Bladder dysfunction in children with refractory monosymptomatic primary nocturnal enuresis

Bladder wall thickness and urodynamic correlation in children with primary nocturnal enuresis

OBJECTIVE

To investigate the correlations between ultrasonographic bladder wall thickness (BWTh) and urodynamic study (UDS) findings and estimate the diagnostic value of BWTh for prediction of DO in children with monosymptomatic and non-monosymptomatic primary nocturnal enuresis (PNE).

PATIENTS AND METHODS

Ultrasound measurements (US) and UDS were performed on a total of 100 children, 50 consecutive boys and 50 consecutive girls, 6-14 years old, with monosymptomatic PNE (group 1, n = 75), and non-monosymptomatic PNE (group 2, n = 25). The US Protocol was specially designed for the evaluation of BWTh. All children underwent urodynamic studies for detailed assessment of any underlying bladder overactivity. Findings were compared between the two groups of patients.

RESULTS

The mean BWTh was increased in the group 2 compared to the group 1 (mean ± SD = 2.4 ± 0.41 mm, mean ± SD = 1.52 ± 0.18 mm respectively, p < 0.05). Detrusor overactivity (DO) occurred in 23/75 (30.5%) children of the group 1 and in 17/25 (68%) children of the group 2 (p < 0.05). Comparing the BWTh between the two groups of patients and the UDS findings, it was found that BWTh was significantly correlated with DO(r = 0.92 and p < 0.001), children with DO presented significantly increased BWTh compared to those without (mean ± SD = 2.1 ± 0.4 mm, mean ± SD = 1.5 ± 0.4 mm respectively, p < 0.05) and the maximum amplitude of DO occurred in 20 children who had non-monosymptomatic PNE.

CONCLUSIONS

We suggest that BWTh could be applied as a screening tool to identify the cases of DO between the children with PNE. Children with non-monosymptomatic PNE presented increased BWTh and higher percentages of DO.

Refractory enuresis in children and adolescents: how can urodynamics affect management and what is the optimum test?

OBJECTIVE

After failure of medical and behavioral therapy in enuresis, the usual next step is to investigate using urodynamics. The aim of this study was to determine the actual benefit and optimal method of urodynamics in the treatment of refractory enuresis.

METHODS

This prospective randomized study included 56 patients: 17 males and 39 females with an age range of 7-16 years. All had tried multiple courses of medical treatment for enuresis for at least 6 months without response. Thirty patients underwent investigation by cystometrogram, uroflowmetry and electromyogram (UFM/EMG), while 26 patients underwent pressure/flow/EMG (P/F/EMG) studies.

RESULTS

Bladder filling abnormalities were found in 25 out of the 56 patients (44.6%) and included low bladder capacity in 39%, hypocompliance in 32%, and detrusor overactivity in 45%. With regard to voiding dysfunction, 70% of the UFM/EMG group had detrusor‒sphincter dyssynergia and 67% of the P/F/EMG group had bladder outlet obstruction.

CONCLUSIONS

Urodynamics can help in cases of refractory enuresis by detecting dysfunctional voiding, which is present in a large percentage of these patients. This can be diagnosed by UFM/EMG, rather than P/F/EMG, as a non-invasive test. UFM alone may be misleading. Alpha adrenergic blockers may be of benefit in treating these patients.

Nocturnal enuresis

Nocturnal enuresis (NE) is increasingly seen as part of a heterogeneous phenomenon that at times will include daytime lower urinary tract symptoms such as urgency, frequency and wetting - with reduced bladder storage, usually due to an overactive bladder. In turn, these may be associated with constipation and/or faecal soiling. This paper discusses these considerations in the management of NE.

Does combination therapy with desmopressin and tolterodine improve the treatment outcomes of patients with monosymptomatic nocturnal enuresis? A randomized clinical controlled trial

Several therapeutic options have been described for children with nocturnal enuresis, but still their efficacy and outcomes are controversial. This study compares the combined Desmopressin and Tolterodine efficacy versus Desmopressin alone efficacy in the treatment of nocturnal enuresis. One hundred children 5–16 years old with nocturnal enuresis were enrolled in a randomized trial study and were assigned to two equal groups. In a double-blind manner, we used 2 mg of Tolterodine tablet plus 20 μg of nasal Desmopressin in group A and 20 μg of nasal Desmopressin plus placebo in group B. The two groups were matched for age and sex (P = 0.547, P = 0.414). The mean number of the wet nights was reduced in both groups (P < 0.001, P < 0.001). Upon ICCS scoring in the Tolterodine + Desmopressin group, 27 (54%) had full response, 17 (34%) had partial response, and 5 (10%) had an unsuccessful outcome. In the Desmopressin + placebo group, 17 (34%) had full response, 23 (46%) had partial response, and 10 (20%) had an unsuccessful outcome. The response in the Tolterodine + Desmopressin group was significantly higher (P = 0.049). Regarding the results, combined Tolterodine plus Desmopressin is slightly more effective than monotherapy.

Lower urinary tract function in childhood; normal development and common functional disturbances

This review aims to provide researchers and clinicians involved with the adult lower urinary tract with background knowledge regarding the early development of bladder function and its most common disturbances in childhood. Bladder development begins in weeks 4-6 and the detrusor muscle is formed during weeks 9-12 of gestation. Higher CNS centres are involved in micturition at birth, and the infant usually wakes up, at least briefly, to void. Voiding during the first years of life is often incomplete, owing to detrusor-sphincter dyscoordination, but this disappears when bladder control is attained. Approximately 5-10% of 7-year-old children suffer from daytime incontinence and/or nocturnal enuresis, and a few per cent of them will not outgrow it. Daytime incontinence in childhood is usually attributable to detrusor overactivity, although it is unclear to what extent it is the detrusor or the micturition reflex per se that is overactive. Enuresis - nocturnal incontinence - is caused by either nocturnal polyuria and/or nocturnal detrusor overactivity, in both cases combined with high arousal thresholds. Bladder problems in childhood constitute a risk factor for the development or persistence of bladder problems in adulthood.

