Simple behavioural and physical interventions for nocturnal enuresis in children

Effects of sex, toilet training, stress, and caffeine on nocturnal enuresis among school children in Gondar Town, the metropolitan city of Ethiopia: a community-based study in 2023

Background

Nocturnal enuresis is associated with severe social and psychological problems that affect one's self-esteem, later in life, harmed adolescent and adult life, emotional stress on the family, and poor school performance. Moreover, enuresis children may cause panic attacks, mood disorders, and depression. This study aims to assess the prevalence and associated factors of nocturnal enuresis among children aged 5-14 years in Gondar city, Northwest Ethiopia, 2023.

Methods

A community-based, cross-sectional study was conducted from April 1, 2023, to May 30, 2023. A stratified multistage sampling technique was used to select study subject from kebeles in Gondar city. The data were collected by using a structured, interviewer-administer Questionnaire. The data were entered using EPI DATA version 4.6.02 software, and processed,and analyzed using the statistical package for the social sciences (SPSS) version 25. All variables with P ≤ 0.25 in the bivariate analysis were included in the final model of multivariate analysis. The multivariate binary logistic regression was used to assess the association between the independent and outcome variable. The direction and strength of statistical association were measured with an adjusted odds ratio along with 95% CI and a P-value <0.05 was considered statistically significant.

Result

The overall prevalence of nocturnal enuresis among children aged 5-14 years was 162 (22.2%). The findings showed that being boys [AOR = 0.54; 95% CI (0.31, 0.93)], child and no toilet training practices [AOR = 2.50; 95% CI (1.02, 6.15)], Having no caffeine [AOR = 0.16; 95% CI (0.09, 0.29)], and exposure to stressful events [AOR = 20; 95% CI (11.12, 33.34)] had a significant association with nocturnal enuresis, p-value <0.05.

Conclusion

In this study, the prevalence of nocturnal enuresis children age 5-14 years was higher than that in previous studies. Sex of child, toilet training practices, caffeine c before bed, and presences of stressful event were a significant predictor of nocturnal enuresis.

Effect of laser acupuncture on monosymptomatic nocturnal enuresis in adolescent females: A randomized controlled trial

BACKGROUND AND AIM

Nocturnal enuresis (NE) is prevalent in children and adolescents and affects their social life later. Therefore, the objective of this study was to ascertain laser acupuncture (LA) therapy's effect on NE in adolescent females.

METHODS

Sixty adolescent females diagnosed with chronic monosymptomatic nocturnal enuresis (MNE) were randomly divided into two equal groups: The intervention group (received LA and desmopressin) and the control group (received desmopressin only) (n = 30 each). Treatment was delivered and LA was used three times a week for 12 successive weeks. Abdominal ultrasonography and voiding calendar were used to assess bladder capacity and maximum voiding volume (MVV), respectively. The frequency of bed wetness was assessed throughout the trial period in a diary.

RESULTS

Statistically significant differences were reported in the intervention group. Bladder capacity significantly increased in the intervention group (LA and desmopressin) than in the control group.

CONCLUSIONS

The results of this study suggest the beneficial influences of LA on MNE, despite the very poor quality of the literature's available evidence.

Influence of rapid maxillary expansion on nocturnal enuresis in children

OBJECTIVES

To evaluate the influence of rapid maxillary expansion (RME) on nocturnal enuresis (NE) in children to discuss whether RME can be indicated as an alternative treatment for NE in those patients.

MATERIALS AND METHODS

An electronic search was performed in the following databases: PubMed/MEDLINE, Cochrane Library, Scopus, Science Direct, Google Scholar and LILACS. The literature review was blindly performed by two reviewers. References of each selected study were manually searched to identify articles that were not found by the electronic search. Kappa statistics were used to analyze interexaminer agreement after the selection of the articles. After reading the selected full-text articles, the studies that met the inclusion criteria were assessed qualitatively using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) and the Revised Cochrane risk-of-bias tool for randomized controlled trials-2 (RoB 2). The certainty level of evidence was assessed through the Grading of Recommendations, Assessment, Development and Evaluation tool. Kappa tests were used to analyze the interexaminer concordance level after the quality assessment of the studies.

RESULTS

A total of 488 articles were found; however, after applying the inclusion and exclusion criteria, only 8 studies were selected for the systematic review. A low certainty level of evidence suggested that RME seems to promote a variable reduction in frequency or a remission of NE in children in both the short (4, 6, and 8 months) and long term (13, 36, 48, and 120 months).

CONCLUSIONS

Based on currently available information, RME seems to promote an improvement in NE in children. However, the low quality of the existing evidence weakens the recommendation.

Definitions, indications and practice of urotherapy in children and adolescents: - A standardization document of the International Children's Continence Society (ICCS)

BACKGROUND

Urotherapy is an umbrella term for all non-surgical, non-pharmacological interventions for lower urinary tract disorders (LUTD) in children and adolescents. Urotherapy is a specialized practice, which has become mainstay therapy not only for daytime urinary incontinence, but also for nocturnal enuresis, functional constipation and fecal incontinence. The aim of urotherapy is to achieve the normalization of the micturition and bowel pattern and to prevent further functional disturbances by repeated training. It is well known that in the treatment of adult and childhood incontinence a team approach is best, where there are shared areas of expertise and also discipline-specific expertise available.

