The association between monosymptomatic enuresis and allergic diseases in children

Yılmaz-Durmuş S, Alaygut D, Soylu A, Alparslan C, Köse SŞ, Anal Ö. The association between monosymptomatic enuresis and allergic diseases in children. Turk J Pediatr 2018; 60: 415-420. This clinical study was designed to evaluate correlation between monosymptomatic enuresis (MSE) and allergic diseases (asthma, allergic rhinitis, eczema, and food allergy) in pediatric patients. The study was conducted on 50 pediatric patients with a MSE clinic who were ≥7 years old and applied to two tertiary health institutions between November 2015 and June 2016. Fifty healthy children of similar age, who applied to pediatric outpatient clinics for various reasons, were included as the control group. A questionnaire questioning the presence of food allergy and enuresis in the family and also including the questions of International Study of Asthma and Allergies in Childhood (ISAAC) was distributed to the parents of the children included in the study. It was found that 52% of 100 children participating in the study were boys and 48% were girls and their mean age was 10.8±2.8 years. While allergic diseases accompanied 34% of the cases with enuresis, this rate was found as 12% in the control group (p < 0.01). It was determined that the family history in terms of enuresis and atopy was at a higher rate in the study group (40% and 26%, respectively) and at a lower rate in the control group (2% and 6%, respectively) (p < 0.01). It was observed that allergic diseases were more frequent in the cases with MSE at a statistically significant level compared to the group without enuresis.

Refugee Status as a Possible Risk Factor for Childhood Enuresis

This study investigated the influence of refugee status on the occurrence of enuresis. It was performed among school children aged 6 to 11 years and their parents in the Vukovarsko-srijemska County (eastern Croatia), which had many displaced persons and refugees (mostly women and children) in the 1990s due to the wars in Croatia and Bosnia and Herzegovina. A specially designed questionnaire (about the child’s age and gender, the child’s enuresis history and that of the parents, and data on parental refugee status in childhood) was completed by one of the parents. Adequate data were collected for 3046 children. The prevalence of enuresis among the studied children was quite low (2.3%) but the prevalence distribution according to gender, the decline by age, and the higher odds ratio for paternal enuresis were in line with the results of other studies. The prevalence of parental enuresis in childhood was higher than their children’s enuresis (mothers: 5.8%, fathers: 3.6%, p < 0.001), and significantly higher among parents who had been refugees (mothers: p = 0.001, fathers: p = 0.04). Parental refugee status had no influence on the children’s enuresis. The results suggest that refugee status is a risk factor for the occurrence of enuresis in childhood.

International Continence Society (ICS) report on the terminology for nocturia and nocturnal lower urinary tract function

INTRODUCTION

The terminology for nocturia and nocturnal lower urinary tract function is reviewed and updated in a clinically and practically-based consensus report.

METHODS

This report has been created by a Working Group under the auspices and guidelines of the International Continence Society (ICS) Standardisation Steering Committee (SSC). All relevant definitions were updated on the basis of research over the last 16 years since the publication of the first nocturia standardization document in 2002. An extensive process of 16 rounds of internal and external reviews was involved to examine each definition exhaustively, with decision-making by collective opinion (consensus).

RESULTS

A clinically-based terminology report for nocturia and nocturnal lower urinary tract function, encompassing five key definitions divided into signs and symptoms has been developed. Clarity and user-friendliness have been key aims to make it interpretable by healthcare professionals and allied healthcare practitioners involved in the care of individuals with nocturnal lower urinary tract function.

CONCLUSION

A consensus-based terminology report for nocturia and nocturnal lower urinary tract function has been produced to aid clinical practice and research.

[Event-related potentials of working memory impairment in children with primary nocturnal enuresis]

OBJECTIVE

To study the cognitive neural mechanism of working memory impairment in children with primary nocturnal enuresis using event-related potential (ERP).

METHODS

A total of 14 children with primary nocturnal enuresis were enrolled as enuresis group, and 14 normal children were enrolled as control group. The learning-recognition task test was applied, and the ERP components (P2, N2, and P3) at Fz lead while identifying old pictures (learned) and new ones (unlearned) were measured and compared between the two groups.

RESULTS

While identifying the old pictures, the enuresis group had a lower amplitude of P2 and N2 than the control group (P<0.05). There were no significant differences between the two groups in the latency of P2, N2, and P3 and the amplitude of P3. While identifying the new pictures, the enuresis group had a longer latency of P2 and a significantly lower amplitude of N2 than the control group (P<0.05). There were no significant differences between the two groups in the amplitude of P2 and P3 and the latency of N2 and P3.

CONCLUSIONS

Compared with normal children, the children with primary nocturnal enuresis have reduced abilities of classified information extraction, a prolonged reaction time, and reductions in memory capacity, memory consolidation, and conflict monitoring, which causes working memory impairment.

Nocturnal enuresis and sleep disordered breathing in primary school children: Potential implications

INTRODUCTION

The association between nocturnal enuresis (NE) and sleep disordered breathing (SDB) has been repeatedly reported, but has primarily been focused on clinical cohorts. The purpose of this study, was to assess whether SDB-related symptoms such as snoring and unrefreshing sleep in the morning are associated with NE in a large-scale community school-based survey.

METHODS

A cross-sectional assessment using a standard questionnaire was conducted on nearly 20 000 primary school children (5-12 years old) in Matsuyama, Japan. Associations between NE and the frequencies of snoring and unrefreshing sleep were evaluated using multivariate logistic and regression analyses.

RESULTS

Multivariate adjusted odds ratios (95% confidence intervals) for enuresis were 1.21 (1.04 to 1.40) and 1.36 (1.07 to 1.73) in boys who snored 1 or 2 nights per week and ≥3 nights per week, respectively (P for trend <0.0001). Those for enuresis were 1.67 (1.41 to 1.99) and 1.96 (1.63 to 2.36) in boys who showed unrefreshing sleep 1 or 2 nights per week and ≥3 nights per week, respectively (P for trend <0.0001). Significant associations between NE and snoring frequency emerged among children who did not report unrefreshing sleep (P-trend for boys and girls were <0.0001 and <0.01, respectively), while significant associations between NE and frequency of unrefreshing sleep were detected among children who snored ≥1 nights per week (P for trend >0.1).

CONCLUSIONS

The pathogenic mechanisms linking snoring and unrefreshing sleep to increased risk of NE are unknown. However, snoring, a surrogate reporter of SDB, is associated with increased urine production, while unrefreshing sleep may result from disrupted sleep facilitating increased sleep pressure and elevated arousal thresholds. Thus, both SDB and unrefreshing sleep are potential independent risk factors of NE in school age children.

Rectal diameter assessment in enuretic children-exploring the association between constipation and bladder function

OBJECTIVES

Detrusor overactivity and constipation often co-exist in children with enuresis. Constipation is known to be linked to detrusor overactivity. The voiding chart is the best non-invasive way to investigate bladder function, whereas the ultrasonographical detection of rectal dilatation is the best way to objectify constipation. We wanted to investigate a possible relationship between the rectal diameter and voiding chart data in enuretic children.

METHODS

Children with therapy-resistant enuresis were retrospectively evaluated. All had completed a voiding chart for at least 48 h. The rectal diameter was assessed ultrasonographically. The cutoff for rectal dilatation was set at 30 mm.

RESULTS

We evaluated 74 patients (12 girls) aged 10.2 ± 2.8 years, 35 of whom had rectal dilatation. No significant differences in voiding chart parameters were found between children with normal versus dilated rectum. Neither did urgency or a history of daytime incontinence differ between the groups. Boys were more likely to have rectal dilatation than girls (p = 0.02).

CONCLUSIONS

The absence of differences regarding voiding chart data may be explained as two mechanisms neutralizing each other: behavioral factors may make the constipated children void seldom and with large volumes, whereas detrusor overactivity caused by rectal compression of the bladder may have the opposite effect. Another option may be that the voiding chart is too blunt an instrument to detect detrusor overactivity. Constipation, and thus presumably bladder dysfunction, seems to be more important in enuretic boys than girls.