Role of posterior tibial nerve stimulation in the treatment of refractory monosymptomatic nocturnal enuresis: a pilot study

PURPOSE

We evaluated the early clinical and urodynamic results of posterior tibial nerve stimulation in patients with refractory monosymptomatic nocturnal enuresis.

MATERIALS AND METHODS

We randomly assigned 28 patients with refractory monosymptomatic nocturnal enuresis to 2 equal groups. Group 1 received a weekly session of posterior tibial nerve stimulation for 12 weeks and group 2 was the placebo group. Evaluation was performed in each group at baseline and after posterior tibial nerve stimulation to compare clinical and urodynamic findings. Another clinical assessment was done 3 months after the first followup.

RESULTS

The 2 groups were comparable in baseline clinical and urodynamic data. Overall, 13 patients (46.4%) had detrusor overactivity and 14 (50%) had decreased bladder capacity. After treatment 11 group 1 patients (78.6%) had a partial or full response to posterior tibial nerve stimulation but only 2 (14.3%) in group 2 had a partial response (p = 0.002). Also, the average number of wet nights in group 1 was significantly lower than at baseline (p = 0.002). All urodynamic parameters significantly improved in group 1. In contrast, the number of wet nights and urodynamic parameters did not change significantly in group 2. At 3-month followup the number of patients with a partial or full response in group 1 had decreased from 11 (78.6%) to 6 (42.9%). No change was evident in group 2.

CONCLUSIONS

Posterior tibial nerve stimulation can be a viable treatment option in some patients with refractory monosymptomatic nocturnal enuresis. However, deterioration in some responders with time suggests the need for maintenance protocols.

Effect of indomethacin on desmopressin resistant nocturnal polyuria and nocturnal enuresis

PURPOSE

We evaluated the acute effect of indomethacin on renal water and solute handling in children with coexisting monosymptomatic nocturnal enuresis and desmopressin resistant nocturnal polyuria, and in healthy controls.

MATERIALS AND METHODS

A total of 23 subjects were recruited, consisting of 12 children with monosymptomatic nocturnal enuresis and nocturnal polyuria with partial or no response to desmopressin, and 11 age matched controls. Children completed a 48-hour inpatient study protocol consisting of fractional urine collections and blood samples. Sodium and water intake were standardized. During the second night a dose of 50 mg indomethacin was administered orally before bedtime. Diuresis, urine osmolalities, clearances and fractional excretions were calculated for sodium, potassium, urea, osmoles and solute-free water. Renin, angiotensin II, aldosterone and atrial natriuretic peptide were measured in plasma. Prostaglandin E(2) was measured in urine.

RESULTS

Indomethacin markedly decreased the nocturnal sodium, urea and osmotic excretion in children with enuresis and controls. The overall effect on nocturnal urine output was inconsistent in the group with enuresis. Subjects in whom nocturnal diuresis was decreased following administration of indomethacin remained dry.

CONCLUSIONS

Prostaglandin inhibition leads to antidiuresis, reducing the amount of sodium, urea and osmotic excretion in children with monosymptomatic nocturnal enuresis and desmopressin resistant nocturnal polyuria. The sodium regulating hormones do not seem to mediate these processes. The overall effect in desmopressin nonresponders with nocturnal polyuria is variable. The extent to which indomethacin can be applied in the treatment of enuresis needs further evaluation.

The correlation between bladder volume wall index and the pattern of uroflowmetry/external sphincter electromyography in children with lower urinary tract malfunction

OBJECTIVE

To evaluate the relationship between bladder volume wall index (BVWI) and the pattern of uroflowmetry in children with lower urinary tract malfunction.

PATIENTS & METHODS

91 children aged 4-15 years with history of bladder dysfunction and 59 age/sex-matched healthy children with negative urine culture in previous month were enrolled. Uroflowmetry and kidney and bladder sonography were performed in all children. BVWI was measured by dividing maximum bladder volume index by mean bladder thickness. It was expressed as percentage by dividing calculated BVWI by expected BVWI, and values between 70% and 130% were presumed normal. Urodynamic study was done in symptomatic cases.

RESULTS

The bladder was thick (<70%) in 39 (28 cases, 11 controls) and thin (>130%) in 35 (18 cases, 17 controls) (P > 0.05). Uroflowmetry was abnormal in 82 (61 cases, 21 controls) (P < 0.05). Severe sphincter dyssynergia was detected in 47% of cases compared with 20% of controls (P < 0.05).There was no relationship between BVWI and uroflowmetry in cases or in controls (P > 0.05). The median post-void residual urine was not statistically different between the groups (20 vs 12.3 ml) (P > 0.05). When both bladder sonography and uroflowmetry were abnormal, they had an association with abnormal urodynamics (P < 0.05).

CONCLUSION

Among children with lower urinary tract dysfunction, the pattern of uroflowmetry could not be predicted from the BVWI, but in cases with combined abnormal bladder sonography and uroflowmetry results, there was a significant association with an abnormal urodynamic study.

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.

Chinese medicine and the surgeon

The surgeon aims at a direct, complete removal of the pathology. In spite of the modern advancements of imaging facilities and precision instrumentations, unsatisfactory results and recurrences are not uncommon. This paper provides a general review of the four specific areas in surgery that would benefit from Chinese medicine. Extensive searches were made on four surgical areas based on available English language journals, viz. low-back pain, chronic ulcers, renal calculus, and enuresis in children, in the past 10 years. The quoted communications are mainly related to clinical evidences, while a smaller number of crucial laboratory reports are also included. Low-back pain, a most frequent orthopaedic problem, would benefit from acupuncture treatment. Chronic leg ulcers could achieve better results of healing using herbal supplements. Problems of renal stones, besides the conventional methods of removal, could be further supplemented with herbal drinks that aim at prevention of recurrences. Enuresis in children, an untreatable common condition, may respond well to acupuncture. Surgeons should keep an open mind. In case of difficulties, they could seriously consider options of traditional treatment.

