Alarm interventions for nocturnal enuresis in children

The value of case history and early treatment data as predictors of enuresis alarm therapy response

BACKGROUND AND AIM

Two central problems with the enuresis alarm are the family workload and the lack of predictors of therapy response. We wanted to look at predictors of alarm response in a setting reflecting clinical reality.

METHODS

An alarm linked to a smartphone app was provided to enuretic children managed at pediatric outpatient wards. Baseline data (sex, age, daytime incontinence, urgency, previous therapies, arousal thresholds and baseline enuresis frequency) were recorded. Further information, such as enuretic episodes and actual alarm use, was gathered via the app during therapy. Therapy was given for 8-12 weeks or until 14 consecutive dry nights had been achieved.

RESULTS

For the 196 recruited children the outcome was as follows: full responders (FR) 18.4%, partial responders (PR) 20.4%, nonresponders (NR) 22.4% and dropouts 38.8%. We found no clear predictors of response or adherence among baseline data. But as treatment progressed responders reduced their enuresis frequency as compared to NR (week two P = 0.003, week three and onwards P < 0.001). This is further illustrated in the Figure below. Furthermore, the children unable to complete the full treatment had more non-registered nights already from the second week (week two P = 0.005, week three P = 0.002 and so on).

DISCUSSION

Anamnestic data give little predictive information regarding enuresis alarm response or adherence. Contrary to common belief neither daytime incontinence nor previous alarm attempts influenced treatment success. But after 2-4 weeks of therapy the children with a good chance of treatment success could be discerned by decreasing enuresis frequency, and the families that would not be able to comply with the full treatment showed incomplete adherence already during the first weeks.

CONCLUSIONS

Maybe the enuresis alarm strategy should be changed so that the treatment is reassessed after one month and only children with a high chance of success continue. This way, unnecessary frustration for the families of therapy-resistant children may be reduced.

Daytime urotherapy in nocturnal enuresis: a randomised, controlled trial

OBJECTIVE

According to international guidelines, children with enuresis are recommended urotherapy, or basic bladder advice, before treatment with evidence-based alternatives such as the enuresis alarm is given. The efficacy of this strategy has, however, not been supported by controlled studies. We wanted to test if basic bladder advice is useful in enuresis.

DESIGN

Randomised, controlled trial.

SETTING

Paediatric outpatient ward, regional hospital.

PATIENTS

Treatment-naïve enuretic children aged ≥6 years, with no daytime incontinence.

INTERVENTIONS

Three groups, each during 8 weeks: (A) basic bladder advice-that is, voiding and drinking according to a strict schedule and instructions regarding toilet posture, (B) enuresis alarm therapy and (C) no treatment (control group).

MAIN OUTCOME MEASURES

Reduction in enuresis frequency during week 7-8 compared with baseline.

RESULTS

The median number of wet nights out of 14 before and at the end of treatment were in group A (n=20) 12.5 and 11.5 (p=0.44), in group B (n=22) 11.0 and 3.5 (p<0.001) and in group C (n=18) 12.5 and 12.0 (p=0.55). The difference in reduction of enuresis frequency between the groups was highly significant (p=0.002), but no difference was found between basic bladder advice and controls.

CONCLUSIONS

Urotherapy, or basic bladder advice, is ineffective as a first-line treatment of nocturnal enuresis. Enuretic children who are old enough to be bothered by their condition should be offered treatment with the alarm or desmopressin.

TRIAL REGISTRATION NUMBER

NCT03812094.

Boxer Underwear Incorporating Textile Moisture Sensor to Prevent Nocturnal Enuresis

Around 15% of children still wet their bed after five years old. Although bedwetting alarms have proven to be effective to achieve nighttime dryness, they are cumbersome so children could be reluctant to use them. Therefore, the moisture sensor and wire were made unobtrusive by seamlessly integrated them into fully textile underwear by using conductive yarns. Consequently, the alarm acceptability should be enhanced by improving children’s comfort. Three conductive textile metallic yarns, made of silver or stainless steel, were considered to fabricate the urine leakage sensor. Silver-plated-nylon yarn, which showed the highest electrical conductivity, outperformed the stainless-steel yarns regarding its ability to detect urine leakage as well as its detection speed. Furthermore, it was proven to withstand multiple urine soakings and the following machine-washings, even at high temperature (60 °C). However, the electrical current, necessary to detect the leakage, tends to corrode the silver. Therefore, the detection circuit was adapted. Eventually, the designed leakage sensor was seamlessly integrated into a child’s trunk underwear, into which a miniaturized alarm can be plugged. The resulting textile underwear aims at replacing the rigid alarm system currently available, hence improving the quality of life of enuretic children and help them achieving nighttime dryness.