[Comorbid cognitive impairments in children with nocturnal enuresis and their treatment]

AIM

To study comorbid cognitive impairments in children with enuresis and assess the efficacy and safety of cerebrolysin in treatment of comorbid pathology.

MATERIAL AND METHODS

Seventy patients, aged from 7 to 10 years, with the primary monosymtomatic form of enuresis were examined. Enuresis was assessed by the mean number of 'wet' nights per week. Neuropsychological tests were administered to measure short-term auditory-verbal and visual memory as well as SNAP-1V inattention and TOVA impulsivity. Electroencephalography was used as well.

RESULTS AND CONCLUSION

Children with enuresis performed lower on auditory-verbal and visual memory and attention tests compared to the patients of the control group. Electroencephalography showed activation deficit and synchronized effects of thalamic structures. The high efficacy of cerebrolysin (the improvement was seen in 80% of the patients) was demonstrated.

A consecutive case series analysis of a behavioral intervention for enuresis in children with developmental disabilities

Children with developmental disabilities (DD) are more likely than typically developing peers to have issues with enuresis. Past research has shown the success of behavioral treatments consisting of scheduled sits and reinforcement for continent voids. However, this research has included small sample sizes, while studies with larger numbers have lacked key information (i.e., baseline rates and follow-up data to evaluate maintenance and generalization). The current study conducted a consecutive case series analysis of 44 individuals with developmental disabilities who completed a 2-week program for enuresis. Results showed significant improvement in continent voids and follow-up data suggested positive results maintained when treatment was implemented by caregivers in a home environment.

Alarm therapy and desmopressin in the treatment of patients with nocturnal enuresis

PURPOSE

The purpose of this study was to compare the rates of success, relapse, and compliance to treatment in patients undergoing alarm therapy or receiving desmopressin for primary monosymptomatic nocturnal enuresis (PMNE).

MATERIALS AND METHODS

This retrospective study was performed by reviewing the medical files of patients undergoing alarm therapy (Group 1) or receiving desmopressin (Group 2) for PMNE, between January 2010 and July 2014. Patients undergoing treatment in the 3^rd and 6^th month as well as 1^st year follow-up data were analyzed. Two groups were compared with regard to treatment success, relapse rate, and compliance to treatment.

RESULTS

Group 1 included 64 and Group 2 included 70 children. Relapse rates at the 3^rd month, 6^th month, and 1^st year were 67.2%, 71.9%, and 17.0% for Group 1 and 74.3%, 80.0%, and 21.4% for Group 2, respectively. There was no statistically significant difference between relapse rates at any point of follow-up.

CONCLUSIONS

Alarm therapy and desmopressin have the same success rate and relapse rates for PMNE. Compliance with alarm therapy is higher and we recommend it as the first-line treatment. On the other hand, desmopressin has low side effects and can also be used.

Prevalence, patient and consultation characteristics of enuresis in Australian paediatric practice

AIM

To describe the prevalence and consultation characteristics of enuresis in Australian paediatric practice and assess for changes over a period of 5 years.

METHODS

Data collected prospectively by paediatricians (outpatient settings) in 2008 and 2013, as part of the Children Attending Paediatricians Study. Consultations on children aged 5 years or over were included. Consultations in each cohort (2008 and 2013) categorised as either listing or not listing enuresis. Characteristics of the 'enuresis' versus 'non-enuresis' subgroup in each cohort were compared as were the enuresis subgroups 2008 versus 2013.

RESULTS

Of 4175 and 4181 consultations in 2008 and 2013, enuresis was reported in 178 (4.3% - 2008) and 193 (4.6% - 2013). Constipation and encopresis were more prevalent in the enuresis versus non-enuresis subgroups (46 (25.8%) vs. 136 (3.4%) for constipation and 25 (14%) vs. 65 (1.6%) for encopresis in 2008; 52 (26.9%) vs. 160 (4%) for constipation and 25 (13%) vs. 78 (2%) for encopresis in 2013, both P < 0.001). The enuresis subgroup had more referrals to multidisciplinary teams (19 (10.7%) vs. 148 (3.7%) - 2008 and 21 (10.9%) vs. 163 (4.1%) - 2013, both P < 0.001) and allied health professionals (29 (16.3%) vs. 230 (5.8%) - 2008; 27 (14%) vs. 178 (4.5%) - 2013, both P < 0.001).

CONCLUSION

The overall frequency of presentation of children for management of enuresis was low. Prevalence/Consultation characteristics of enuresis were comparable over 5 years. Constipation and encopresis were significantly more prevalent in the enuresis subgroups.

Symptoms of Obstructive Sleep Apnea, Nasal Obstruction, and Enuresis in Children With Nonsyndromic Cleft Lip and Palate: A Prevalence Study

OBJECTIVE

To estimate the prevalence of symptoms of obstructive sleep apnea (OSA), nasal obstruction, and enuresis in children with nonsyndromic unilateral cleft lip and palate.

DESIGN

Prospective cross-sectional study.

SETTING

Referral care center.

PARTICIPANTS

One hundred seventy-four children aged 6 to 12 years of both genders.

INTERVENTIONS

Symptoms of OSA and nasal obstruction were investigated by analysis of scores obtained by the Sleep Disturbance Scale for Children (SDSC) and Congestion Quantifier (CQ-5). Enuresis was considered as present when urinary loss was reported during sleep (at least 1 episode/month, last 3 months). To characterize the enuresis as mono- or polysymptomatic, symptoms of dysfunction of the lower urinary tract (DLUT) were investigated by the Dysfunctional Voiding Scoring System (DVSS). Statistical analysis was performed at a 5% level of significance.

RESULTS

Positive SDSC scores for OSA were observed in 60 (34%) children; positive CQ-5 scores for nasal obstruction in 45 (26%), positive DVSS scores for DLUT in 30 (17%), and enuresis was reported by 29 (17%), being categorized as primary in 66% and polysymptomatic in 72% of the children. Compared to the pediatric population, OSA, nasal obstruction, and enuresis prevalence ratios were up to 7 (95% confidence interval [CI] 5-9), 2 (95% CI 2-3), and 3 times (95% CI 2-5) higher, respectively. There was a positive/moderate correlation between symptoms of OSA and nasal obstruction ( P = .0001). No correlation was seen between symptoms of OSA and enuresis.

CONCLUSIONS

Children with nonsyndromic cleft lip and palate have high prevalence of nasal obstruction and enuresis and are at risk of OSA.

An Integrated Nurse Practitioner-Run Subspecialty Referral Program for Incontinent Children

INTRODUCTION

Evidence suggests that urinary and fecal incontinence and abnormal voiding and defecation dynamics are different manifestations of the same syndrome. This article reports the success of an innovative program for care of children with incontinence and dysfunctional elimination. This program is innovative because it is the first to combine subspecialty services (urology, gastroenterology, and psychiatry) in a single point of care for this population and the first reported independent nurse practitioner-run specialty referral practice in a free-standing pediatric ambulatory subspecialty setting. Currently, services for affected children are siloed in the aforementioned subspecialties, fragmenting care.

METHODS

Retrospective data on financial, patient satisfaction, and patient referral base were compiled to assess this program.

RESULTS

Analysis indicates that this model is fiscally sound, has similar or higher patient satisfaction scores when measured against physician-run subspecialty clinics, and has an extensive geographic referral base in the absence of marketing.

DISCUSSION

This model has potential transformative significance: (a) the impact of children achieving continence cannot be underestimated, (b) configuration of services that cross traditional subspecialty boundaries may have broader application to other populations, and (c) demonstration of effectiveness of non-physician provider reconfiguration of health care delivery in subspecialty practice may extend to the care of other populations.

The adverse effects of oral desmopressin lyophilisate (MELT): personal experience on enuretic children

Objective

The aim of this study was to evaluate adverse effects of oral desmopressin lyophilisate (MELT) in enuretic children.