Correlation between Lower Urinary Tract Scoring System, Behavior Check List, and Bladder Sonography in Children with Lower Urinary Tract Symptoms

Purpose

The Pediatric Lower Urinary Tract Scoring System (PLUTSS) is a standardized questionnaire used for screening and evaluation of the response of children with lower urinary tract symptoms (LUTS) to therapy. We presumed that adding the Child Behavior Check List (CBCL) and bladder volume wall index (BVWI) to the PLUTSS would increase its validity in the detection of children with LUTS.

Materials and Methods

One hundred twenty-two children aged 5 to 15 years with LUTS were enrolled in the study. Seventy-two healthy, age-matched children without urinary complaints were considered as controls. The PLUTSS and CBCL were filled out for all children. Sonography was performed to measure BVWI. Chi-square test and likelihood ratio were used to compare frequencies, receiver operating curve (ROC) analysis was used to evaluate the correlation, and Cohen's kappa was used to measure the agreement between variables. p-values <0.05 were considered significant.

Results

Behavior problems were significantly more common in children with LUTS than in healthy children (p<0.05). The frequency of thick, thin, and normal BVWIs did not differ significantly in the two groups (p>0.05). ROC analysis showed that there was no correlation between PLUTSS, CBCL, and BVWI in either the LUTS subgroup or in the controls (p>0.05). The PLUTSS had the highest sensitivity and specificity, and adding the two other tests decreased its validity for the diagnosis of children with LUTS.

Conclusions

The PLUTSS by itself was the best predictor of LUTS. The CBCL and BVWI were not helpful in making a diagnosis; however, the CBCL was useful in the detection of behavior problems in children with non-monosymptomatic enuresis.

Reboxetine in therapy-resistant enuresis: Results and pathogenetic implications

OBJECTIVE

To investigate whether the norepinephrine reuptake inhibitor reboxetine is effective as a non-cardiotoxic alternative to imipramine in the treatment of therapy-resistant enuresis.

MATERIAL AND METHODS

Twenty-two children with severely socially handicapping enuresis resistant to urotherapy, the enuresis alarm, desmopressin and anticholinergics (all children had tried all these treatments) were given reboxetine, 4-8 mg at bed-time, for compassionate reasons.

RESULTS

Thirteen of the children (59%) achieved complete dryness with reboxetine, either as monotherapy or combined with desmopressin. Side-effects were minor and did not lead to discontinuation of treatment.

CONCLUSIONS

Although the results of this study need to be confirmed in randomized, placebo-controlled trials, reboxetine may prove to be a useful treatment for therapy-resistant nocturnal enuresis.

Exploring the differences between mono- and polysymptomatic nocturnal enuresis

OBJECTIVE

Recently the heterogeneity of nocturnal enuresis has been manifest in the distinction between mono- and polysymptomatic forms, based on the absence or presence of bladder overactivity, respectively. Although this classification has important clinical implications, there is a lack of empirical work relating to associated symptom expression and psychological functioning. The aim of this study was to identify variables associated with the two forms of nocturnal enuresis by means of a large population survey.

MATERIAL AND METHODS

From a cohort of 11,021 parents surveyed as part of the Avon Longitudinal Study of Parents and Children when their children were aged 7(1/2) years, 8242 questionnaires were returned, with 7935 children meeting the inclusion criteria. Parents were invited to complete a questionnaire containing items relating to bedwetting, toileting behaviour, day-time wetting, bowel functioning and psychological variables.

RESULTS

A total of 194 children met the Diagnostic and Statistical Manual of Mental Disorders-IV definition of nocturnal enuresis, of whom 133 (68.5%) were classified as monosymptomatic and 61 (31.5%) as polysymptomatic. Those with the polysymptomatic form were significantly more likely to have multiple episodes of bedwetting, to show signs (such as fidgeting) of needing to urinate during the day, to need a reminder to toilet during the day and to have day-time wetting and soiling.

CONCLUSIONS

The proportion of mono- to polysymptomatic nocturnal enuresis was 2:1. Children with the polysymptomatic form had a number of associated bladder and bowel problems. Clinically it is important to distinguish between the two types of nocturnal enuresis in order to identify the most appropriate treatment intervention.

Diuretic treatment of nocturnal enuresis

OBJECTIVE

Nocturnal polyuria is considered a major pathogenetic factor in nocturnal enuresis, and the antidiuretic drug desmopressin, given at bed-time, is consequently recognized as a first-line treatment alternative. The aim of this open, non-randomized study was to see whether diuretic medication, given in the afternoon, could give similar therapeutic benefit.

MATERIAL AND METHODS

Sixty-three children suffering from primary, monosymptomatic, nocturnal enuresis were included in the study by their primary care paediatrician. After 14 days without any treatment and 14 days for which 0.4 mg of desmopressin was given orally at bed-time, the children were given furosemide 1 mg/kg in the afternoon for 14 consecutive days. The numbers of wet and dry nights were recorded.

RESULTS

The numbers of wet nights at baseline, during desmopressin treatment and during furosemide treatment were 10.2+/-3.5, 6.4+/-4.6 and 8.2+/-4.5, respectively. Both drugs were significantly better than no treatment, but only a small proportion of patients became completely dry: 24% on desmopressin and 12% on furosemide. Desmopressin was significantly better than furosemide. Three children who showed no therapeutic effect on desmopressin treatment had a favourable response to furosemide.

CONCLUSION

Furosemide, given in the afternoon, has minor therapeutic potential in nocturnal enuresis.

Diagnosis and management of nocturnal enuresis

PURPOSE OF REVIEW

To highlight recent advances in enuresis research.

RECENT FINDINGS

Many discoveries have distanced us from the time when bedwetting was considered a psychiatric disorder. Instead, it is now agreed that nocturnal polyuria, detrusor overactivity, and high arousal thresholds are, in various combinations, central to enuresis pathogenesis. All three mechanisms have been further elucidated during the last year. It has been found that solute diuresis, and not just free-water diuresis due to vasopressin deficiency, may be causative. Sonographical bladder wall measurements have been shown to have prognostic value in detrusor-dependent enuresis, and fascinating proof for the interplay between the bladder and the sleeping brain has been put forward. And, ironically, sleep research has caused psychiatry to make a slight comeback, as studies have indicated that enuretic children may suffer from cognitive problems due to suboptimal sleep. Less has been achieved regarding treatment, but some evidence has finally supported the experience that anticholinergics may be effective in therapy-resistant enuresis.