AIM

We present a consensus view from a cross-professional team of experts affiliated with the International Children's Continence Society on definitions, indications and practice of urotherapy. This is a selective, non-systematic review with practical recommendations for the implementation and research on urotherapy.

METHODS

The document uses the globally accepted ICCS terminology. Evidence-based literature serves as the basis, but in areas lacking in primary evidence, expert consensus is used. Before submission, a full draft was made available to all ICCS members for additional comments.

RESULTS

Urotherapy uses non-pharmacological, non-surgical methods and focuses on behavioral interventions, largely based on cognitive-behavioral psychotherapy (CBT). Standard urotherapy comprises components such as provision of information, instructions, life-style advice, counselling and registration of symptoms. Specific urotherapy is tailored towards specific disorders and includes alarm treatment, biofeedback training, pelvic floor training, neurostimulation and other interventions. Fig. 1. Urotherapy is a treatment that addresses all aspects of incontinence, leading to the best clinical outcome. This includes somatic, psychosocial, and behavioral problems and quality of life. Therefore urotherapy is recommended by the ICCS as the first-line treatment for most types of LUTD. The document is intended to be clinically useful in primary, secondary and tertiary care.

Conquering Bedwetting: Non-Pharmacologic Methods for Managing Nocturnal Enuresis

Bedwetting, also called nocturnal enuresis, is a common developmental problem in school-aged children. In a study by Van Tijen, Messer, & Namdar (1998), children ranked it as the third most stressful life event, after parental fighting and divorce. About 15% of affected children outgrow bedwetting on their own each year without medical intervention (Kiddoo, 2015), but inadequate knowledge and lack of support and guidance from family may lead to low self-esteem and mental distress in children dealing with this situation. Nonpharmacologic interventions like bedwetting alarms have a higher success rate (75%) and lower relapse rate (41%) than pharmacologic interventions (Monda & Husmann, 1995). This article discusses nonpharmacologic interventions for nocturnal enuresis: bedwetting alarms, motivational therapy, dietary modification, behavioral modification, and pelvic floor muscle training.

Brazilian consensus in enuresis-recomendations for clinical practice

Introduction

Enuresis, defined as an intermittent urinary incontinence that occurs during sleep, is a frequent condition, occurring in about 10% of children at 7 years of age. However, it is frequently neglected by the family and by the primary care provider, leaving many of those children without treatment. Despite of many studies in Enuresis and recent advances in scientific and technological knowledge there is still considerable heterogeneity in evaluation methods and therapeutic approaches.

Materials and Methods

The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Enuresis and elaborated a draft of the document. On September 2018 the panel met to review, discuss and write a consensus document.

Results and Discussion

Enuresis is a multifactorial disease that can lead to a diversity of problems for the child and family. Children presenting with Enuresis require careful evaluation and treatment to avoid future psychological and behavioral problems. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.

The efficacy of electrical stimulation in treating children with nocturnal enuresis: A systematic review and meta-analysis

AIM

We performed a systematic review and meta-analysis to evaluate the efficacy of electrical stimulation (ES) in treating children with nocturnal enuresis (NE).

METHODS

Randomized controlled trials (RCTs) of the use of ES for the treatment of NE in children were searched using EMBASE, MEDLINE, and the Cochrane Controlled Trials Register. The references of related articles were also searched. The systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-analyses.

RESULTS

Four RCTs involving 171 patients were studied. We found that there was statistically significant difference in the wet nights per week (mean difference [MD], -0.70; 95% confidence interval [CI], -0.89 to -0.51; P < .00001), the number of patients with clinical response (MD, 26.88; 95% CI, 11.16 to 64.74; P < .00001), and bladder capacity (MD, -0.70; 95% CI -0.89 to -0.51; P < .00001) in the ES group compared with the placebo group with the exception of maximum voided volume (MVV) (MD, 19.48; 95% CI, -9.18 to 48.14; P = .18).

CONCLUSIONS

The study provides a significant improvement in statistics in the wet nights per week, the number of patients with clinical response and bladder capacity for children with NE compared with the placebo group with the exception of MVV.

The Diagnosis and Treatment of Enuresis and Functional Daytime Urinary Incontinence

BACKGROUND

Elimination disorders in childhood are common and treatable. Approximately 10% of 7-year-olds wet the bed at night, and 6% are affected by incontinence during the daytime. Two main types of disturbance are distinguished: nocturnal enuresis and functional (i.e., non-organic) daytime urinary incontinence. Each type contains a wide variety of subtypes. Effective treatment requires precise identification of the subtype of elimination disorder.

METHODS

This review is based on a selection of current publications, including principally the German S2k-AWMF guideline and the recommendations of the International Children's Continence Society (ICCS).

RESULTS

Diagnostic assessment focuses on the clinical picture, is non-invasive, and can be carried out in most health care settings. If the child is suffering from multiple types of elimination disorder at once, then fecal incontinence or constipation is treated first, daytime urinary incontinence next, and enuresis last. 20-50% of children with elimination disorders have a comorbid mental disorder that also needs to be treated. With standard urotherapy, 56% of patients with daytime urinary incontinence become dry within a year. This conservative, symptom-oriented approach consists of educating the patient and his or her parents to promote behavior changes with respect to drinking and micturition. Elements of specific urotherapy are provided only if indicated. For enuresis, the treatment of first choice is alarm therapy, with which 50-70% of the affected children become dry. Pharmacotherapy, e.g., with desmopressin, can be a helpful adjunctive treatment. In intractable cases, training techniques have been found useful.