Material and methods

We enrolled 260 children with nocturnal enuresis (NE) referred to the Pediatric Service, 'Campus Bio-Medico' University of Rome, from April 2014 to April 2017 in the study, of these 23 were excluded. The study was characterized by 2 phases. During Phase 1 a careful patient's medical history was obtained and physical examination was performed. After 3 months of treatment with MELT (Minirin/DDAVP^®) at the dose of 120 mcg a day, a micturition diary was kept, adherence to therapy and any possible adverse effects were checked during the Phase 2. The study was carried out in compliance with the Helsinki Declaration.

Results

Among 237 patients included in the study 11 male and 6 female (n=17; 7.2%) patients with a mean age 10.06±2.49 years, reported 22 adverse effects, with an absolute risk of 7.17%. In particular, 5 neurological symptoms, 3 gastrointestinal effects, 4 sleep disturbances, 8 psycho-behavioral disorders, 2 symptoms of fatigue were reported.

Conclusion

In our study MELT with its higher bioavailability guaranteed lower frequency of adverse effects which resolved spontaneously and rapidly. The MELT formulation actually represents the first line and safe treatment for the NE.

Nocturnal enuresis in children from Santo Domingo, Dominican Republic: a questionnaire study of prevalence and risk factors

OBJECTIVE

To determine the prevalence of paediatric nocturnal enuresis in Santo Domingo, Dominican Republic.

DESIGN

A cross-sectional study was performed using a pretested questionnaire.

SETTING

Three different schools in Santo Domingo, Dominican Republic.

PARTICIPANTS

700 children aged 5-11 years attending one of the different schools in Santo Domingo, Dominican Republic.

INTERVENTION

The study was carried out from November 2017 to December 2017.

MAIN OUTCOME MEASURES

Prevalence of nocturnal enuresis.

RESULTS

700 questionnaires were sent to be filled and 682 were returned. 655 fully filled questionnaires met the requirements of the study. 183 children were identified with nocturnal enuresis among which 88 were boys and 95 were girls. Only 11% of children with enuresis sought medical help. The prevalence of nocturnal enuresis was 27.9%. No statistical significance was found between gender, order in the family, constipation and breast feeding (p>0.05). Age, deep sleep and family history of enuresis were strongly associated with nocturnal enuresis.

CONCLUSIONS

The prevalence of nocturnal enuresis in Santo Domingo was found to be 27.9% and it was higher compared with some Asian countries but lower than Morocco and Jamaica. Only 11% of children with enuresis sought medical help. Nocturnal enuresis is an important problem in the paediatric population of Santo Domingo, but very few children receive treatment due to the financial costs of healthcare in the Dominican Republic.

Mother's Work Status on Children's Bruxism in a Subset of Saudi Population

Aims and Objectives:

The aims and objectives of this study were to determine if an association exists between mothers work status and her children's incidence of bruxism and habits related to bruxism.

Materials and Methods:

A cross-sectional study was conducted through data collection of a questionnaire answered by 561 mothers’ about their working status and their child's habits and behaviors. The survey consisted of 5 parts with a total of 34 questions: mother's information, child's behavior, child's sleeping pattern, mother's knowledge about bruxism, and child's medical history. Odds ratios, Chi-square, and their corresponding 95% confidence intervals are reported. Statistical significance was set at P ≤ 0.05.

Results:

The work status of the mother was not statistically significant in increasing the incidence of a child to have bruxism. However, this study clearly elucidates that 7 of the 15 habits correlate significantly with a status of bruxism. According to this sample, a child, that is, reported to be aggressive is more than twice as likely to have nocturnal bruxism. Likewise, any child that bites their nails, complains of headaches, drools in their sleep, snores, complains of muscle cramps, and colic is more than twice as likely to be a nocturnal bruxer than a child that does not have these habits.

Conclusion:

The prevalence of children's bruxism in this convenient sample was 34.5% (n = 141). The concerning habits related to bruxism can serve the pediatric dentist, general dentist, general practitioner, and primary care provider of children having these red flags as indicators of bruxism. It is imperative that parents of these children be made aware these habits that may occur together, alone or even simultaneously with bruxism.

A pilot investigation of an iOS-based app for toilet training children with autism spectrum disorder

We developed an iOS-based app with a transmitter/disposable sensor and corresponding manualized intervention for children with autism spectrum disorder. The app signaled the onset of urination, time-stamped accidents for analysis, reminded parents to reinforce intervals of continence, provided a visual outlet for parents to communicate reinforcement, and afforded opportunity for timely feedback from clinicians. We compared this intervention with an intervention that uses standard behavioral treatment in a pilot randomized controlled trial of 33 children with autism spectrum disorder aged 3-6 years with urinary incontinence. Parents in both groups received initial training and four booster consultations over 3 months. Results support the feasibility of parent-mediated toilet training studies (e.g., 84% retention rate, 92% fidelity of parent-implemented intervention). Parents used the app and related technology with few difficulties or malfunctions. There were no statistically significant group differences for rate of urine accidents, toilet usage, or satisfaction at close of intervention or 3-month follow-up; however, the alarm group trended toward greater rate of skill acquisition with significantly less day-to-day intervention. Further development of alarm and related technology and future comparative studies with a greater number of participants are warranted.

EEG Measurement of Emotion Processing in Children with Daytime Urinary Incontinence

OBJECTIVE

Daytime urinary incontinence (DUI) is common in childhood. The aim of the study was to neurophysiologically analyse the central emotion processing in children with DUI.

METHOD

In 20 children with DUI (mean age 8.1 years, 55 % male) and 20 controls (mean age 9.1 years, 75 % male) visual event-related potentials (ERPs) were recorded after presenting emotionally valent (80 neutral, 40 positive, and 40 negative) pictures from the International Affective Picture System (IAPS) as an oddball-paradigm. All children received a full organic and psychiatric assessment.

RESULTS

Children with DUI did not differ significantly from controls regarding responses to emotional pictures in the frontal, central, and parietal regions and in the time intervals 250-450 ms, 450-650 ms, and 650-850 ms after stimulus onset. The patient group had more psychological symptoms and psychiatric comorbidities than the control group.

CONCLUSIONS

EEG responses to emotional stimuli are not altered in children with DUI. Central emotion processing does not play a major role in DUI. Further research, including a larger sample size, a more homogeneous patient group (regarding subtype of DUI) or brain imaging techniques, could reveal more about the central processing in DUI.

Recent advances in managing and understanding enuresis

Enuresis, particularly in children during sleep, can be a debilitating condition, affecting the quality of life of the child and his or her family. The pathophysiology of nocturnal enuresis, though not clear, revolves around the inter-related mechanisms of overactive bladder, excessive nocturnal urine production, and sleep fragmentation. The first mechanism is more related to isolated nocturnal voiding, whereas the latter two are more related to nocturnal enuresis, in which circadian variations in arginine vasopressin hormone play a key role. A successful treatment would depend upon appropriately addressing the key factors precipitating nocturnal enuresis, necessitating an accurate diagnosis. Thus, advancements in diagnostic tools and treatment options play a key role in achieving overall success. This review summarizes recent advances in understanding the pathophysiology of nocturnal enuresis, diagnostic tools, and treatment options which can be explored in the future.

CPAP Treats Enuresis in Adults With Obstructive Sleep Apnea

ABSTRACT

Enuresis, or "bedwetting," in children is associated with obstructive sleep apnea (OSA), and often resolves with treatment of OSA. However, it is poorly understood whether a similar relationship exists in adults. We describe a case series of 5 adult patients in whom OSA was diagnosed by laboratory polysomnography, who presented with enuresis that resolved after treatment with continuous positive airway pressure (CPAP). All cases occurred in the setting of obesity, in addition to other known risk factors for urinary incontinence and enuresis. OSA was diagnosed as severe in all but one case, which was mild. One patient noted recurrence of enuresis that coincided with malfunction of his CPAP machine. There is growing evidence that CPAP therapy may alleviate OSA and enuresis in adults with both conditions. Clinicians should routinely ask about enuresis in patients suspected of having OSA. A systematic study of the association between enuresis and OSA in adults is warranted.