SUMMARY

During the last years, increased insight has been gained into the multifaceted pathogenesis of enuresis, but there is still an irritating lack of proven effective therapies.

Combination therapy with desmopressin and an anticholinergic medication for nonresponders to desmopressin for monosymptomatic nocturnal enuresis: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

Desmopressin is an approved medical therapy for the treatment of monosymptomatic primary nocturnal enuresis. In cases of limited response to desmopressin, we have added anticholinergic therapy to desmopressin (combination therapy). To evaluate this treatment strategy, we examined the efficacy of combination therapy for primary nocturnal enuresis in desmopressin-nonresponders.

METHODS

Only patients with primary nocturnal enuresis refractory to the maximal dosage of desmopressin were enrolled. Children with lower urinary tract symptoms or bowel dysfunction were excluded, on the basis of a 3-day, 24-hour, frequency-volume chart and elimination record. Children continued to take desmopressin and were assigned randomly, in a double-blind manner, to receive either extended-release anticholinergic medication or placebo. Patients were reassessed after 1 month of therapy, with a 1-week nocturnal record.

RESULTS

Forty-one desmopressin-nonresponders were enrolled, and 7 patients were excluded because of noncompliance. The treatment groups were equally matched with respect to age, gender, functional bladder capacity, and number of wet nights per week. After 1 month of treatment, there was a significant reduction in the mean number of wet nights in the combination therapy group, compared with the placebo group. With a generalized estimating equation approach, there was a significant 66% decrease in the risk of a wet episode, compared with the placebo group.

CONCLUSIONS

This study represents the first prospective, placebo-controlled trial examining the effect of desmopressin in combination with long-acting, anticholinergic, bladder-relaxing therapy for monosymptomatic primary nocturnal enuresis.

Variety of congenital urethral lesions in boys with lower urinary tract symptoms and the results of endoscopic treatment

OBJECTIVES

We described various types of congenital urethral anomalies seen in boys with LUTS such as refractory enuresis. Their urethrograpic and endoscopic finding were reviewed and the effect of trans-urethral incision (TUI) was analyzed.

PATIENTS AND METHODS

We evaluated 67 boys with lower urinary tract symptoms (LUTS, mean: 9 years old), in a period of three and a half years. A voiding cystourethrogram (VCUG) was performed in 37 patients and if we suspected a urethral abnormality, endoscopy was performed. Congenital urethral obstruction was diagnosed from VCUG and endoscopic findings and classified into Types 1, 3 and 4 posterior urethral valves (PUV) according to Douglas Stephens' description. Trans-urethral incision (TUI) was carried out for congenital urethral obstruction and the effect was judged three months later.

RESULTS

On VCUG, 17 patients (45.8%) had an abnormal urethral configuration. On endoscopy, nine patients (24.3%) were diagnosed as having PUV. The effect of TUI on PUV excluding Type 3 was 80%, while that on Type 3 was 25%.

DISCUSSIONS

The incidence of PUV compared to bulbar urethral narrowing was significantly different from that described in previous Japanese reports, but similar to other countries. The reason is thought to be the lack of standardized interpretations of VCUG images and endoscopic findings, resulting in the overestimation of the bulbar urethral lesion.

CONCLUSION

The incidence of PUV in Japanese boys with LUTS was higher than had ever been described. The improvement rate by TUI was high in PUV excluding Type 3, but low in Type 3. The ring like strictures at the bulbar urethra may be less important than has previously been thought.

Exploring potential mechanisms in alarm treatment for primary nocturnal enuresis

OBJECTIVE

In the treatment of childhood nocturnal enuresis the enuresis alarm has consistently proved effective. However, the various proposals advanced to explain its therapeutic mechanism generally lack empirical support. In this clinical trial we investigated the hypothesis that the alarm promotes reduced nocturnal urine production through increased urine concentration (enabling the child to sleep through the night).

MATERIAL AND METHODS

Measurements of urinary vasopressin and osmolality were made pre- and post-alarm treatment in a group (n=12) of outpatient children (aged 7-12 years) with severe (more than four times a week) nocturnal enuresis.

RESULTS

Of the study group, 75% achieved the success criteria, with 89% predominantly sleeping through the night on dry nights, confirming that arousability is unlikely to be the principal mode of action. All those becoming dry showed an increase in urine concentration post-treatment. For half this was associated with an increase in post-treatment vasopressin whilst for the rest, although increases in osmolality were observed, there was no associated increase in vasopressin.

CONCLUSIONS

Although based on a small sample this study offers an insight into possible therapeutic mechanisms of an enuresis alarm. It suggests that most children who become dry sleep through the night and that increased nocturnal urine concentration (and thus reduced urine volume) is likely to be the means whereby this is achieved. Furthermore, the study suggests two possible mechanisms whereby nocturnal urine concentration is achieved: either increased production of vasopressin or enhanced water transport across the urothelium.

Nocturnal polyuria is related to 24-hour diuresis and osmotic excretion in an enuresis population referred to a tertiary center

PURPOSE

Primary nocturnal enuresis is a heterogeneous disorder, causing a mismatch between overnight diuresis volume and functional bladder capacity. Despite increasing insights in pathogenesis, lack of efficacy of the available treatments is a major problem. We evaluated characteristics of bladder volume and diuresis rate in patients with nocturnal enuresis referred to a tertiary enuresis center.

MATERIALS AND METHODS

Noninvasive screening including maximal voided volume, 24-hour circadian rhythm of diuresis and osmotic excretion from 1,000 consecutive patients.

RESULTS

Of the patients referred as having monosymptomatic nocturnal enuresis 32% were subsequently classified as having nonmonosymptomatic nocturnal enuresis. Differences in bladder volume and nocturnal diuresis characteristics between the monosymptomatic nocturnal enuresis and nonmonosymptomatic nocturnal enuresis groups were minimal.