CONCLUSION

Childhood elimination disorders can be treated effectively after targeted diagnostic evaluation and the establishment of specific indications for treatment. In view of the emotional distress these disorders cause, the associated physical and mental disturbances, and their potential persistence into adolescence, they should be evaluated and treated in affected children from the age of five years onward.

Evidence-Based Psychosocial Treatments for Pediatric Elimination Disorders

Pediatric elimination disorders are common in childhood, yet psychosocial correlates are generally unclear. Given the physiological concomitants of both enuresis and encopresis, and the fact that many children with elimination disorders are initially brought to their primary care physician for treatment, medical evaluation and management are crucial and may serve as the first-line treatment approach. Scientific investigation on psychological and behavioral interventions has progressed over the past couple of decades, resulting in the identification of effective treatments for enuresis and encopresis. However, the body of literature has inherent challenges, particularly given the multicomponent nature of many of the treatment packages. This review identified 25 intervention studies-18 for nocturnal enuresis and 7 for encopresis-over the past 15 years and classified them according to the guidelines set forth by the Task Force on the Promotion and Dissemination of Psychological Procedures. For nocturnal enuresis, the urine alarm and dry-bed training were identified as well-established treatments, Full Spectrum Home Therapy was probably efficacious, lifting was possibly efficacious, and hypnotherapy and retention control training were classified as treatments of questionable efficacy. For encopresis, only two probably efficacious treatments were identified: biofeedback and enhanced toilet training (ETT). Best practice recommendations and suggestions for future research are provided to address existing limitations, including heterogeneity and the multicomponent nature of many of the interventions for pediatric elimination disorders.

Chiropractic Care of an 8-Year-Old Girl With Nonorganic, Primary Nocturnal Enuresis: A Case Report

OBJECTIVE

The purpose of this case report is to describe the chiropractic management of an 8-year-old girl with nonorganic, primary nocturnal enuresis.

CLINICAL FEATURES

An 8-year-old female patient presented to a chiropractic clinic with persistent nighttime bedwetting. The patient experienced enuresis, on average, 7 nights per week. The patient presented with no other comorbidities or complaints, such as low back or pelvic pain.

INTERVENTION AND OUTCOMES

Chiropractic treatment included high-velocity, low-amplitude manipulation of the left sacroiliac joint over 3 visits. Follow-up at 3 months revealed only 3 subsequent episodes of nocturnal enuresis.

CONCLUSION

This patient reported the resolution of nonorganic, primary nocturnal enuresis after receiving a series of side-posture chiropractic manipulations of the left sacroiliac joint.

Parental beliefs about nocturnal enuresis causes, treatments, and the need to seek professional medical care

OBJECTIVE

To better understand parental beliefs regarding the etiology and treatment of nocturnal enuresis (NE).

METHODS

A self-administered survey queried parental NE beliefs including perceived etiologies and home behavioral treatments. We assessed for associations between demographic characteristics and propensity to seek medical care for NE.

RESULTS

Of 216 respondents, 78% were female. The most common causes for NE reported were: deep sleeper (56%), unknown (39%), and laziness (26%). Popular home behavioral therapies included: void prior to sleep (77%) and limiting fluid intake at night (71%). Few reported they would use a bedwetting alarm (6%). Fifty-five percent reported they would seek medical care for NE and 28% reported awareness of effective treatments. On multivariable analysis, females (OR 2.3, 95% CI 1.04-5.0) and those with graduate level education (OR 4.8, 95% CI 1.5-15.7) were more likely to seek medical care for their child with NE.

CONCLUSIONS

General parental knowledge of the causes and effective treatments for NE is lacking. Only 55% reported they would seek medical care for their child with NE and only 28% reported awareness of effective treatments. Counseling should focus on dispelling common misconceptions about causes and treatments of NE and focus on proven effective treatments.

The efficacy of systemic therapy for internalizing and other disorders of childhood and adolescence: a systematic review of 38 randomized trials

Systemic therapy (ST) is one of the most widely applied psychotherapeutic approaches in the treatment of children and adolescents, yet few systematic reviews exist on the efficacy of ST with this age group. Parallel to a similar study on adults, a systematic review was performed to analyze the efficacy of ST in the treatment of children and adolescents. All randomized or matched controlled trials (RCT) evaluating ST in any setting with child and adolescent index patients were identified by database searches and cross-references, as well as in existing meta-analyses and reviews. Inclusion criteria were: index patient diagnosed with a DSM-IV or ICD-10 listed psychological disorder, or suffering from other clinically relevant conditions, and trial published by December 2011. Studies were analyzed according to their sample, research methodology, interventions applied, and results at end-of-treatment and at follow-up. This article presents findings for internalizing and mixed disorders. Thirty-eight trials were identified, with 33 showing ST to be efficacious for the treatment of internalizing disorders (including mood disorders, eating disorders, and psychological factors in somatic illness). There is some evidence for ST being also efficacious in mixed disorders, anxiety disorders, Asperger disorder, and in cases of child neglect. Results were stable across follow-up periods of up to 5 years. Trials on the efficacy of ST for externalizing disorders are presented in a second article. There is a sound evidence base for the efficacy of ST as a treatment for internalizing disorders of child and adolescent patients.