Non-REM Sleep Instability in Children With Primary Monosymptomatic Sleep Enuresis

STUDY OBJECTIVES

Sleep enuresis is one of the most common sleep disturbances in childhood. Parental perception of deeper sleep in children with sleep enuresis is not confirmed by objective studies. However, evidence of disturbed sleep has been demonstrated by questionnaire, actigraphy, and polysomnographic studies, but no neurophysiological correlation with low arousability has been found. The goal of this study was to analyze the sleep microstructure of children with sleep enuresis using cyclic alternating pattern (CAP) analysis.

METHODS

Forty-nine children were recruited, 27 with enuresis (19 males and 8 females, mean age 9.78 years, 2.52 standard deviation) and 22 normal control patients (11 males and 11 females, mean age 10.7 years, 3.43 standard deviation); all subjects underwent clinical evaluation followed by a full-night polysomnographic recording. Psychiatric, neurological, respiratory, and renal diseases were excluded.

RESULTS

No differences in sex, age, and apnea-hypopnea index were noted in the patients with enuresis and the control patients. Sleep stage architecture in children with sleep enuresis showed a decrease in percentage of stage N3 sleep. CAP analysis showed an increase in CAP rate in stage N3 sleep and in phase A1 index during stage N3 sleep in the sleep enuresis group, but also a significant reduction of A2% and A3% and of phases A2 and A3 indexes, supporting the concept of decreased arousability in patients with sleep enuresis. The decrease of phase A2 and A3 indexes in our patients might reflect the impaired arousal threshold of children with sleep enuresis. Sleep fragmentation might result in a compensatory increase of slow wave activity (indicated by the increase of CAP rate in stage N3 sleep) and may explain the higher arousal threshold (indicated by a decrease of phase A2 and A3 indexes) linked to an increased sleep pressure.

CONCLUSIONS

The findings of this study indicate the presence of a significant disruption of sleep microstructure (CAP) in children with sleep enuresis, supporting the hypothesis of a higher arousal threshold.

Study of behavioural disorders in children with primary enuresis

BACKGROUND

Enuresis results in behavioural disorder in children. This study investigated the behavioural disorders in children possessing primary enuresis.

MATERIALS AND METHODS

In this cross-sectional study, 100 children with primary enuresis were referred to children's hospital Khorramabad; the census method was used in this study. Data were collected using a short screening instrument for enuresis psychological problems, the reliability and validity of which have been confirmed in previous studies. First, a questionnaire was used to assess academic failure, anxiety, behavioural disorders, sleep, and psychological disorders. Results obtained were compared in terms of gender and age. Statistical analyses using inferential and descriptive statistics including Chi-square and Fisher test were employed.

RESULTS

The average age of children was 8.46 years. Sixty-six per cent of participants were male and the rest of them were female. Ninety per cent of subjects were between the age range of 1-9 years, and 10% were over 10 years old. Forty-three per cent of children suffered from anxiety disorders and 34% had sleep disorders, 4% also suffered from academic failure. Among behavioural disorders, hyperactivity and restlessness were the most common disorders, and they were significantly higher in nine boys. Headache, obsessive, and sleep disorders were more common in children above 10. There was a significant correlation between eating disorders, headache, sleep disorders, and strange movements in males, while feelings of sadness were more common in females.

CONCLUSION

Social personality development in children with enuresis can be improved by informing parents of enuresis.

Behavioural problems in children with enuresis

AIM

Enuresis is defined as involuntary or intentional repeated voiding of urine into clothes or bed at least twice a week for a period of three consecutive months in children older than five years old. It is one of the most frequent chronic childhood disorders. The aim of this study was to investigate the frequency of behavioural problems in children with enuresis.

MATERIAL AND METHODS

The research compared 30 children aged between 7 and 11 years who had consulted to Bakırköy Prof. Dr. Mazhar Osman Mental Health and Neurological Diseases Training and Research Hospital, Child and Adolescent Psychiatry Clinics and diagnosed with enuresis with their 30 peers who were randomly selected from a state elementary school. The Child Behaviour Checklist was applied to both groups.

RESULTS

The subdimension scores of both groups were compared, it was observed that children with enuresis had higher scores compared to their peers in all sub-tests except for the Sluggish Cognitive Tempo, Anxiety Disorders, and Obsessive Compulsive Disorder sub-tests. Enuretic children had higher scores in externalizing (p<0.001), internalizing (p=0.001) and total problem (p<0.001) scales.

CONCLUSION

The results of this study indicate that children with enuresis exhibit behavioral problems with a higher rate compared to their healthy peers. The results are in line with the literature. Moreover, compered to the results of the studies conducted in different countries, significantly higher scores in internalizing problems were obtained. It was thought is possible that this might be related with cultural factors. However, these findings need to be verified with data from larger scale studies.

Medical Comorbidity of Attention-Deficit/Hyperactivity Disorder in US Adolescents

Understanding patterns of medical comorbidity in attention-deficit/hyperactivity disorder (ADHD) may lead to better treatment of affected individuals as well as aid in etiologic study of disease. This article provides the first systematic evaluation on the medical comorbidity of ADHD in a nationally representative sample (National Comorbidity Replication Survey-Adolescent Supplement; N = 6483) using formal diagnostic criteria. Survey-weighted odds ratios adjusted for demographics, additional medical, and mental disorders were calculated for associations between ADHD and medical conditions. Models adjusted for demographics revealed significantly increased odds of allergy, asthma, enuresis, headache/migraine, and serious stomach or bowel problems. After adjusting for comorbidity, across the medical conditions, enuresis and serious stomach problems were the strongest correlates of ADHD. These findings confirm the pervasive medical comorbidity of ADHD reported in previous clinical and community-based studies. The intriguing salience of enuresis and serious stomach or bowel conditions may also provide an important clue to multisystem involvement in ADHD.

Color Vision Deficiency and Functional Disorders Among Israeli Male Adolescents Between 2007 and 2013

Color vision deficiency has been associated with educational difficulties among male children, as well as attention-deficit hyperactivity disorder (ADHD). We examined the association of color vision deficiency with functional conditions, including ADHD, irritable bowel syndrome, enuresis and somatoform disorders, in a large population of male adolescents. We included all Israeli male adolescents that underwent medical and cognitive examinations during conscription between the years 2007 and 2013. The prevalence of ADHD, irritable bowel syndrome, enuresis, and somatoform disorders among color vision deficiency patients was compared to a control group. The study included 305 964 males aging 17 ± 0.6, of which 7584 (2.5%) had color vision deficiency. Using a multivariable analysis, the probability for irritable bowel syndrome, enuresis, and somatoform disorders among color vision deficiency patients was increased by 1.41, 1.94, and 3.87, respectively (P < .05). No significant association was found between ADHD and color vision deficiency. Color vision abnormalities are associated with functional disorders in male adolescents, including irritable bowel syndrome, enuresis, and somatoform disorders.

Effects of adenotonsillar hypertrophy corrective surgery on nocturnal enuresis of children

BACKGROUND

Nocturnal enuresis is considered a common urological complaint especially among children. Respiratory obstructive diseases have been one of the possible etiologies of such a condition. The most common type of upper respiratory obstructive diseases in childhood is adenotonsillar hypertrophy. In this study, it was tried to estimate the prevalence of nocturnal enuresis in adenotonsillar hypertrophy as an upper obstructive airway disease and cure rate after corrective operation.

MATERIALS AND METHODS

In this longitudinal study, 184 children with adenotonsillar hypertrophy as case group and 200 healthy children as control group were randomly compared for nocturnal enuresis incidence and risk factors. Then they were followed after 6 months to estimate the cure rate after corrective operation.

RESULTS

In case group, nocturnal enuresis was more common than control group (26% vs. 17%, P = 0.1). Factors which had a role in enuresis in case group were family history (P = 0.03) and male sex (P = 0.05). Three months after surgery, 48% of children totally cured from enuresis (P = 0.001) and 71% cured both partially or totally (P = 0.03). The response rate after moderate obstruction relieving was 100% while that in severe cases was 60% (P = 0.2).

CONCLUSIONS

Nocturnal enuresis due to upper obstructive airway disease occurs more in male and in the presence of family history. The cure rate after 6 months of operation was more prominent in moderate obstruction which suggests enuresis in severe airway obstruction may need a longer time to subside. Cure rate of primary enuresis due to obstructive airway disease after 6 months of relieving was 48% in children over 5 years old.

