Monosymptomatic nocturnal enuresis in pediatric patients: multidisciplinary assessment and effects of therapeutic intervention

Prevalence of nocturnal enuresis among children of Aseer region in Saudi Arabia

Introduction

Nocturnal enuresis (NE) in children is a very common problem managed in pediatric urology. In this study, we present the prevalence of NE in children in Aseer region in Saudi Arabia.

Methodology

This study was conducted as a descriptive cross-sectional survey to estimate the prevalence of NE among 555 Saudi children aged 5-15 years in Aseer region in Saudi Arabia. Data collection was done through a questionnaire, which included questions on sociodemographic data, personal knowledge, enuresis-related characteristics, risk factors, and management modalities.

Results

This study identified a prevalence of enuresis of 24% of the study population, most of whom were boys. The majority of the parents had a high educational level. Clinical characteristics of the study population showed: 9% have a family history of NE, 2.2% have a history of neurological disorder, 10.0% have a history of urinary tract infections, 66.8% have associated daytime urgency, 67% have urine-holding behavior, and 19.5% have associated daytime enuresis of the study population.

Conclusion

Our study found that 24% of children in the Aseer region in Saudi Arabia have NE. Our study finding helps us to understand the prevalence of NE in Aseer region in Saudi Arabia, and this can be applied to other regions in the kingdom. Furthermore, this finding helps us to understand the need to raise awareness in the community about NE and the need to educate the nonpediatric urologist health-care provider about the best management practice for NE.

Desmopressin in combination with anticholinergic agents in the treatment of nocturnal enuresis: a systematic review and meta-analysis

Background

The desmopressin combined with anticholinergic agents for the treatment of nocturnal enuresis (NE) remains controversial. This meta-analysis assesses the efficacy and safety of desmopressin compared with desmopressin plus anticholinergic agents for the treatment of NE.

Methods

We searched MEDLINE, Embase, and Cochrane Controlled Trials Register databases for RCTs published for the treatment of NE. Systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. This meta-analysis used RevMan v.5.1.0 to analyze data.

Results

Eight studies involving 600 patients (293 in the combination group and 307 in the desmopressin group) contained meaningful data. The results were as follows: after one month of treatment, compared with the desmopressin monotherapy group, the combination group was significantly better in treating NE in FR (full responders, P = 0.003), FR + PR (partial responders) (P < 0.0001), and the mean number of wet nights (P = 0.004); also, the combination group had a better effect in FR (P < 0.00001), FR + PR (P = 0.02) and the mean number of wet nights (P = 0.04) after 3 months' treatment. For side effects, combination therapy does not cause more adverse events in treating NE (P = 0.42).

Conclusions

This study elucidates that desmopressin combined with the anticholinergic agent was demonstrated to be more effective in treating NE than desmopressin monotherapy, and the anticholinergic agent does not increase the risk of adverse events (AEs).

L'évaluation et la prise en charge de l'énurésie en pédiatrie générale

Pour évaluer l'énurésie, un trouble pédiatrique courant, il faut en distinguer la forme monosymptomatique de la forme non monosymptomatique et établir la présence d'affections concomitantes. La prise en charge simultanée des facteurs cooccurrents est le meilleur moyen pour obtenir un résultat satisfaisant. Le traitement commence par l'éducation du patient et de sa famille sur l'évolution naturelle de l'énurésie et par des conseils pratiques sur le comportement. Les données probantes en appui à des interventions particulières sont limitées, et les enfants et les familles devraient participer au choix du traitement approprié. Les dispositifs d'alarme contre l'énurésie et la desmopressine représentent des possibilités thérapeutiques lorsqu'une intervention plus active est souhaitée. Des améliorations cliniques et des traitements combinés sont en voie de se dégager.

Evaluation and management of enuresis in the general paediatric setting

Assessing enuresis involves distinguishing monosymptomatic from non-monosymptomatic for this common paediatric problem, and identifying concomitant comorbidities. Addressing co-occurring factors concurrently ensures the best opportunity for a satisfactory outcome. Treatment begins with patient and family education on the natural history of enuresis and practical behavioural guidance. Evidence to support particular interventions is limited, and children and families should be involved when choosing appropriate therapy. Enuresis alarms and desmopressin are treatment options when more active intervention is desired. Clinical refinements and combined treatment modalities are emerging.