CONCLUSIONS

The most common observation is a nocturnal diuresis volume greater than maximal voided volume, which in both groups can be caused by nocturnal polyuria or small bladder volume for patient age. The most striking observation is that the positive correlation between nocturnal diuresis volume rate and nocturnal osmotic excretion and 24-hour fluid intake is significantly higher than with the inversed urinary osmolality overnight, which is not only unexpected based on the theory of the primary suppression of vasopressin levels overnight, but also points to a more important role for nutritional and fluid intake than accepted, if not in the primary pathogenesis, then at least in therapy resistance.

Extracorporeal magnetic innervation therapy in children with refractory monosymptomatic nocturnal enuresis

OBJECTIVES

To evaluate the effect of extracorporeal magnetic innervation (ExMI) therapy in children with refractory monosymptomatic nocturnal enuresis (MNE).

METHODS

A total of 55 children (34 boys and 21 girls, median age 8.0 years, range 5 to 13) who wetted the bed more than twice per week because of MNE that was refractory to treatment with desmopressin, anticholinergics, and enuretic alarm were assessed prospectively using a voiding diary before and after ExMI, administered once a week for at least 4 weeks with a size-adjusted magnetic chair (each session lasted 20 minutes).

RESULTS

After all sessions of ExMI, the mean frequency of nocturnal enuresis decreased significantly to 2.09 +/- 2.47 in all patients (P = 0.04), and the mean functional bladder capacity increased 1.88 times in all patients (P = 0.00). In total, 63.6% of our patients had a nocturnal enuresis frequency of less than 50% after a mean of 6.62 +/- 4.26 ExMI sessions.

CONCLUSIONS

From our results, reduced functional bladder capacity might be the main pathophysiologic cause in children with MNE refractory to established treatment. ExMI might have an acute inhibitory effect in these children with refractory MNE by increasing functional bladder capacity. However, long-term follow-up data and controlled study with a sham-stimulation group are necessary to determine the durability of this new therapy for refractory MNE.

Usefulness of a New Dysfunctional Voiding and Incontinence Scoring System in Predicting Treatment Effect in Children with Voiding Dysfunction

AIM

To assess the role of the dysfunctional voiding and incontinence scoring system (DVAISS) in children with voiding dysfunction.

METHODS

Ninety-three children were divided into three groups: those who had wetting only (group 1), recurrent urinary tract infections (UTIs) and wetting (group 2) and vesicoureteral reflux together with wetting and UTIs (group 3). Individualized multiple treatments modalities were applied. The success criteria defined by the reduction in the rate of wetting described as complete response (more than 90%), partial response (50-90%), no response (less than 50%).Also, in group 3, improvement was determined as a decrease of at least two grades in reflux. Scores of patients were determined before and after treatment.

RESULTS

Complete response rates for groups 1, 2 and 3 were 67.5, 88.8 and 85.71%, respectively. The specificity of the DVAISS in predicting the complete response was 79, 88 and 100%, respectively, and its sensitivity was 100% in all groups. In group 3, improvement rate was 71.4%. The specificity and sensitivity of the DVAISS in predicting the improvement were 83 and 100%, respectively.

CONCLUSION

The sensitivity of the DVAISS is higher in predicting the treatment effect; however, its specificity is decreased. The DVAISS may be an auxiliary diagnostic tool in voiding dysfunction patients.

Effect of Carbamazepine on Urinary Volume and Osmolality, Water Clearance, and Serum Osmolality in Patients with Primary Enuresis

OBJECTIVE

In this study we investigate the effects of carbamazepine (CBZ) on urinary volume, frequency of micturition, serum and urine osmolality, osmotic and creatinine clearance, and free water clearance in patients with primary nocturnal enuresis. This information might help in our understanding of the mechanism of action of CBZ in management of patients with enuresis.

PATIENTS AND METHODS

The study comprised eight patients with primary enuresis (age range, 8-14 yr) who wet at night on a daily basis. Enuretics were given, CBZ 200 mg each night; urine volume, urinary osmolality and electrolytes, serum osmolality and electrolytes, osmotic clearance, fractional excretion of sodium, and free water clearance were assayed before CBZ treatment and after 15 d of treatment. Frequencies of bed-wetting and dry nights were observed during treatment.

RESULTS

Mean number (+/-SD) of dry nights was increased from zero dry nights (daily bed-wetting) to 9.7 (2.8) per 15 d of treatment (65%). CBZ decreased the 24-h urinary volume by 41%, the night volume by 45%, the day volume by 38%, and frequency of micturition by 28%. CBZ increased the 24-h urinary osmolality by 43%. Serum osmolality changed significantly from 283.7 mOsm/l to 277.2 mOsm/l. CBZ decreased osmotic clearance by 37% and free water clearance by 34%. Creatinine clearance was decreased by 19% after CBZ treatment (p < 0.05).

CONCLUSION

CBZ reduced urine volume, increased urine osmolality, and decreased the free water clearance, the osmotic clearance, and the frequency of micturition in enuretics; this might help in understanding its mechanism of action.

Funktionelle Störungen des unteren Harntrakts im Kindesalter

Functional disorders of the lower urinary tract as well as vesicoureteral reflux involved in the disease complex of urinary tract infection/permanent renal parenchymal damage can be considered predisposing or risk factors. Two main forms can be distinguished, i.e., unstable bladder and dysfunctional voiding, while transitional forms between the two exist. Functional disorders of the lower urinary tract obstruct spontaneous resolution of vesicoureteral reflux. They are found in about 50% of cases in all children with urinary tract infection and are associated with an increased risk of developing renal parenchymal scars. They are observed during the newborn period up to school age. In the first few months of life, particularly boys with bilateral high-grade reflux and congenital renal parenchymal damage are affected. At later ages girls are also affected, but in this age group bladder instability predominates. Incontinence as the leading clinical symptom appears in approximately 70% of all cases and is closely correlated with chronic constipation. Imaging procedures in addition to urodynamic methods are of decisive importance for diagnosis and treatment, but noninvasive approaches such as sonography should be given preference.