Simple behavioural interventions for nocturnal enuresis in children

BACKGROUND

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15% to 20% of five year olds and up to 2% of adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs can be great. Behavioural interventions for treating bedwetting are defined as interventions that require a behaviour or action by the child which promotes night dryness and includes strategies which reward that behaviour. Behavioural interventions are further divided into:(a) simple behavioural interventions - behaviours or actions that can be achieved by the child without great effort; and(b) complex behavioural interventions - multiple behavioural interventions which require greater effort by the child and parents to achieve, including enuresis alarm therapy.This review focuses on simple behavioural interventions.Simple behavioural interventions are often used as a first attempt to improve nocturnal enuresis and include reward systems such as star charts given for dry nights, lifting or waking the children at night to urinate, retention control training to enlarge bladder capacity (bladder training) and fluid restriction. Other treatments such as medications, complementary and miscellaneous interventions such as acupuncture, complex behavioural interventions and enuresis alarm therapy are considered elsewhere.

OBJECTIVES

To determine the effects of simple behavioural interventions in children with nocturnal enuresis.The following comparisons were made:1. simple behavioural interventions versus no active treatment;2. any single type of simple behavioural intervention versus another behavioural method (another simple behavioural intervention, enuresis alarm therapy or complex behavioural interventions);3. simple behavioural interventions versus drug treatment alone (including placebo drugs) or drug treatment in combination with other interventions.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 15 December 2011). The reference lists of relevant articles were also searched.

SELECTION CRITERIA

All randomised or quasi-randomised trials of simple behavioural interventions for treating nocturnal enuresis in children up to the age of 16. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials and extracted data. Differences between reviewers were settled by discussion with a third reviewer.

MAIN RESULTS

Sixteen trials met the inclusion criteria, involving 1643 children of whom 865 received a simple behavioural intervention. Within each comparison, outcomes were mostly addressed by single trials, precluding meta-analysis. The only exception was bladder training versus enuresis alarm therapy which included two studies and demonstrated that alarm therapy was superior to bladder training.In single small trials, rewards, lifting and waking and bladder training were each associated with significantly fewer wet nights, higher full response rates and lower relapse rates compared to controls. Simple behavioural interventions appeared to be less effective when compared with other known effective interventions (such as enuresis alarm therapy and drug therapies with imipramine and amitriptyline). However, the effect was not sustained at follow-up after completion of treatment for the drug therapies. Based on one small trial, cognitive therapy also appeared to be more effective than rewards. When one simple behavioural therapy was compared with another, there did not appear to be one therapy that was more effective than another.

AUTHORS' CONCLUSIONS

Simple behavioural methods may be superior to no active treatment but appear to be inferior to enuresis alarm therapy and some drug therapy (such as imipramine and amitriptyline). Simple behavioural therapies could be tried as first line treatment before considering enuresis alarm therapy or drug therapy, which may be more demanding and have adverse effects, although evidence supporting their efficacy is lacking.

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.

Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics)

BACKGROUND

Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 20% of five-year olds and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis.

OBJECTIVES

To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi-randomised trials. The reference lists of relevant articles were also searched.

SELECTION CRITERIA

All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author.

MAIN RESULTS

A total of 40 randomised or quasi-randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials.For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights.Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects.

AUTHORS' CONCLUSIONS

There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials.

Predictors of severity and treatment response in children with monosymptomatic nocturnal enuresis receiving behavioral therapy

OBJECTIVE

To evaluate the role of bladder volume and bladder wall thickness measurement by ultrasound in assessing severity and predicting response to behavioral therapy in children with monosymptomatic nocturnal enuresis.

METHODS

122 children (68 boys and 54 girls) aged 5-9 years underwent ultrasound evaluation of bladder volume and bladder wall thickness, followed by calculation of the bladder volume wall thickness index (BVWI). They were treated using first-line management (behavioral therapy) for 4 months. Correlation of severity and treatment response to ultrasound bladder measurements was investigated.

RESULTS

Only 74 children completed the study: 16 showed complete response to treatment, 25 good response, 18 partial response, and 15 children showed no response. Age, gender and location of residence did not correlate to severity or to treatment response. Ultrasound measured bladder volume also did not correlate to either severity or response. Bladder wall thickness showed a strong correlation to both severity and response to treatment, as did BVWI.

CONCLUSION

Ultrasound measured bladder wall thickness and BVWI are strongly associated with the severity of nocturnal enuresis and are highly predictive of treatment response to behavioral therapy. It is recommended that any child with monosymptomatic nocturnal enuresis should undergo an abdominal ultrasound examination before starting treatment.

Complementary and miscellaneous interventions for nocturnal enuresis in children

BACKGROUND

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15% to 20% of five year olds, and up to 2% of young adults.

OBJECTIVES

To assess the effects of complementary interventions and others such as surgery or diet on nocturnal enuresis in children, and to compare them with other interventions.

SEARCH METHODS

We searched PubMed (1950 to June 2010), EMBASE (1980 to June 2010), the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) (1984 to June 2010), Chinese Biomedical Literature Database (CBM) (1975 to June 2010), China National Knowledge Infrastructure (CNKI) (1979 to June 2010), VIP database (1989 to June 2010), and the reference lists of relevant articles, all last searched 26 June 2010. No language restriction was used.