Practical recommendations of the EAU-ESPU guidelines committee for monosymptomatic enuresis-Bedwetting

BACKGROUND AND AIMS

The objective of this update of the EAU-ESPU guidelines recommendations for nocturnal enuresis was to review the recent published literature of studies, reviews, guidelines regarding the etiology, diagnosis and treatment options of nocturnal enuresis and transform the information into a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist and urologist.

MATERIAL AND METHODS

Since 2012 a monthly literature search using Scopus® was performed and the relevant literature was reviewed and prospectively registered on the European Urology bedwetting enuresis resource center (http://bedwetting.europeanurology.com/). In addition, guideline papers and statements of the European Society for Paediatric Urology (ESPU), the European Association of Urology (EAU), the National Institute for Health and Care Excellence (NICE) and the International Children Continence Society (ICCS) were used to update the knowledge and evidence resulting in this practical recommendation strategy. Recommendations have been discussed and agreed within the working group of the EAU-ESPU guidelines committee members.

RESULTS

The recommendations focus to place the child and his family in a control position. Pragmatic analysis is made of the bedwetting problem by collecting voiding and drinking habits during the day, measuring nighttime urine production and identification of possible risk factors such as high-volume evening drinking, nighttime overactive bladder, behavioral or psychological problems or sleep disordered breathing. A questionnaire will help to identify those risk factors.

CONCLUSION

Motivation of the child is important for success. Continuous involvement of the child and the family in the treatment will improve treatment compliance, success and patient satisfaction.

Adesão em saúde e psicoterapia: conceituação e aplicação na enurese noturna

Existem diversos estudos sobre preditores da não adesão, mas poucos mostram estratégias efetivas para lidar com esse problema. Uma revisão da literatura sobre desistência em psicoterapia mostrou que quase metade dos pacientes que ingressam num atendimento não o concluem. A medida na psicoterapia em geral é a de não adesão, ou desistência do tratamento; no presente trabalho serão apresentados dados relativos à adesão ao tratamento da enurese com alarme de urina. A taxa de desistência em um grupo de 61 crianças e adolescentes foi levantada considerando três condições: suas famílias não compareceram aos atendimentos, não responderam ao contato telefônico ou relataram ter abandonado os procedimentos. A desistência correspondeu a 19,6% da amostra e a idade do grupo dos desistentes era significativamente inferior, quando comparada à daqueles que aderiram ao tratamento. A já demonstrada associação entre a intolerância parental e a idade do filho explica os resultados e aponta para a necessidade de trabalho educativo intenso com os pais de adolescentes portadores de enurese.

[Evaluation and management of enuresis. An update]

Enuresis is defined as nocturnal bed wetting for at least 2 nights per month in children older than 5 years. At this age the prevalence of enuresis is about 15-20%. More than 50% of these children show day time symptoms, such as frequency, urgency and incontinence (non-monosymptomatic enuresis). The other children are asymptomatic during day time and wet the bed during the night time (monosymptomatic enuresis). The main pathogenetic factors are nycturia, detrusor overactivity and reduced arousability. Psychological and psychiatric aspects, genetics and obstipation play an additional role in the etiology. Basic diagnostic investigations are mandatory before treatment. Clinical history, physical examination, sonography of the urinary tract, urinalysis and bladder diary are prerequisites before any therapeutic steps are taken. The cornerstones of primary enuresis therapy are general lifestyle advice, pharmacotherapy and alarm devices. Therapy-resistant children deserve further evaluation and a multidisciplinary therapy approach. After careful evaluation specific therapy is efficient in approximately 80% of patients.