Management of treatment-resistant nocturnal enuresis

Nocturnal enuresis is defined as intermittent urinary incontinence during sleep in children 5 years of age and older, occurring at least once a month for at least 3 months. In Japan, pediatricians who do not specialize in nocturnal enuresis have become more proactive in treating the condition since 2016, when the guidelines for treating it were revised for the first time in 12 years. For monosymptomatic nocturnal enuresis, the first step is lifestyle guidance, with a focus on the restriction of fluid intake at night; however, if lifestyle guidance does not decrease the frequency of nocturnal enuresis, aggressive treatment should be added. The first choice of aggressive treatment is oral desmopressin, an antidiuretic hormone preparation, or alarm therapy. However, there remain patients whose wet nights do not decrease with oral desmopressin or alarm therapy. In such cases, it is necessary to reconfirm the method of desmopressin administration and check for factors that may decrease the efficacy of desmopressin. If alarm therapy does not increase the number of dry nights, it is possible that the patient is fundamentally unsuitable for alarm therapy. If dry nights do not increase with oral desmopressin or alarm therapy, the next treatment strategy should be considered immediately to keep the patient motivated for treatment.

Fecal disimpaction in children with enuresis and constipation does not make them dry at night

BACKGROUND

Constipation, daytime incontinence and nocturnal enuresis often overlap. Treatment of constipation has been shown to be an important aspect of therapy for children with daytime incontinence. However, the value of fecal disimpaction, as a part of constipation therapy, in children with enuresis has not been evaluated.

AIM

Our aim was to evaluate the antienuretic effect of fecal disimpaction in children with enuresis and concomitant constipation.

METHODS

The bladder and bowel function was assessed noninvasively in children aged six to ten years who sought help for enuresis for the first time. If they were constipated according to the Rome IV criteria or had a rectal diameter exceeding 30 mm, as assessed by ultrasound, they were given standard evacuation with mini-enemas and macrogol therapy for at least two weeks. Enuresis frequency was documented 14 nights preceding and following therapy.

RESULTS

In total, 66 children (20 girls, 46 boys) were evaluated, 23 (35%) of whom were constipated. There were no differences in age, sex or baseline bladder function between the two groups. The enuresis frequency per two weeks was 9.8 ± 4.1 nights before and 9.3 ± 5.1 nights after constipation therapy (p = 0.43).

DISCUSSION

This study found that fecal disimpaction in children with enuresis who are also constipated did not alleviate nocturnal enuresis. Bowel problems may still need to be addressed but the child should not be given the false hope that this approach alone will make them dry at night. It might be that evidenced based therapies, such as the enuresis alarm and desmopressin, could be less efficient in children with enuresis and constipation unless their bowel disturbance is first properly addressed.

CONCLUSIONS

Fecal disimpaction in children with enuresis and concomitant constipation will, by itself, not make the children dry at night.

Bibliometric and visual analysis of nocturnal enuresis from 1982 to 2022

Nocturnal enuresis is a common disorder among children that seriously affects physical and mental health and has become a social problem. Bibliometric analysis is a valid way to examine existing research results, current research hotspots and research frontiers. Current studies on nocturnal enuresis are numerous and complex, but a bibliometric analysis of the existing research on nocturnal enuresis has yet to be published. To better identify the research trends and frontiers in nocturnal enuresis, it is necessary to conduct a comprehensive review and analysis. We used bibliometric and visualization methods to analyze the 1,111 papers published between 1982 and 2022 from the Web of Science core collection. Basic information about the country, institution, and authors was analyzed, which led to a basic understanding of nocturnal enuresis. The United States is the most prolific country, Ghent University is the most influential institution, and Rittig Soren is the most prominent scholar. The frequency of keywords, clustering, and the cited literature were analyzed to understand the hotspots and frontiers of research, and a brief review of the highly cited literature was conducted. The current research hotspots are the treatment modalities for nocturnal enuresis, epidemiological investigations, and the exploration of pathogenesis. Clinical research, adenoidectomy, aquaporin 2, and response inhibition are potential research hotspots. The standardization of terminology in nocturnal enuresis and the pathologies of polyuria and sleep disorder are at the forefront of research. In summary, the results of our bibliometric analysis reveal views on the current situation and the trend of nocturnal enuresis research for the first time. This study may provide guidance for promoting research on nocturnal enuresis.

Effect of education given to children with enuresis on quality of life

INTRODUCTION

The quality of life of children diagnosed with enuresis is affected negatively compared with that of healthy children.

OBJECTIVES

This study aimed to evaluate the effect of the education program given within the framework of nursing activities on the quality of life of children diagnosed with enuresis.

STUDY DESIGN

The study was conducted on 60 children aged 7-12 years who applied to the urology clinic of a hospital in Turkey and were diagnosed with enuresis. Data were collected using the Pediatric Incontinence Questionnaire (PINQ). Children who met the study criteria were divided into two groups, control and experimental, using the random draw method. Participants in the experimental group were educated by the researcher with using the Enuresis Education Booklet.