SELECTION CRITERIA

All randomised or quasi-randomised trials of complementary and other miscellaneous interventions for nocturnal enuresis in children were included except those focused solely on daytime wetting. Comparison interventions could include no treatment, placebo or sham treatment, alarms, simple behavioural treatment, desmopressin, imipramine and miscellaneous other drugs and interventions.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

In 24 randomised controlled trials, 2334 children were studied, of whom 1283 received a complementary intervention. The quality of the trials was poor: 5 trials were quasi-randomised, 5 showed differences at baseline and 17 lacked follow up data.The outcome was better after hypnosis than imipramine in one trial (relative risk (RR) for failure or relapse after stopping treatment 0.42, 95% confidence interval (CI) 0.23 to 0.78). Psychotherapy appeared to be better in terms of fewer children failing or relapsing than both alarm (RR 0.28, 95% CI 0.09 to 0.85) and rewards (RR 0.29, 95%CI 0.09 to 0.90) but this depended on data from only one trial. Medicinal herbs had better results than desmopressin in one trial (RR for failure or relapse after stopping treatment 0.35, 95% CI 0.14 to 0.85). Acupuncture had better results than sham control acupuncture (RR for failure or relapse after stopping treatment 0.67, 95% CI 0.48 to 0.94) in a further trial. Active chiropractic adjustment had better results than sham adjustment (RR for failure to improve 0.76, 95% CI 0.60 to 0.95). However, each of these findings came from small single trials, and must be verified in further trials. The findings for diet and faradization were unreliable, and there were no trials including homeopathy or surgery.

AUTHORS' CONCLUSIONS

There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture, chiropractic and medicinal herbs but it was provided in each case by single small trials, some of dubious methodological rigour. Robust randomised trials are required with efficacy, cost-effectiveness and adverse effects clearly reported.

Case study: a patient-clinician collaboration that identified and prioritized evidence gaps and stimulated research development

OBJECTIVE

To assess the effect of a research prioritization partnership that aimed to influence the research agenda relating to urinary incontinence (UI).

STUDY DESIGN AND SETTING

Research often neglects important gaps in existing evidence so that decisions must be made about treatments without reliable evidence of their effectiveness. In 2007-2009, a United Kingdom partnership of eight patient and 13 clinician organizations identified and prioritized gaps in the evidence that affect everyday decisions about treatment of UI. The top 10 prioritized research questions were published and reported to research funders in 2009. A year later, new research or funding applications relating to the prioritized topics were identified through reviews of research databases and consultation with funding organizations, elements of the research community, and organizations that participated in the partnership.

RESULTS

Since dissemination of the prioritized topics, five studies are known to have been funded, three in development; five new systematic reviews are under way, one is being updated; five questions are under consideration by a national research commissioning body.

CONCLUSION

The partnership successfully developed and used a methodology for identification and prioritization of research needs through patient-clinician consensus. Prioritization through consensus can be effective in informing the development of clinically useful research.

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.

Efficacy of desmopressin and enuresis alarm as first and second line treatment for primary monosymptomatic nocturnal enuresis: prospective randomized crossover study

PURPOSE

We compared the efficacy of desmopressin and enuresis alarm as first and second line treatment options for monosymptomatic nocturnal enuresis.

MATERIALS AND METHODS

A total of 104 children with monosymptomatic nocturnal enuresis were randomly assigned to either desmopressin (54) or enuresis alarm (50) as first line treatment. Following 12 weeks of first line treatment children with a full response were evaluated for relapse 12 weeks after withdrawal of treatment. Children with partial or no response were switched to the alternative treatment and then evaluated after 12 weeks of crossover treatment. Relapse was defined as more than 1 episode of bedwetting monthly.

RESULTS

Following first line treatment 77.8% of the desmopressin group and 82% of the enuresis alarm group achieved a successful result, including full response in 37% and 50% of the groups, respectively (p=0.433). Of the children with a full response 50% in the desmopressin group and 12% in the enuresis alarm group experienced a relapse when treatment stopped (p=0.005). Following second line crossover treatment 71.4% of the enuresis alarm-desmopressin group and 67.8% of the desmopressin-enuresis alarm group achieved a successful result, including full response in 47.6% and 45.2% of the groups, respectively (p=0.961).

CONCLUSIONS

There was no difference between desmopressin and enuresis alarm during treatment for achieving dryness, but the chance of relapse after treatment stopped was higher following desmopressin. Switching to the alternative treatment following partial or no response provided an additional benefit.

Mixed treatment comparison analysis provides internally coherent treatment effect estimates based on overviews of reviews and can reveal inconsistency

OBJECTIVES

To propose methods for mixed treatment comparisons (MTC) based on pooled summaries of the type produced in overviews of reviews.

STUDY DESIGN AND SETTING

Overviews of reviews (umbrella reviews) summarize the results of multiple systematic reviews into a single document. They report the summary estimates from the original pairwise meta-analyses and discuss them in narrative form, with the intention of identifying the most effective treatment. We present methods for MTC synthesis, tailored for use with overviews of reviews. These generate a single internally consistent summary of all the relative treatment effects and assessments of whether the summary is consistent with the data. These methods are applied to a published overview of treatments for childhood nocturnal enuresis. We apply the methods to both fixed-effect (FE) and random-effects (RE) meta-analyses of the original trials.