Moderate agreement between bladder capacity assessed by frequency volume charts and uroflowmetry, in adolescent and adult enuresis patients

AIMS

Frequency Volume Charts (FVC) are recommended for the evaluation of enuretic patients. Although this is a good instrument for the assessment of functional bladder capacity, it is known that patient compliance could introduce problems. Therefore, we assessed whether uroflowmetry and post-void residual volume could replace FVC recordings in specific cases, by comparing the bladder capacity as measured by FVC or uroflowmetry.

METHODS

We performed post-hoc analyses using data from a retrospective cohort study, in secondary/tertiary care. This included 907 patients between 2003 and 2013, aged ≥11 years, suffering from enuresis (≥1 wet night/fortnight). Data were collected from the medical files. Bland Altman plots were made to compare the two methods.

RESULTS

Agreement between uroflowmetry and FVC was reasonable only when uroflowmetry was between 200 and 450 ml.

CONCLUSIONS

For individual clinical purposes, uroflowmetry can be used if values are in this range. For future research, we recommend to keep measuring bladder capacity with an FVC. Neurourol. Urodynam. 36:745-747, 2017. © 2016 Wiley Periodicals, Inc.

Cardiac Autonomic Nervous System Activity in Children with Bladder and Bowel Dysfunction

PURPOSE

Bladder and bowel dysfunction is a common reason for referral to pediatric urology. The role of the autonomic nervous system in the pathogenesis of bladder and bowel dysfunction has not been well investigated. We compared autonomic nervous system activity in children with bladder and bowel dysfunction to that in healthy controls. We hypothesized that children with dysfunction have a different autonomic profile as measured by parameters from spectral analysis of heart rate variability and impedance cardiography.

MATERIALS AND METHODS

We recruited 40 children, including 25 girls, with a median age of 10 years (range 5 to 18) in whom bladder and bowel dysfunction was clinically diagnosed by a validated questionnaire and 19 healthy controls, including 9 girls, with a median age of 8 years (range 5 to 16). Cardiac autonomic activity was assessed at baseline and during voiding. The primary outcome measures were the main parameters of heart rate variability, including total power and high frequency, as well as pre-ejection period and heart rate.

RESULTS

Comparison of outcomes at baseline showed significantly lower total power and high frequency heart rate variability in bladder and bowel dysfunction cases (p = 0.001 and 0.002, respectively). Children with dysfunction also showed a significantly smaller decrease in sympathetic nervous system activity during voiding (p = 0.05).

CONCLUSIONS

Our results demonstrate that compared to healthy controls children with bladder and bowel dysfunction show a different cardiac autonomic profile at rest and in response to voiding. This difference may be used in future studies to further clarify the pathophysiology of bladder and bowel dysfunction, and introduce novel treatment targets to manage the condition.

Tricyclic and related drugs for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) affects up to 20% of five year-olds and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Tricyclics have been used to treat enuresis since the 1960s.

OBJECTIVES

To assess the effects of tricyclic and related drugs compared with other interventions for treating children with enuresis.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (containing trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings), on 30 November 2015, and reference lists of relevant articles.

SELECTION CRITERIA

We included all randomised and quasi-randomised trials comparing a tricyclic or related drug with another intervention for treating enuresis. We also included combination therapies that included tricyclics. We excluded trials for treating daytime wetting.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the quality of the eligible trials, and extracted data. We settled differences by discussion with a third review author.

MAIN RESULTS

Sixty-four trials met the inclusion criteria, involving 4071 children. The quality of many trials was poor, with comparisons addressed by single studies. Minor adverse effects were common, and reported in 30 trials. These included dizziness, headache, mood changes, gastrointestinal discomforts and neutropenia. More serious side-effects can occur but were not reported. Seven trials reported no adverse effects.Tricyclics are more effective than placebo, particularly for short-term outcomes. Compared to placebo, imipramine resulted in one fewer wet nights per week (mean difference (MD) -0.95, 95% confidence interval (CI) -1.40 to -0.50; 4 trials, 347 children), with fewer failing to achieve 14 consecutive dry nights (78% versus 95% for placebo, RR 0.74, 95% CI 0.61 to 0.90; 12 trials, 831 children). Amitriptyline and desipramine were more effective than placebo, but nortriptyline and mianserin showed no difference. Most tricyclics did not have a sustained effect after ceasing treatment, with 96% wetting at follow-up for imipramine versus 97% for placebo.Imipramine combined with oxybutynin is also more effective than placebo, with 33% failing to achieve 14 consecutive dry nights at the end of treatment versus 78% for placebo (RR 0.43, 95% CI 0.23 to 0.78; 1 trial, 47 children) and 45% wetting at follow-up versus 79% for placebo (RR 0.58, 95% CI 0.34 to 0.99; 1 trial, 36 children).There was insufficient evidence to judge the effect between different doses of tricyclics, and between different tricyclics. Treatment outcomes between tricyclic and desmopressin were similar, but were mixed when tricyclic was compared with an anticholinergic. However, when imipramine was compared with desmopressin plus oxybutynin (1 trial, 45 children), the combination therapy was more effective, with one fewer wet nights per week (MD 1.07, 95% CI 0.06 to 2.08) and 36% failing to achieve 14 consecutive dry nights versus 87% for imipramine (RR 2.39, 95% CI 1.35 to 4.25). Tricyclics were also more effective or showed no difference in response when compared to other drugs which are no longer used for enuresis.Tricyclics were less effective than alarms. Although there was no difference in the number of wet nights, 67% failed to achieve 14 consecutive dry nights for imipramine versus only 17% for alarms (RR 4.00, 95% CI 1.06 to 15.08; 1 trial, 24 children). Alarm therapy also had a more sustained effect after ceasing treatment with 100% on imipramine versus 58% on alarms wetting at follow-up (RR 1.67, 95% CI 1.03 to 2.69; 1 trial, 24 children).Imipramine was more effective than simple behavioural therapies during treatment, with one fewer wet nights per week compared with star chart plus placebo (MD -0.80, 95% CI -1.33 to -0.27; 1 trial, 250 children). At follow-up 40% were wet with imipramine versus 80% with fluids and avoiding punishment (RR 0.50, 95% CI 0.28 to 0.89; 1 trial, 40 children). However, imipramine was less effective than complex behavioural therapies, with 61% failing to achieve 14 consecutive dry nights for imipramine versus 33% for the three-step programme (RR 1.83, 95% CI 1.08 to 3.12; 1 trial, 72 children) and 16% for the three-step programme combined with motivational therapy and computer-led education (RR 3.91, 95% CI 2.30 to 6.66; 1 trial, 132 children) at the end of treatment, with similar results at follow-up.Tricyclics were more effective than restricted diet, with 99% failing to achieve 14 consecutive dry nights versus 84% for imipramine (RR 0.84, 95% CI 0.75 to 0.93; 1 trial, 147 children).There was insufficient evidence to judge the effect of tricyclics compared to the other miscellaneous interventions studied.At the end of treatment there were about two fewer wet nights for imipramine plus oxybutynin compared with imipramine monotherapy (MD -2.10, 95% CI -2.99 to -1.21; 1 trial, 63 children) and 48% on imipramine plus oxybutynin failed to achieve 14 consecutive dry nights compared with 74% on imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.92; 2 trials, 101 children). At follow-up, 45% on imipramine plus oxybutynin were wetting versus 83% on imipramine monotherapy (RR 0.55, 95% CI 0.32 to 0.92; 1 trial, 36 children).When imipramine combined with desmopressin was compared with imipramine monotherapy, there was no difference in outcomes. However, when imipramine plus desmopressin was compared with desmopressin monotherapy, the combination was more effective, with 15% not achieving 14 consecutive dry nights at the end of treatment for imipramine plus desmopressin versus 40% for desmopressin monotherapy (RR 0.38, 95% CI 0.17 to 0.83; 1 trial, 86 children). Tricyclics combined with alarm therapy were not more effective than alarm monotherapy, alarm combined with desmopressin or alarm combined with nortriptyline. The addition of a tricyclic to other behavioural therapies did not alter treatment response.