Nocturnal enuresis at 7.5 years old: prevalence and analysis of clinical signs

OBJECTIVE

To determine the prevalence of nocturnal enuresis (NE) in a large cohort of children at 7.5 years old, and to examine the frequency of variables such as gender, severity, associated elimination problems, and clinical signs within the identified group.

SUBJECTS AND METHODS

Of an original cohort of 13 971 infants alive at 12 months, 11 251 who were still active in the Avon Longitudinal Study of Parents and Children (ALSPAC) survey, were followed at 91 months. The mother or main carer was given a questionnaire which asked, amongst other items, about the presence and frequency of bedwetting, other elimination problems, and signs related to the wetting behaviour; 8269 (73.5%) questionnaires were returned and 8151 contained information on the frequency of bedwetting.

RESULTS

In all, 1260 children (15.5%) at 7.5 years wet the bed, but most wet once or less a week, and only 215 (2.6%) met the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria of NE (wetting at least twice a week). A higher prevalence was reported in boys than girls and 266 children (3.3%) had both daytime wetting and bedwetting, with 189 (2.3%) having both daytime soiling and bedwetting. Daytime urgency increased with severity of bedwetting and occurred in 28.9% of children with NE.

CONCLUSION

At 7.5 years old the incidence of bedwetting is high, but only 2.6% of this large population-based sample wet at a frequency meeting the definition of NE. Although a small percentage of children had both daytime wetting and bedwetting, the evidence suggests that these are discrete problems. Amongst children with NE, indicators of bladder overactivity were present, supporting the view of heterogeneity and the importance of individual assessment in deciding on appropriate treatment.

DYSFUNCTIONAL VOIDING AND INCONTINENCE SCORING SYSTEM: QUANTITATIVE EVALUATION OF INCONTINENCE SYMPTOMS IN PEDIATRIC POPULATION

PURPOSE

Functional voiding problems in children are common. Although pathophysiology and presentation of this clinical entity are well described, there is not yet a generally accepted method of quantitative and standard evaluation of clinical symptoms, and there are few studies addressing the issue of symptom scoring in children. We investigated use of a symptom scoring system in children with functional voiding problems and the normal population, and validated it using a scientific tool.

MATERIALS AND METHODS

A symptom scoring system was designed empirically. The questionnaire was composed of items regarding daytime symptoms, nighttime symptoms, voiding habits, bowel habits and quality of life. There were 2 groups whose symptoms were evaluated using this scoring system. Group 1 consisted of 86 patients who were admitted to our clinic with various wetting and daytime voiding problems. Group 2 consisted of 265 controls with no urological complaints. Parents of all children were asked to fill out a questionnaire that included the symptom scoring system. Boys with lower urinary tract abnormalities, and patients with spina bifida occulta and neurogenic bladder were excluded from the study. Odds ratios of answers to each item in the questionnaire were used to define strength of the questions to differentiate patients from healthy controls. According to the value of odds ratios, questions were modified and a score for each question was given. Receiver operating characteristic plots were used to define detection cutoff or threshold score, and Youden's index was used to detect best reflecting optimal sensitivity and specificity.

RESULTS

The total score was determined to range from 0 to 35, and items were modified to 13 questions and 1 quality of life question at the end of the study. Among the 86 patients in group 1 (female-to-male ratio 1.5:1) mean score was 18.56. Among the 265 controls in group 2 (female-to-male ratio 1.5:1) mean score was 2.88. Statistical analysis revealed that within a confidence interval of 96.2% patients with a score of 8.5 or greater had voiding abnormalities, with 90% sensitivity and 90% specificity. There were no statistically significant differences between the 2 genders and 2 age groups of 4 to 7 and 8 to 10 years.

CONCLUSIONS

This statistically validated functional voiding problems symptom score may provide accurate, objective and scientific bases to grade the symptoms in comparative research, diagnosis, treatment and followup of patients with wetting and functional voiding disorders.

Childhood nocturnal enuresis: Developing a conceptual framework

Nocturnal enuresis has been described as the most prevalent and chronic of all childhood problems. The experience, particularly for the older child, can be extremely distressing and limiting. It is now thought that psychological distress (emotional, behavioural, and self-esteem) arises as a consequence of bedwetting, and reaches clinical importance in only a minority who are vulnerable. Many aetiological theories have been proposed with the cause of nocturnal enuresis now regarded as heterogeneous. Based on empirical findings, a new model, termed 'the three systems,' has facilitated a greater clinical understanding of the problem and identification of the appropriate intervention. The model proposes bedwetting results from excessive nocturnal urine production and/or nocturnal bladder overactivity coupled with an inability to arouse to bladder sensations. Effective treatment arises from identification of the child's particular need and application of the appropriate psychological and pharmacological approach. Treatment methods are reviewed in terms of the new model, the mode of action, effectiveness, and application in combination.

Impact of urodynamics in treatment of primary nocturnal enuresis persisting into adulthood

OBJECTIVES

To investigate the urodynamic profiles of adults with primary nocturnal enuresis (PNE) and the association of the urodynamic profile findings with the efficacy of desmopressin and/or tolterodine pharmacotherapy. At least 2% of adults are enuretic during the night. The diagnostic and treatment approach for PNE is empirically the same in children and adults.

METHODS

A total of 20 nocturnal enuretic patients (12 women and 8 men) with a mean age of 27.1 years (range 20 to 42) were studied. They had wet their bed at least twice per week for the past 6 months. Urodynamic studies, including filling and voiding cystometry, pressure-flow study, and pelvic floor electromyography with superficial electrodes, were performed on all patients. Two of them had daytime symptoms, and two had prior failed desmopressin therapy. All patients began taking oral desmopressin 0.4 mg for 1 month. Their continence was assessed and tolterodine 4 mg was added for those in whom desmopressin alone failed. The patients responsive to desmopressin alone or desmopressin plus tolterodine were weaned from medication at 6 and 12 months to reassess continence. The mean follow-up period was 11.6 +/- 3.3 months (range 4 to 14).

