What they didn't teach in med school

Remember one of the indignities of childhood, wetting your pants? It happens to almost everyone. In my case, I remember a rainy Halloween afternoon. I was in kindergarten. After a candy-filled afternoon parading around the school grounds in my hobo costume along with fairies, witches, and ghosts, I missed the school bus. Forced to walk home with schoolmates who lived on my street, I was overcome with anxiety. Hopefully, nobody noticed the dampening of the hobo outfit.

In pediatrics, this is called daytime enuresis. A child who is fully toilet trained suddenly has unexplained accidents during the day. On a busy Wednesday afternoon recently, I greeted a shy, foreign-born kindergartner who stood quietly next to his parents in the exam room. "He has been wetting his pants at school," his father explained.

Hardly an unusual chief complaint, daytime enuresis can be caused by several possibilities. Urinary tract infection, new onset diabetes mellitus (too much sugar in the blood), diabetes insipidus (an inability to conserve water), viral cystitis (bladder irritation from a virus), and constipation (pressure against the wall of the bladder) are some of the medical possibilities. More commonly, however, young children often wait until the last minute to void -- too busy to interrupt play. Many kindergarten kids have a backup outfit for such emergencies.

A simple urinalysis and physical exam showed a healthy young boy with no sign of disease. The father then asked if he could shut the door. He explained that in his son's school there is one bathroom in the kindergarten room that is heavily utilized during breaks, sometimes necessitating trips to a common bathroom in the hallway. Older children frequent this bathroom as well. The story came out slowly. It seems that on one of these urgent trips to the hallway bathroom, older children poked their heads under the stall and allegedly touched this small boy's private parts. It was difficult for this modest family to demonstrate and communicate the details of this encounter.

After digesting the details of the boy's story, it seemed clear that the new-onset wetting was caused by fear and anxiety about the bathroom hoodlums.

Simple story. Simple answer. My dilemma now was one of proportionality. Here is a family, new to this country, whose son has been traumatized by a school bathroom incident. Looking to me for guidance, the parents were upset and not sure where to turn for help.

Such situations are not rehearsed in medical school, where we focused on the details of diseases, not on what to advise families struggling with problems like childhood obesity, parental smoking, overdose, television abuse, Internet pornography, and anxiety.

Today, any sort of genital touching is taken seriously -- as it should be. But we should also be careful not to overreact. Were these normal children being silly? Were they schoolyard bullies who needed detention? Were these future child molesters who needed counseling?

Recent statistics suggest that one in five women and one in 10 men report past sexual abuse. It is hard to know what to make of these reported statistics -- how is sexual abuse defined? Does "past" mean child abuse, date rape, or more recent events? When is genital touching normal childhood exploration (playing "doctor") or silliness (I seem to remember heads poking under the stalls), and when is it reportable?

As a doctor, I am required by law to report possible abuse -- sexual or physical -- to the authorities, but my dilemma was more: what response would be most helpful to this confused family.

After a discussion with the parents, we decided on a plan that seemed to be proportionate to the event. The parents would discuss the situation with the child's teacher, and then, along with the teacher, meet with the principal.

The outcome was good in this case. While the boy was unable to identify the perpetrators, the teacher would be sure all young children were accompanied to the hallway bathroom. The daytime accidents have stopped.

Dr. Victoria Rogers McEvoy is the chief of pediatrics and the medical director of the Mass. General West Medical Group and assistant professor of pediatrics at Harvard Medical School.