AUTHORS' CONCLUSIONS

There was evidence that tricyclics are effective at reducing the number of wet nights during treatment, but do not have a sustained effect after treatment stops, with most children relapsing. In contrast, there was evidence that alarm therapy has better short- and long-term outcomes. There was some evidence that tricyclics combined with anticholinergics may be more effective that tricyclic monotherapy.

Reference values for frequency volume chart and uroflowmetry parameters in adolescent and adult enuresis patients

AIMS

Reference values of Frequency Volume Chart (FVC) and uroflowmetry parameters for adolescent and adult enuresis patients are lacking. In this study, we aim to describe those parameters, in order to interpret findings from FVCs and uroflowmetries in those patients.

METHODS

Retrospective, descriptive cohort study, concerning 907 patients aged 11 years and older, suffering from enuresis of at least one wet night per fortnight, treated in a secondary/tertiary centre, between 2003 and 2013. The main FVC parameters of interest were: maximum voided volume (MVV), 24 hr urine production and nocturnal urine volume (NUV) including first morning void (FMV). Nocturnal polyuria (NP) was defined based on both International Children's Continence Society (ICCS, 2014) and International Continence Society (ICS, 2002) definitions. Data of all patients were collected from the medical files.

RESULTS

Age had an impact on diurnal and nocturnal FVC parameters. Median MVV excluding FMV was 250 ml in the youngest, 11-year-old males and 363 ml in the eldest, ≥18-yr-old males. For females, these values were 230 ml and 310 ml. Median 24 hr urine production increased from 1,025 ml to 1,502 ml (males) and from 1,007 ml to 1,557 ml (females). Median NUV showed an increase from 387 ml to 519 ml (males) and from 393 ml to 525 (females). Forty-two percent of men and 30% of women had a small MVV (for age). Prevalence of NP differed when assessed by the ICS or the ICCS definition: following ICS guidelines, NP was present in 96% of our male and 93% of our female population, compared to 27% and 41%, respectively, following ICCS guidelines.

CONCLUSIONS

Both small MVV and NP were found frequently in our adolescent and adult enuresis patients, which is in line with the current thoughts on causal factors. NP prevalence is quite different when using ICS or ICCS definitions, respectively. We would like to encourage the development of an unambiguous definition of NP to use both in pediatric and adult urology. Neurourol. Urodynam. 36:463-468, 2017. © 2016 Wiley Periodicals, Inc.

Incidence of obsessive-compulsive disorder in children with nonmonosymptomatic primary nocturnal enuresis

Introduction:

Enuresis is defined as the repeated voiding of urine into clothes or bed at least twice a week for at least 3 consecutive months in a child who is at least 5 years of age. The behavior is not due exclusively to the direct physiologic effect of a substance or a general medical condition. Diurnal enuresis defines wetting, whereas awake and nocturnal enuresis refers to voiding during sleep. Primary enuresis occurs in children who have never been consistently dry through the night, whereas secondary enuresis refers the resumption of wetting after at least 6 months of dryness. Monosymptomatic enuresis has no associated daytime symptoms, and nonmonosymptomatic enuresis, which is more common, often has at least one subtle daytime symptom. Monosymptomatic enuresis is rarely associated with significant organic underlying abnormalities. Obsessive–compulsive disorder (OCD) is a chronic disabling illness characterized by repetitive, ritualistic behaviors over which the patients have little or no control. The purpose of this study was to investigate the relationship between OCD and nonmonosymptomatic nocturnal enuresis (NMNE).

Materials and Methods:

In this case–control study, we evaluated 186 children aged 6–17 years old who were visited in the pediatric clinics of Amir Kabir Hospital, Arak, Iran. The control group included 93 healthy children, and the case group included 93 age- and sex-matched children with stage 1–3 chronic kidney disease (CKD). Then, the children's behavioral status was evaluated using the Children's Yale-Brown Obsessive–Compulsive Scale.

Results:

The difference in compulsion was significant (P = 0.021), whereas the difference in obsession was significant between the two groups (P = 0.013). The most common symptom in CKD children with compulsion was silent repetition of words.

Conclusion:

Compulsive and obsessive are more common in NMNE versus healthy children. The observed correlation between compulsive-obsessive and NMNE makes psychological counseling mandatory in children with NMNE.

Topical use of Matricaria recutita L (Chamomile) Oil in the Treatment of Monosymptomatic Enuresis in Children: A Double-Blind Randomized Controlled Trial

AIM

To evaluate the efficacy of topical use of Matricaria recutita L oil in the treatment of enuresis in children.

METHODS

Eighty patients diagnosed as monosymptomatic nocturnal or daytime enuresis were allocated to receive Matricaria recutita L (chamomile) oil or placebo topically for 6 weeks in a double-blind randomized placebo-controlled trial with a parallel design. Patients were evaluated prior to and following 8 weeks of the intervention in terms of frequency of enuresis and any observed adverse events.

RESULTS

The mean frequency of enuresis at the first, second, and third 2 weeks was lower in the intervention group compared with the placebo group, and the differences were statistically significant (P < .001, P = .03, and P < .001, respectively). There was no report of any adverse event in the study groups.

CONCLUSION

The findings of this study showed that the topical use of (chamomile) oil can decrease the frequency of nocturia in children with monosymptomatic nocturnal or daytime enuresis.

The management of childhood urinary incontinence

The International Children's Continence Society (ICCS) has undertaken an enormous effort to standardize both the terminology and management of various aspects of incontinence in children, including enuresis, bladder overactivity, dysfunctional voiding and psychological comorbidities. A number of guidelines have been published to aid those involved in the care of children with lower urinary tract symptoms. This review addresses a number of recommended diagnostic and therapeutic strategies, including urotherapy and pharmacological treatment, with emphasis on a focused medical history, information acquired from bladder diaries and uroflow evaluations. The major role of urotherapy is underlined with supportive pharmacotherapy, when indicated. The article provides both a summary of ICCS guidelines and a brief review of recently published papers related to the contemporary management of childhood incontinence, a health issue still underestimated by both the child's caregivers and healthcare providers.

A pilot randomized controlled trial evaluating the effectiveness of group vs individual urotherapy in decreasing symptoms associated with bladder-bowel dysfunction

PURPOSE

We determined the feasibility of a definitive trial comparing the effectiveness of group vs individual urotherapy for children with bladder-bowel dysfunction.

MATERIALS AND METHODS

Children 6 to 10 years old with bladder-bowel dysfunction were recruited during the course of 1 year. Feasibility data on screening, eligibility, recruitment and protocol compliance rates were collected. Patients with high grade hydronephrosis, vesicoureteral reflux or learning disabilities and those who had previously undergone urotherapy were excluded. Patients were randomized to 1-hour group urotherapy or 15-minute individual urotherapy. Symptoms and quality of life were measured using the Vancouver Nonneurogenic Lower Urinary Tract Dysfunction/Dysfunctional Elimination Syndrome Questionnaire and the Pediatric Incontinence Questionnaire at baseline and at 3 to 6 months of followup. Within/between group comparisons were conducted using t-tests.

RESULTS

Of 455 screened children 79 were eligible and 60 were recruited to participate. A total of 24 patients randomized to group urotherapy and 25 randomized to individual urotherapy completed the pilot trial (6 undergoing group and 5 undergoing individual urotherapy withdrew from the study). Symptomology scores between group and individual urotherapy were not different at followup (mean ± SD 14.7 ± 7.9 vs 13.4 ± 6.3, p = 0.54, 95% CI -5.4-2.8). Quality of life scores between patients undergoing group and individual urotherapy at baseline differed (mean ± SD 21.1 ± 10.8 vs 31.0 ± 14.3, p < 0.01, 95% CI 2.7-7.3) but became similar at followup (21.0 ± 14.2 vs 20.1 ± 15.3, p = 0.84, 95% CI -9.4-7.6). Within group analyses demonstrated improvement in symptomology from baseline to followup in patients undergoing group (mean ± SD 3.6 ± 7.6, p = 0.03, 95% CI 0.4-6.8) and individual urotherapy (6.0 ± 5.4, p < 0.01, 95% CI 3.8-8.3). Within group quality of life analyses revealed improvement in Pediatric Incontinence Questionnaire scores from baseline to followup in patients undergoing individual urotherapy (p < 0.01, 95% CI 5.0-16.9) only.

