not only children..but adults too...but the core would be to rule out organic renal issues by a properly trained Urologist....
VHP1: I will concur with this thought.
VHP2: No medical doctors ever come to a diagnosis of psychosomatic without ruling out any organic etiology...
The poor fella is obviously super stressed, could not hold his urine at all during the US, UA looks good, PE is normal, appetite and sleep remain normal.
So, mine is a thought process...of probable D/D
Daytime overactive bladder is a common pediatric problem which usually resolves over time with reassurance and relaxation and behavioral therapy. But, need to do at least some blood work to r/o systemic issues, and ped urology referral if available.
Would be interested in knowing how the poor kid turns out to be, please keep us posted. Sounds like it is a Telemedicine case.
VHP 4: Not diabetic?
VHP2: Well, diabetic kids will pee frequently, but not this frequently, and that do have to wake up at night to go pee or have accidents usually.. the UA is normal...
So, blood work for fasting blood sugar, electrolytes, creatinine/BUN needed.
Moderator: Yes we shall gather all these inputs and ask them to get these investigations and consults suggested locally if available and accessible
VHP 1 : Some kids have posterior urethral valves which makes it difficult to empty the bladder - this May account for frequency of urination but no nocturnal enuresis and bed wetting. So a physical examination is essential and consideration of suitability of MCUG + baseline bloods
VHP 1: You are correct - likely psycho somatic as history is only for 4 months
VHP 5 : Why are you ignoring the past history of inguinal hernia….. ????
VHP 6: Diabetics have frequency as they produce increased urine. This child is only passing 7ml at a time and bladder is never full. Total amount of urine passed in 24 hrs is probably normal so diabetic mellitus and insipidus very unlikely
VHP 5 : Psychosomatic definitely high on differential
VHP 6: In PUV the bladder would not be empty on USG. Even if there is no residual urine there should be some signs in bladder wall but I suppose that's operater dependant
VHP 6 : First diagnosis. Wouldn't do too many investigations. MCUG is quite invasive. I would try reassurance and relaxation first.
VHP 7 : A good USG is essential
VHP 6: Correct.
PUV usually is detected much earlier, I have seen only 2 PUVs in my career so far, one was a baby born with Nephrotic syndrome and the other was an infant with recurrent UTIs and diagnosed via VCUG as part of his w/u.
A previously healthy 8 yo boy with no h/o UTI ever, no bed wetting, no h/o dribbling etc in the past is unlikely PUV, which though, if very mild, can present later in life.
VHP 7 : Agreed. I've seen a few PUV but mainly newborns. None beyond infancy although we always read that they can present at any age!
VHP 1 : Lovely clinical discussion ! Really enjoyed it 👌
Further Inputs :
Please further share your valued inputs to resolve the current diagnostic and therapeutic uncertainty in this patient and provide some relief and hope for the anxious mother .
Pollakiuria?
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