What is the recommended initial management approach for a child who has failed two courses of treatment for nocturnal enuresis?

When a child has failed two courses of treatment for nocturnal enuresis, referring to secondary care is the recommended initial management approach. This step is crucial because persistent enuresis despite treatment can indicate an underlying issue that may need specialized assessment or intervention. Secondary care providers, such as pediatric urologists or nephrologists, have access to more comprehensive evaluations and management strategies that go beyond standard first-line treatments.

At this stage, a specialist can conduct further investigations to determine if there are any anatomical, neurological, or psychological factors contributing to the enuresis. Additionally, they may suggest more advanced treatment options that are not typically available in primary care settings, including specific behavioral therapies or medications suited to the child’s unique circumstances.

In contrast, continuing with the current treatment may not address the underlying issue and could lead to further frustration for both the child and the caregivers. Switching medications might be considered at some point, but without a comprehensive evaluation, it may not be the optimal first step. Incorporating behavioral techniques can be beneficial, but in cases of treatment failure, it might be more effective as part of a broader strategy devised by a specialist rather than a solitary approach. Thus, referral to secondary care provides the child with a thorough evaluation and access to