CONCLUSIONS

Urotherapy, regardless of modality, effectively improved bladder-bowel dysfunction symptoms. A definitive randomized controlled trial is feasible, considering that a high recruitment rate (76%) for this population has been established.

Is there a correlation between intravaginal ejaculatory latency time and enuresis? An exploratory study

INTRODUCTION

Premature ejaculation (PE) is the most common male sexual dysfunction. Monosymptomatic enuresis (ME) is nocturnal bed wetting, without any daytime symptoms. Recent clinical studies report an association between lifelong PE and ME. The purpose of this study was to compare the intravaginal ejaculatory time (IELT) between lifelong PE in men with and without ME. The goal was to determine if there is an association between the severity of ME and of IELT.

MATERIAL AND METHODS

A total of 137 men with lifelong PE were included in this study. Subjects were asked if they had childhood ME. The characteristics and mean IELTs of patients with and without ME were compared using the student's t-test, and the correlation between severity of ME and IELT was assessed with trend test.

RESULTS

Of the 137 lifelong PE patients, 57 reported ME. There was a strong negative correlation in patients with ME between the severity of enuresis and IELT, with IELT being shorter in patients with severe ME.

CONCLUSIONS

A strong correlation between IELT and the severity of ME suggests a common underlying mechanism. Further studies are required to confirm these findings and elucidate the exact pathophysiology.

Why does adenotonsillectomy not correct enuresis in all children with sleep disordered breathing?

PURPOSE

We analyzed the outcome of nocturnal enuresis after adenotonsillectomy in children with sleep disordered breathing. We also evaluated differences in demographic, clinical, laboratory and polysomnography parameters between responders and nonresponders after adenotonsillectomy.

MATERIALS AND METHODS

We prospectively evaluated children 5 to 18 years old diagnosed with sleep disordered breathing (snoring or obstructive sleep apnea syndrome) on polysomnography and monosymptomatic primary nocturnal enuresis requiring adenotonsillectomy to release upper airway obstruction. Plasma antidiuretic hormone and brain natriuretic peptide were measured preoperatively and 1 month postoperatively.

RESULTS

Sleep studies were done in 46 children and 32 also underwent blood testing preoperatively and postoperatively. Mean ± SD patient age was 8.79 ± 2.41 years and the mean number of wet nights weekly was 6.39 ± 1.26. Polysomnography revealed obstructive sleep apnea syndrome in 71.7% of patients and snoring in 28.3%. After adenotonsillectomy 43.5% of patients became dry. Preoperative polysomnography findings indicated that responders, who were dry, had significantly more arousals and obstructive apnea episodes but fewer awakenings than nonresponders, who were wet. Significant increases in plasma antidiuretic hormone and significant decreases in plasma brain natriuretic peptide were seen in all children with no difference between responders and nonresponders. No difference between the groups was noted in age, gender, race, body mass index, constipation, preoperative number of wet nights weekly or type of sleep disordered breathing.

CONCLUSIONS

Nocturnal enuresis resolved after adenotonsillectomy in almost half of the children with sleep disordered breathing. Those who became dry had more frequent arousal episodes caused by apnea events than those who remained wet.

Sodium valproate induced increased frequency of micturition and enuresis

Sodium valproate is a commonly used antiepileptic drug (AED) for control of a broad range of seizures. Adverse drug reactions (ADR) due to sodium valproate range from sedation to nausea, vomiting, weight gain, idiosyncratic adverse effects like hepatotoxicity and life threatening conditions like pancreatitis. We present a case of sodium valproate induced enuresis in child. This ADR of valproate is an underreported ADR and requires special attention of pediatricians as it can interfere with the further treatment of the disease.

Incidence of enuresis and encopresis among children with attention-deficit/hyperactivity disorder in a population-based birth cohort

OBJECTIVE

This study reports the incidence of enuresis and encopresis among children with attention-deficit/hyperactivity disorder (ADHD) versus those without ADHD.

METHODS

Subjects included 358 children (74.5% boys) with research-identified ADHD from a 1976 to 1982 population-based birth cohort (n = 5718) and 729 (75.2% boys) non-ADHD control subjects from the same birth cohort, matched by gender and age. All subjects were retrospectively followed from birth until a diagnosis of enuresis or encopresis was made or last follow-up before 18 years of age. The complete medical record for each subject was reviewed to obtain information on age of initial diagnosis of an elimination disorder, frequency and duration of symptoms, and identification of exclusionary criteria specified by DSM-IV, with confirmation of the diagnosis by expert consensus.

RESULTS

Children with ADHD were 2.1 (95% confidence interval [CI], 1.3-3.4; P = .002) times more likely to meet DSM-IV criteria for enuresis than non-ADHD controls; they were 1.8 (95% CI, 1.2-2.7; P = .006) times more likely to do so than non-ADHD controls when less stringent criteria for a diagnosis of enuresis were employed. Though not significant, children with ADHD were 1.8 (95% CI, 0.7-4.6; P = .23) times more likely to meet criteria for encopresis than non-ADHD controls. The relative risk was 2.0 (95% CI, 1.0-4.1; P = .05) when a less stringent definition for encopresis was utilized.

CONCLUSIONS

Children with ADHD are more likely than their peers without ADHD to develop enuresis with a similar trend for encopresis.

Sodium valproate-induced enuresis in a pediatric bipolar patient

Sodium valproate (SV) is effective and well tolerated for the treatment of epilepsy and mood disorders. There are several cases of SV-induced enuresis noted in epileptic patients. No alternative medication has been suggested to manage this problem. We present the first case of a pediatric bipolar patient who developed diurnal and nocturnal enuresis during SV therapy. Clinicians should be aware of this side effect, as it has not been reported in nonepileptic patients, and it may be detrimental to treatment adherence.

Desmopressin melt improves response and compliance compared with tablet in treatment of primary monosymptomatic nocturnal enuresis

Primary nocturnal enuresis is a prevalent childhood condition that can persist into adulthood. Desmopressin is an antidiuretic available as orally disintegrating lyophilisate (melt) or solid tablet. Recent findings suggesting different food interactions and clinical characteristics, including compliance, between desmopressin melt and tablet motivated a post hoc analysis of a previously reported randomised, crossover study. The efficacy of desmopressin melt compared with tablet was evaluated using the International Children's Continence Society (ICCS) responder definitions. Compliance was further analysed using detailed criteria, and the association between efficacy and compliance was examined. In total, 221 patients aged 5-15 years, already receiving desmopressin tablets were randomised to the treatment sequence melt (120/240 μg)/tablet (0.2/0.4 mg) or tablet/melt in two consecutive 3-week periods. The probability of being a responder (partial or full) during either period was significantly more likely with desmopressin melt compared with tablet (odds ratio, 2.0; confidence intervals, 1.07-3.73; p = 0.03). There was no period effect on compliance in the tablet/melt sequence and no difference in the number of completely compliant patients in each formulation group; however, more patients were >75 % compliant in period 1 compared with period 2 in the melt/tablet sequence. Increased compliance was associated with greater reductions in the number of wet nights for both formulations.

CONCLUSIONS

Desmopressin melt, compared with tablet, improves the probability of being a responder. Switching from tablet to melt formulation increased patient compliance. Increased compliance was associated with increased efficacy. Switching to desmopressin melt may benefit patients with suboptimal responses to desmopressin tablet.