RESULTS

The summary relative risks based on FE meta-analyses, as originally published, were highly inconsistent. Those based on RE meta-analyses were consistent and could, given standard assumptions on comparability of treatment effects in meta-analysis, form a basis for coherent decision making.

CONCLUSION

Along with the summaries from systematic reviews, MTC methods should be used in overviews to provide a single coherent analysis of all treatment comparisons and to check for evidence consistency.

The short- and long-term effects of simple behavioral interventions for nocturnal enuresis in young children: a randomized controlled trial

OBJECTIVE

To assess the short- and long-term effects of 3 simple behavioral interventions to overcome nocturnal enuresis in young children.

STUDY DESIGN

We performed a randomized controlled trial in children aged four to five years with mono-symptomatic nocturnal enuresis (n = 570). The children were placed in one of four groups: (1) lifting to urinate and ask for a password; (2) the same as group 1, without a password; (3) using a reward system; or (4) a control group. Each participant was asked to carry out the appointed intervention for 6 months or until 14 consecutive dry nights occurred, which was the continence criterion. A follow-up was performed approximately 3 years after the study.

RESULTS

After 6 months, lifting the child to the toilet without the use of a password was the only intervention that resulted in significantly more dry children (37%) than the control group (21%). Three years later, both lifting groups had the highest (78%) and the control group the lowest (69%) percentage of dry children.

CONCLUSIONS

The intervention lifting to urinate without the use of a password leads to more dry children compared with no active treatment in children aged 4 to 5 years with nocturnal enuresis.

Eficacia del tratamiento conductual en la enuresis nocturna

BACKGROUND

Nocturnal enuresis is a common, often misunderstood condition that affects millions of children. Although the rate of spontaneous resolution is 15 % per year, treatment is often required for social or psychological reasons.

OBJECTIVE

To determine the prevalence of nocturnal enuresis in a primary health care area, how was it diagnosed, which treatments were employed and treatment response.

MATERIAL AND METHODS

A retrospective study was performed that included all the medical records of children aged between 6 and 14 years old in a basic health area.

RESULTS

Twenty-seven children with a diagnosis of nocturnal enuresis were identified (4.3 %). Among these, 21 were boys (77.7 %) and six were girls (22.3 %). There was a family history of nocturnal enuresis in 15 patients (55.5 %). Nocturnal enuresis was not the reason for consultation in 24 of the 27 patients (88.8 %) but was diagnosed collaterally by anamnesis. All the children had simple primary nocturnal (monosymptomatic) enuresis. Five patients abandoned the treatment (18 %), 15 (55.5 %) recovered with behavioral intervention exclusively, the remaining seven children were treated with desmopressin, which was successful in three of them. The remaining four patients were still receiving treatment when the data were collected.

CONCLUSIONS

The prevalence of nocturnal enuresis in this primary health area (4.3 %) is similar that reported in other series. In a high percentage (88.8 %) of patients, nocturnal enuresis was not the reason for consultation but was diagnosed during anamnesis. Behavioral intervention was effective in more than half (55.5 %) of the patients.

Complementary and miscellaneous interventions for nocturnal enuresis in children

BACKGROUND

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults.

OBJECTIVES

To assess the effects of complementary interventions and others such as surgery or diet on nocturnal enuresis in children, and to compare them with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 22 November 2004), the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) (January 1984 to June 2004) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials of complementary and other miscellaneous interventions for nocturnal enuresis in children were included except those focused solely on daytime wetting. Comparison interventions could include no treatment, placebo or sham treatment, alarms, simple behavioural treatment, desmopressin, imipramine and miscellaneous other drugs and interventions.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

In 15 randomised controlled trials, 1389 children were studied, of whom 703 received a complementary intervention. The quality of the trials was poor: four trials were quasi-randomised, five showed differences at baseline and ten lacked follow up data. The outcome was better after hypnosis than imipramine in one trial (relative risk (RR) for failure or relapse after stopping treatment 0.42, 95% confidence interval (CI) 0.23 to 0.78). Psychotherapy appeared to be better in terms of fewer children failing or relapsing than both alarm (RR 0.28, 95% CI 0.09 to 0.85) and rewards (0.29, 95% 0.09 to 0.90) but this depended on data from only one trial. Acupuncture had better results than sham control acupuncture (RR for failure or relapse after stopping treatment 0.67, 95% CI 0.48 to 0.94) in a further trial. Active chiropractic adjustment had better results than sham adjustment (RR for failure or relapse after stopping treatment 0.74, 95% CI 0.60 to 0.91). However, each of these findings came from small single trials, and need to be verified in further trials. The findings for diet and faradization were unreliable, and there were no trials including homeopathy or surgery.

AUTHORS' CONCLUSIONS

There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture and chiropractic but it was provided in each case by single small trials, some of dubious methodological rigour. Robust randomised trials are required with efficacy, cost-effectiveness and adverse effects carefully monitored.

Alarm interventions for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults.

OBJECTIVES

To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised trials register (searched 22 November 2004) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

Fifty five trials met the inclusion criteria, involving 3152 children of whom 2345 used an alarm. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95% CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (4/22 (18%) vs 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69). Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94).

AUTHORS' CONCLUSIONS

Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.

Complex behavioural and educational interventions for nocturnal enuresis in children

BACKGROUND

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults.