RESULTS

Urodynamic studies of 20 PNE adult patients revealed detrusor instability in 10 (50%), hypocompliance in 8 (40%), nonneurogenic detrusor-sphincter dyssynergy in 1 (5%), and no abnormality in 10 (50%). Of the 20 patients, 19 (95%) had no voiding bladder problems. Of the 10 patients responsive to desmopressin alone, 6 (60%) had a normal urodynamic profile; the remaining 4 (40%) had detrusor instability and/or hypocompliance. Of the 5 patients who received desmopressin and tolterodine, 3 achieved continence. The overall continence rate was 86% (13 of 15), and 12 (92%) of the 15 patients required maintenance therapy. In 2 patients (13.3%), desmopressin and tolterodine therapy failed. The efficacy of desmopressin alone and of desmopressin plus tolterodine were not related to the urodynamic profile findings (P >0.05). The urodynamic profile was also not related to the relapse rate after any form of pharmacotherapy (P >0.05).

CONCLUSIONS

PNE persisting into adulthood may be associated with abnormal urodynamic findings. Patients may benefit from urodynamic studies, because if the findings are abnormal, they might have the best chance of successful treatment.

URODYNAMIC FINDINGS IN ADULTS WITH PRIMARY NOCTURNAL ENURESIS

PURPOSE

We evaluate bladder function in adults with primary nocturnal enuresis (PNE) since childhood.

MATERIALS AND METHODS

We recruited all patients older than 16 years who presented to our PNE clinic with persistent enuretic symptoms. All patients were assessed by a detailed voiding diary, uroflowmetry and ultrasonography of the urinary tract. Urodynamic studies were performed for those with moderate or severe PNE (more than 3 wet nights a week).

RESULTS

The study included 18 males and 29 females with a mean age of 20 years (range 16 to 43). Of these patients 37 (79%) had moderate or severe symptoms and 17 (38%) also had daytime urinary symptoms. Urodynamic studies were conducted in 30 patients, including 12 males and 16 females (93%) with detrusor overactivity. In addition, 73% of patients had urodynamic evidence of functional bladder outflow obstruction, including dysfunctional voiding and detrusor sphincter or detrusor pelvic discoordination. Two male patients (6.7%) had an obstructive pattern on urodynamics and subsequent cystoscopic examination confirmed the presence of congenital obstructive urethral lesions. Sixteen patients (53%) had significantly reduced bladder capacity of less than 300 ml.

CONCLUSIONS

Unlike in early childhood, the majority (79%) of enuretic adults had significant symptoms, and more than a third also had daytime urinary symptoms. We believe that PNE in adults is not only a psychologically disturbing condition, but also a urological disorder with significant underlying bladder dysfunction that warrants special attention to management.

SODIUM FRACTION EXCRETION RATE IN NOCTURNAL ENURESIS CORRELATES WITH NOCTURNAL POLYURIA AND OSMOLALITY

PURPOSE

We verify the sodium fraction excretion rate (FE Na) and potassium fraction excretion (FE K) rates in monosymptomatic nocturnal enuresis. We also correlate FE Na and FE K to urinary osmolality, nocturnal polyuria and vasopressin in the same population.

MATERIALS AND METHODS

A total of 438 children 6 to 15 years old (mean age 9.7) presenting with monosymptomatic nocturnal enuresis were recruited from different centers. Inclusion criteria were 3 or greater wet nights a week, no daytime incontinence and no treatment in the previous 2 months. Exclusion criteria were cardiopathy, endocrinopathy, psychiatric problems and urinary tract abnormalities. Micturition chart, diurnal (8 am to 8 pm) and nocturnal (8 pm to 8 am) urine collection, including separate diuresis volumes, (Na, K and Ca) electrolytes and osmolality were evaluated, as well as serum electrolytes, creatinine and nocturnal (4 am) vasopressin. Diurnal and nocturnal FE K and FE Na were calculated. ANOVA test, chi-square test, Student's t test and Pearson correlation test were used for statistical analysis.

RESULTS

: Nocturnal polyuria (diurnal to nocturnal diuresis ratio less than 1) was found in 273 children (62.3%, group 1 and nocturnal urine volumes were normal in 165 with enuresis (37.7%, group 2). Nocturnal FE Na was abnormal in 179 children (40.8%), including 118 in group 1 (43.2%) and 61 in group 2 (36.9%) (chi-square not significant). FE Na was also increased in nocturnal versus daytime diuresis (Student's t test p <0.001). In group 1 nocturnal FE Na correlated with nocturnal diuresis (Pearson correlation p = 0.003, r = +0.175), while daytime FE Na and nocturnal FE Na correlated with diurnal diuresis (Pearson correlation p = 0.001, r = +0.225 and Pearson correlation p = 0.001, r = +0.209, respectively). In group 2 nocturnal FE Na did not correlate with diuresis (Pearson correlation p = 0.103, r = +0.128) but correlated with vasopressin values (Pearson correlation p = 0.042, r = -0.205). Urine osmolality was reduced in 140 children (31.9%) and correlated with nocturnal diuresis (Pearson correlation p = 0.003, r = -0.321). Vasopressin was decreased in 332 children (75.8%, 62.6% in group 1 and 13.2% in group 2). No significant difference was found between sexes and age of enuretic subgroups.

CONCLUSIONS

Nocturnal FE Na correlates with nocturnal diuresis, whereas daytime FE Na does not. FE K in daytime and nighttime diuresis does not statistically differ in nocturnal polyuric and nonpolyuric enuretic groups. Osmolality correlates with nocturnal diuresis, and vasopressin at 4 am was lower in the nocturnal polyuric group. The hypothesis of a subset of enuretic patients presenting with nocturnal polyuria associated with high nocturnal natriuria and low vasopressin values has been confirmed.

Characteristics of primary nocturnal enuresis in adults: an epidemiological study

OBJECTIVE

To evaluate the prevalence and characteristics of primary nocturnal enuresis (PNE) in adults in Hong Kong, as there are currently limited epidemiological data in adults.