Practical consensus guidelines for the management of enuresis

Despite the high prevalence of enuresis, the professional training of doctors in the evaluation and management of this condition is often minimal and/or inconsistent. Therefore, patient care is neither optimal nor efficient, which can have a profound impact on affected children and their families. Once comprehensive history taking and evaluation has eliminated daytime symptoms or comorbidities, monosymptomatic enuresis can be managed efficaciously in the majority of patients. Non-monosymptomatic enuresis is often a more complex condition; these patients may benefit from referral to specialty care centers. We outline two alternative strategies to determine the most appropriate course of care. The first is a basic assessment covering only the essential components of diagnostic investigation which can be carried out in one office visit. The second strategy includes several additional evaluations including completion of a voiding diary, which requires extra time during the initial consultation and two office visits before treatment or specialty referral is provided. This should yield greater success than first-line treatment.

CONCLUSION

This guideline, endorsed by major international pediatric urology and nephrology societies, aims to equip a general pediatric practice in both primary and secondary care with simple yet comprehensive guidelines and practical tools (i.e., checklists, diary templates, and quick-reference flowcharts) for complete evaluation and successful treatment of enuresis.

Sleep Disturbances in Pediatric Bipolar Disorder: A Comparison between Bipolar I and Bipolar NOS

INTRODUCTION

The diagnosis of bipolar disorder (BD) in youths has been controversial, especially for the subtype BD not otherwise specified (BD-NOS). In spite of growing evidence that sleep is a core feature of BD, few studies characterize and compare sleep disturbances in youth with BD type I (BD-I) and BD-NOS. Sleep disturbances are frequently reported in clinical descriptions of children and adolescents with BD, however the reporting of the frequency and characteristics of sleep symptoms in youth with BD-NOS and BD-I during episodes remain poor. This study compares symptom of sleep disturbance as occurring in manic and depressive episodes in BD-I and BD-NOS youth using Kiddie-schedule for affective disorders and schizophrenia, present and lifetime version (K-SADS-PL) interview data. The study also addresses whether symptoms of sleep disturbance vary in different age groups.

MATERIALS AND METHODS

The sample consisted of 70 children and adolescent outpatients at an urban specialty clinic (42M/28F, 10.8 ± 3.6 years old) including 24 BD-I and 46 BD-NOS assessed using K-SADS-PL-parent interview.

RESULTS

Sleep disturbances including insomnia and decreased need for sleep were reported by 84.3% of the sample. Enuresis was diagnosed in 27% of sample. There were no significant differences in frequency of sleep symptoms between BD-I and BD-NOS. Regardless of BD subtype, current functioning was negatively correlated with decreased need for sleep but not insomnia, and regardless of BD subtype.

CONCLUSION

The majority of youth with BD presents with sleep symptoms during mood episodes. BD-NOS presents with the same proportion of sleep symptoms as BD-I in our sample.

Nocturnal enuresis-theoretic background and practical guidelines

Nocturnal polyuria, nocturnal detrusor overactivity and high arousal thresholds are central in the pathogenesis of enuresis. An underlying mechanism on the brainstem level is probably common to these mechanisms. Enuretic children have an increased risk for psychosocial comorbidity. The primary evaluation of the enuretic child is usually straightforward, with no radiology or invasive procedures required, and can be carried out by any adequately educated nurse or physician. The first-line treatment, once the few cases with underlying disorders, such as diabetes, kidney disease or urogenital malformations, have been ruled out, is the enuresis alarm, which has a definite curative potential but requires much work and motivation. For families not able to comply with the alarm, desmopressin should be the treatment of choice. In therapy-resistant cases, occult constipation needs to be ruled out, and then anticholinergic treatment-often combined with desmopressin-can be tried. In situations when all other treatments have failed, imipramine treatment is warranted, provided the cardiac risks are taken into account.

Micturitional dryness and attitude of parents towards enuresis in children attending outpatient unit of a tertiary hospital in Abeokuta, Southwest Nigeria

BACKGROUND

There is significant variability of the age at which children achieve dryness.

OBJECTIVES

We determine the age at achievement of micturational dryness and attitude of parents about enuresis among urban Nigerian children.

METHOD

A total of 346 questionnaires were administered to parents of children between the ages of 12 - 180 months who came for routine paediatric care at the outpatient unit of Federal Medical Centre, Abeokuta.

RESULTS

At age 36 months, 86 (51.8 %) and 34 (20.5 %) out of 166 children had achieved dryness at daytime and night time respectively. Achievement of dryness was significantly related to low maternal education (p = 0.022) and low social class (p = 0.009). Twenty-four (26.7 %) children had nocturnal enuresis. Four (4.4 %) of these children also had diurnal enuresis. All the parents/guardians were aware about enuresis but only 9.8 % correctly identified it as a health problem. Even though none of the children with enuresis ever visited health facility for their problem, a statistically significant proportion of the parents desire to discuss with health practitioners (p = 0.015).

CONCLUSIONS

The proportion of children achieving dryness by age 36 months is very small when compared with children from developed parts of the world. There is also a high prevalence of enuresis which are not reported. Therefore, health workers in the tropics should as a routine enquire about enuresis in their daily paediatric care particularly for those children from polygamous homes and high social class.

Urofacial syndrome: A subset of neurogenic bladder dysfunction syndromes?

The urofacial syndrome is probably a subset of neurogenic bladder dysfunction syndromes characterized by detrusor-sphincter discoordination along with a characteristic inversion of facial expression with laughing. This characteristic facial expression can facilitate early detection of this disorder, which leads to poor bladder emptying with high residual urine, hydro-nephrosis with vesico-ureteral reflux and potentially renal failure if left untreated. The etiology of the urofacial syndrome is unknown. In our case, a 12-year-old boy of Middle-Eastern origin presented to the Outpatient Department of our hospital with left pyelonephritis, hydronephrosis and bladder dilatation. Voiding cystourethrography performed 15 days later revealed left vesicoureteral reflux. Cystoscopy revealed bladder trabeculation however an anatomic urethral obstruction was not noticed. Both, neurological examination and radiography of the lumbosacral spine were normal. Urodynamic evaluation revealed the typical findings of detrusor-sphincter discoordination.

children: results from a nationally representative study

OBJECTIVE

There are no published nationally representative prevalence estimates of enuresis among children in the United States using standardized diagnostic criteria. This study sets out to describe the prevalence, demographic correlates, comorbidities, and service patterns for enuresis in a representative sample of U.S. children.

METHOD

The diagnosis of enuresis was derived from parent-reported data for "enuresis, nocturnal" collected using the computerized version of the Diagnostic Interview Schedule for Children (C-DISC 4.0) from a nationally representative sample of 8- to 11-year-old children (n = 1,136) who participated in the 2001-2004 National Health and Nutrition Examination Surveys.

RESULTS

The overall 12-month prevalence of enuresis was 4.45%. The prevalence in boys (6.21%) was significantly greater than that in girls (2.51%). Enuresis was more common at younger ages and among black youth. Attention-deficit/hyperactivity disorder (ADHD) was strongly associated with enuresis (odds ratio 2.88; 95% confidence interval 1.26-6.57). Only 36% of the enuretic children had received health services for enuresis.

CONCLUSIONS

Enuresis is a common condition among children in the United States. Few families seek treatment for enuresis despite the potential for adverse effects on emotional health. Child health care professionals should routinely screen for enuresis and its effects on the emotional health of the child and the family. Assessment of ADHD should routinely include evaluation for enuresis and vice versa. Research on the explanations for the association between enuresis and ADHD is indicated.

Psychosis and enuresis during disulfiram therapy

Disulfiram is the drug that is commonly prescribed for the treatment of alcohol dependence syndrome, and transient functional psychosis has been reported as one of its side-effects. Enuresis is another rare adverse effect reported. This report discusses a case of acute psychosis and enuresis in a patient on disulfiram who had ingested alcohol.

Enuresis: are we using the optimal treatment?

A multitude of treatments are currently being used for enuresis. This article reviews the scientific evidence supporting various treatments and indicating their effectiveness. Recent evidence demonstrating the significant improvement of psychological well-being as a result of treatment indicates that treatment should be started early. The literature shows that 48% of parents do not seek medical help for children with enuresis. They tend to use ineffective and sometimes damaging treatment, such as punishment. The authors conclude that the modern enuretic alarm is relatively safe, painless, easy to use, and is the most effective treatment available.