OBJECTIVES

To assess the effects of complex behavioural and educational interventions on nocturnal enuresis in children, and to compare them with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles. Date of the most recent searches: December 2002.

SELECTION CRITERIA

All randomised or quasi-randomised trials of complex behavioural or educational interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and physical behavioural methods, alarms, desmopressin, tricyclics, and miscellaneous other interventions.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

Sixteen trials involving 1081 children were identified which included a complex or educational intervention for nocturnal enuresis. The trials were mostly small and some had methodological problems including the use of a quasi-randomised method of concealment of allocation in three trials and baseline differences between the groups in another three.A complex intervention (such as dry bed training (DBT) or full spectrum home training (FSHT)) including an alarm was better than no-treatment control groups (eg RR for failure or relapse after stopping DBT 0.25; 95% CI 0.16 to 0.39) but there was not enough evidence about the effects of complex interventions alone if an alarm was not used. A complex intervention on its own was not as good as an alarm on its own or the intervention supplemented by an alarm (eg RR for failure or relapse after DBT alone versus DBT plus alarm 2.81; 95% CI 1.80 to 4.38). On the other hand, a complex intervention supplemented by a bed alarm might reduce the relapse rate compared with the alarm on its own (eg RR for failure or relapse after DBT plus alarm versus alarm alone 0.5; 95% CI 0.31 to 0.80).There was not enough evidence to judge whether providing educational information about enuresis was effective, irrespective of method of delivery. There was some evidence that direct contact between families and therapists enhanced the effect of a complex intervention, and that increased contact and support enhanced a package of simple behavioural interventions, but these were addressed only in single trials and the results would need to be confirmed by further randomised controlled trials, in particular the effect on use of resources.

REVIEWER'S CONCLUSIONS

Although DBT and FSHT were better than no treatment when used in combination with an alarm, there was insufficient evidence to support their use without an alarm. An alarm on its own was also better than DBT on its own, but there was some evidence that combining an alarm with DBT was better than an alarm on its own, suggesting that DBT may augment the effect of an alarm. There was also some evidence that direct contact with a therapist might enhance the effects of an intervention.

Simple behavioural and physical interventions for nocturnal enuresis in children

BACKGROUND

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs can be great. Simple behavioural methods of treating bedwetting include reward systems such as star charts given for dry nights, lifting or waking the children at night to urinate, retention control training to enlarge bladder capacity (bladder training) and fluid restriction.

OBJECTIVES

To assess the effects of simple behavioural interventions on nocturnal enuresis in children, and to compare these with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (searched 18 September 2003). The reference list of a previous version of this review was also searched.

SELECTION CRITERIA

All randomised or quasi-randomised trials of simple behavioural interventions for nocturnal enuresis in children up to the age of 16. Trials focused solely on daytime wetting were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials and extracted data.

MAIN RESULTS

Thirteen trials met the inclusion criteria, involving 702 children of whom 387 received a simple behavioural intervention. However, within each comparison each outcome was addressed by single trials only, precluding meta-analysis. In single small trials, reward systems (e.g. star charts), lifting and waking were each associated with significantly fewer wet nights, higher cure rates and lower relapse rates compared to controls. There was not enough evidence to evaluate retention control training (bladder training), whether compared with controls or dry bed training, or used as a supplement to alarms, or versus desmopressin. Cognitive therapy may have lower failure and relapse rates than star charts, but this finding was based on one small trial only. One small trial of poor quality suggested that star charts were initially less successful than amitriptyline but this difference did not persist after the treatments stopped. Another suggested that imipramine was better than fluid deprivation and avoidance of punishment.

REVIEWERS' CONCLUSIONS

Simple behavioural methods may be effective for some children, but further trials are needed, in particular in comparison with treatments known to be effective, such as desmopressin, tricyclic drugs and alarms. However, simple methods could be tried as first line therapy before considering alarms or drugs, because these alternative treatments may be more demanding and may have adverse effects.

Tricyclic and related drugs for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults.

OBJECTIVES

To assess the effects of tricyclic and related drugs on nocturnal enuresis in children, and to compare them with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles including two previously published versions of this review. Date of the most recent searches: December 2002.

SELECTION CRITERIA

All randomised and quasi-randomised trials of tricyclics or related drugs for nocturnal enuresis in children were included in the review. Comparison interventions included placebo, other drugs, alarms, behavioural methods or complementary/miscellaneous interventions. Trials focused solely on daytime wetting were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

Fifty four randomised trials met the inclusion criteria, involving 3379 children. The quality of many of the trials was poor. Most comparisons or outcomes were addressed only by single trials. Treatment with most tricyclic drugs (such as imipramine, amitriptyline, viloxazine, nortriptyline, clomipramine and desipramine) was associated with a reduction of about one wet night per week while on treatment (eg imipramine compared with placebo, weighted mean difference (WMD) -1.19, 95% CI -1.56 to -0.82). The exception was mianserin, where results from one small trial did not reach statistical significance. About a fifth of the children became dry while on treatment (relative risk for failure (RR) 0.77, 95% CI 0.72 to 0.83), but this effect was not sustained after treatment stopped (eg imipramine versus placebo, RR 0.98, 95% CI 0.95 to 1.03). There was not enough information to assess the relative performance of one tricyclic against another, except that imipramine was better than mianserin. The evidence comparing desmopressin with tricyclics was unreliable or conflicting, but in one small trial all the children failed or relapsed after stopping active treatment with either drug.The evidence comparing tricyclics with alarms was also unreliable or conflicting during treatment. In one small trial all the children failed or relapsed after tricyclics stopped, compared with about half after alarms. This result was compatible with the results in the Cochrane review of alarm treatment, which found that about half the children remained dry after alarm treatment was finished. There was a little evidence from single trials to suggest that imipramine might be better than a simple reward system with star charts during treatment; worse than a complex intervention involving education, counseling, waking and retention control training; better than a restricted diet; and worse than hypnosis. However, these results need to be confirmed by further research.