SUBJECTS AND METHODS

After a telephone survey, 8534 respondents (3996 males and 4538 females) aged 16-40 years were selected for the study and stratified in age groups. The questionnaire used comprised two parts; the first started with questions mainly about the general demographic background to decrease the sensitivity of the study and to establish rapport. The second part was conducted through an automated telephone interview service, with the questions being asked by recorded messages and the respondents then keying in their responses with no need to converse with an interviewer. This part included questions about enuretic symptoms and a subjective assessment of social and psychological effects of bedwetting, and measurements of the individual's self-esteem (Rosenberg Self-esteem Scale) and depression (The Centre for Epidemiological Studies Depression Scale).

RESULTS

Of the 8534 subjects interviewed, 196 had PNE, giving an overall prevalence of 2.3% (2.7% males and 2.0% females); of these 196, 36 (18.4%) also had daytime urinary incontinence. Hence, 1.9% of adults (2.2% males and 1.7% females) had monosymptomatic PNE. Of these, 53% wet >3 nights/week and 26% wet every night. Prevalence rates remained relatively stable among different age groups, with no apparent trend of a reduction with age. Compared with nonenuretic normal controls, significantly fewer enuretics reached tertiary education (33.4% vs 17.8%, P < 0.01). Bedwetters had a significantly higher incidence of depression and lower self-esteem, and a higher incidence of sleep disturbances than the control group. Among bedwetters, 32-40% felt that there was some effect on their choice of job, work performance and social activities, whilst 23% felt the condition affected their family life and in making friends of either sex. However, there was no significant difference in the marital status. Interestingly, only 34.5% of females and half of males used various methods before bedtime to prevent bedwetting.

CONCLUSIONS

Overall, 2.3% of Hong Kong adults aged 16-40 years have persistent PNE. Unlike PNE in early childhood the prevalence remained relatively unchanged with age, suggesting that enuretic symptoms persisting into adulthood are probably less likely to resolve with time. Also, significantly more patients had more severe enuretic symptoms. These findings therefore highlight the possibility that PNE in adults may represent a more pronounced form of the condition, and with a more serious social and psychological effect on affected individuals. Further work is needed to evaluate the pathogenesis and management strategy.

Evidence against a synergistic effect of desmopressin with conditioning in the treatment of nocturnal enuresis

OBJECTIVE

To test the hypothesis that desmopressin facilitates acquisition of continence, we aimed to establish whether, in children with nocturnal enuresis who are desmopressin nonresponders, adjunct desmopressin increases the rate of sustained continence after treatment with a conditioning alarm. Study design Patients with nocturnal enuresis (n=358; age range, 6-16 years) completed a 4-week "run-in" course of intranasal desmopressin (20-40 microg). Of these, 207 defined as nonresponders (<50% reduction in wet nights) were randomly assigned to receive either desmopressin (n=101) or placebo (n=106) nasal spray, together with conditioning alarm therapy for 8 weeks. Principal outcome measures were remission (28 continuous dry nights) and relapse (>2 wet nights in 2 weeks after having achieved remission).

RESULTS

Remission rates were similar in both groups (51.5% desmopressin, 48.1% placebo; 95% CI on difference, -10%, 17%; P=.63), and relapse rates were not significantly different (13.5% vs 5.9%; 95% CI on difference, -3.7%, 19%; P=.19). Although remission rates were similar, children treated with desmopressin had significantly more dry nights during treatment than those in the placebo group.

CONCLUSIONS

Desmopressin did not act synergistically with alarm treatment to achieve remission. Therefore, we infer that in partial or nonresponders, desmopressin does not enhance learning.

Topographic abnormalities in event-related potentials in children with monosyptomatic nocturnal enuresis

AIMS

A functional maturational delay in the central nervous system is dwelled upon in the pathogenesis of monosymptomatic nocturnal enuresis (MNE). In this study we studied whether according to controls N200 and P300, components of the event-related potential (ERP), which is related to aspects of cognitive processing, showed any difference in its topographic distribution in children within the age group 10-13 with monosymptomatic nocturnal enuresis and discussed its relation to the pathogenesis of MNE.

METHODS

We performed P300 in 18 patients with MNE and in 16 age-matched healthy subjects. P300 were evoked by an auditory oddball paradigm consisting of 150 tone bursts (80% 1 kHz; 20% 2 kHz). The latencies of the N200 and the P300 waves and the amplitude of the P300 wave were measured.

RESULTS

There was no statistical difference between the enuretic group and the controls in N200 and P300 latency and amplitude in the midline frontal (Fz), central (Cz), and parietal (Pz) recording site of the 10-20 International System. In the enuretic group while P300 amplitude in the Fz site was significantly less than the P300 amplitude in the Cz site, there was no statistical difference between the Fz and Pz P300 amplitude values.

CONCLUSIONS

When different levels of maturational delay are considered in MNE, it may be claimed that maturational delay in children whose enuresis lasts until older ages will be different from those whose enuresis ends at an early age. The determination of P300 amplitude in parietal records being less in enuretics when compared to the controls may show that there are regional differences in stimuli processing rate/quality.

Behavioral Therapy for Primary Nocturnal Enuresis

PURPOSE

Recent studies suggest the efficacy of behavioral therapy for enuresis, even in cases of minor daytime voiding problems. We describe our experience with the clinical followup and behavioral therapy of children with primary enuresis.

MATERIALS AND METHODS

We followed 159 boys and 91 girls 5 to 17 years old with primary enuresis who were treated at 3 medical centers with a pediatric nephrology clinic during the last 3 years. A detailed voiding history was obtained. Each child was treated with a bladder training session, including an explanation of the enuretic process, daily diary recording and training to recognize bladder distention and increase voiding frequency.

RESULTS

A total of 226 children (90%) presented with 1 or more symptoms of bladder maturation delay and 13% reported behavioral constipation. Of the patients 185 (74%) completed the proposed treatment, including 111 (60%) who reported a positive and 21 (11%) who reported a partial response. In 53 children (29%) the treatment failed.

CONCLUSIONS

Most children with enuresis have daytime symptoms when an accurate history is recorded. As shown by our data, the efficacy of behavioral therapy is comparable to that of desmopressin or alarm therapy but it requires good compliance of the child with the therapeutic plan. Age is not a determining factor in the success rate.