A 4-year-old female with enuresis and new daytime incontinence at preschool. What is the next best step in evaluation?

• A. Examine the urethral meatus and labia and obtain a dipstick urinalysis
• B. Reassure the parent that the child is simply distracted and voids late
• C. Refer the child to a pediatric urologist for vesicoureteral reflux evaluation
• D. Suggest bladder retraining and use of a nighttime bedwetting alarm

Answer: (A)

When a preschooler has enuresis plus new daytime incontinence, the priority is to identify a reversible, treatable cause and rule out infection. The best next step is a quick, noninvasive evaluation: examine the external genitalia to look for any visible abnormalities or signs of irritation, and obtain a dipstick urinalysis to screen for urinary tract infection, hematuria, or glycosuria. A urinary tract infection can present mainly as daytime incontinence in young children, and detecting it early allows prompt treatment and prevents complications. If the urinalysis is normal, you can pursue evaluation of functional bladder issues, constipation, or behavioral factors and plan management accordingly. Reassurance that the child is simply distracted would miss a potentially treatable condition, and referrals or management focused on nocturnal enuresis alone would be premature without first ruling out infection and performing a basic genital exam.