REVIEWER'S CONCLUSIONS

Although tricyclics and desmopressin are effective in reducing the number of wet nights while taking the drugs, most children relapse after stopping active treatment. In contrast, only half the children relapse after alarm treatment. Parents should be warned of the potentially serious adverse effects of tricyclic overdose when choosing treatment. Further research is needed into comparisons between drug and behavioural or complementary treatments, and should include relapse rates after treatment is finished.

Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics)

BACKGROUND

Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great.

OBJECTIVES

To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children, and to compare them with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register. Date of the most recent search: December 2002. The reference list of a previous version of this review was also searched.

SELECTION CRITERIA

All randomised trials of drugs (excluding desmopressin or tricyclics) for nocturnal enuresis in children were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or other conservative interventions for nocturnal bedwetting. Trials focused solely on daytime wetting were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials and extracted data.

MAIN RESULTS

In 32 randomised controlled trials (25 new in this update), a total of 1225 out of 1613 children received an active drug other than desmopressin or a tricyclic. In all, 28 different drugs or classes of drugs were tested, but the trials were generally small or of poor methodological quality (five were quasi-randomised and the remainder failed to give adequate details about the randomisation process). Although indomethacin and diclofenac were better than placebo during treatment, desmopressin was better than both of them, with less chance of adverse effects. There were no data regarding what happened after treatment stopped. Limited data suggested that an alarm was better than drugs during treatment.

REVIEWER'S CONCLUSIONS

There was not enough evidence to judge whether the included drugs reduced bedwetting. There was limited evidence to suggest that desmopressin, imipramine and alarms were better than the drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective.

Desmopressin for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great.

OBJECTIVES

To assess the effects of desmopressin on nocturnal enuresis in children, and to compare desmopressin with other interventions.

SEARCH STRATEGY

The following electronic databases were searched: MEDLINE to June 1997; AMED; ASSIA; BIDS; BIOSIS Previews (1985-1996); CINAHL; DHSS Data; EMBASE (1974 to June 1997); PsycLIT and SIGLE. Organisations, manufacturers, researchers and health professionals concerned with enuresis were contacted for information. The reference sections of obtained studies were also checked for further trials. Date of the most recent search: July 1997.

SELECTION CRITERIA

All randomised trials of desmopressin for nocturnal enuresis in children were included in the review. Trials were eligible for inclusion if: children were randomised to receive desmopressin compared with placebo, other drugs or other conservative interventions for nocturnal bedwetting; participants with organic causes for their bedwetting were excluded; and baseline assessments of the level of bedwetting were reported. Trials focused solely on daytime wetting were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

Twenty one randomised trials involving 948 children treated with desmopressin, met the inclusion criteria. The quality of many of the trials was poor. Desmopressin was compared with a tricyclic drug in two trials, and with alarms in one. Desmopressin was effective in reducing bedwetting in a variety of doses and forms. Each dose of desmopressin reduced bedwetting by at least one night per week during treatment (eg 20microg: 1.56 fewer wet nights per week, 95% CI -1.94 to -1.19). Participants on desmopressin were 4.6 times more likely to achieve 14 consecutive dry nights (95% CI 1.38 to 15.02) compared with placebo. However, there was no difference after treatment was finished. There was no apparent dose-related effect of desmopressin, but the evidence was limited. Data which compared oral and nasal administration were too few to be conclusive. Desmopressin and imipramine (a tricyclic drug) were equally effective in one small trial. Amitriptyline (another tricyclic) was not consistently better than desmopressin either alone or when used as a supplement. In a single trial, desmopressin was initially superior to using an alarm in reducing the number of wet nights per week: WMD -1.7 (95% CI: -2.96 to -0.45), but this result was not sustained; after three months of treatment, patients using the alarm had 1.4 fewer wet nights per week than with desmopressin: (95% CI: 0.14 to 2.65). Participants receiving the alarm intervention were also nine times less likely to relapse than those given desmopressin: RR 9.2 (95% CI: 1.28 to 65.9). Combining alarm and drug therapy was found to be superior to alarm treatment alone. The addition of desmopressin to an alarm schedule resulted in one less wet night per week: (95% CI: -1.55 to -0.45).

REVIEWER'S CONCLUSIONS

Desmopressin rapidly reduced the number of wet nights per week, but there was some evidence that this was not sustained after treatment stopped. Comparison with alternative treatments suggested that desmopressin and tricyclics had similar clinical effects, but that alarms produced more sustained benefits. However, based on the available evidence, these conclusions can only be tentative. There was some evidence of minor side effects of desmopressin in the included trials, such as nasal irritation and nose bleeds. However, the risk of water intoxication associated with over-drinking before bedtime has been reported. Patients and their families need to be warned of potential adverse effects and advise