RESULTS

Of the 60 children, 43.3% were aged 7-8 years and 63.3% were male. At baseline, the children in the control group revealed a total mean PINQ score of 45.00 ± 11.52, and the total mean PINQ score was 45.80 ± 12.05 at 1 month. At baseline, the children in the experimental group revealed a total mean PINQ score of 47.00 ± 11.88, and the total mean PINQ score of was 32.404 ± 8.62 at 1 month. A measurement carried out in the education and control groups 1 month later showed a statistically significant difference in the total mean PINQ scores (P < 0.001).

CONCLUSION

Explaining the disease thoroughly to a child created a positive effect on the child's quality of life.

Desmopressin versus desmopressin + oxybutynin in the treatment of children with nocturnal enuresis

INTRODUCTION

Enuresis is identified as voluntary or involuntary leakage of urine for at least three consecutive months in the daytime and/or nighttime on clothes for children older than five. Monosymptomatic nocturnal enuresis (MNE) describes nighttime wetting without daytime leakage of urine in children with no pathology in the urinary system and it is 80% more common than enuresis. Desmopressin is the most common medical treatment for MNE. The aim of this study is to retrospectively compare the effectiveness of desmopressin as monotherapy and desmopressin + oxybutynin as a combination therapy in the treatment of nocturnal enuresis.

MATERIAL AND METHOD

This study retrospectively evaluated 183 patients who applied to pediatrics, pediatrics surgery and urology clinics with the complaint of nocturnal enuresis and diagnosed with primary monosymptomatic nocturnal enuresis between January 2014 and December 2019. The patients were divided into two groups (91 patients) who only received desmopressin therapy (Group 1), and those (92 patients) who received desmopressin and oxybutynin combination therapy (Group 2). Response to treatment, compliance and recurrence ratios were determined in the evaluation. Complete response was accepted as 90-100% decrease in the number of nighttime wetting, partial response was accepted as 50-90% decrease in the number of nighttime wetting and those below 50% were regarded as non-response. The 1st, 3rd, and 6th months of control data of treatment effectiveness of both groups were evaluated and their responses to treatment and the side effects of drugs were examined.

RESULTS

The mean age 183 patients of whom 103 were male and 80 were female was 10 (6-16) year. In the first month of control of Group 1, 71.4% had a complete cure, 8.8% had a partial cure and 19.8% had no response to treatment. In the third month of control of Group 1, 74.73% gave a complete response and were cured, 5.5% gave a partial response and 19.78% had no response. In the sixth month of Group 1, 70 patients were evaluated as complete response (79.5%), and 5 patients were evaluated as partial response (5.6%). In the first month of control of Group 2, 75% gave a complete response, 10.9% gave a partial response, 14.1% had no response to treatment. In the third month of control of Group 2, 86.9% gave a complete response, 6.52% gave a partial response, and 6.52% had no response. In the sixth month of the control of Group 2, the number of patients who did not come for control and could not be reached was 2, 83 patients out of 90 patients were evaluated as complete response (92.2%), 6 patients were evaluated as partial response (6.6%).

CONCLUSION

Desmopressin is the only FDA approved pharmacologic treatment for nocturnal enuresis. Desmopressin reduces urine production and the anticholinergic agent allows the bladder to store more urine. Therefore, combined therapy can be recommended in the MNE treatment for specially selected cases.

Evaluation of Factors Affecting Enuresis in 6- to 12-Year-Old Children Referred to the Pediatric Nephrology Clinic

Enuresis is one of the most common disorders in children, and if left untreated can cause anxiety, low self-esteem, and family problems. The aim of this study was to investigate the factors associated with enuresis to provide recommendations for more efficient prevention and treatment. A cross-sectional study was performed on children aged 6 to 12 years with enuresis, referred to the pediatric clinic between April 2017 and April 2018. Children were divided into two groups: monosymptomatic enuresis and healthy subjects. Then, a questionnaire was completed by their parents to assess the factors related to enuresis. The data were analyzed using SPSS software. In this study, out of 140 children with an average age of 8.22 ± 2.01 years, 77 cases (55%) had enuresis, of which 57 (40.7%) had primary enuresis, and 20 cases (14.3%) had secondary enuresis. There was a significant difference between the control and the case groups in terms of: father's education, family income, family history, number of people sleeping in the room, family problems, problems at school, history of urinary tract infections, history of pinworms, difficulty falling asleep, difficulty in waking up, feeling tired after waking up, and drowsiness during the day. Enuresis is associated with several physiological, psychological, and genetic factors. Controlling these factors requires paying attention to the elements such as the mental health of the family and child's sleep health through education, family awareness, and counseling.

Alarm interventions for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) affects up to 20% of five-year-olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs.

OBJECTIVES

To assess the effects of enuresis alarms for treating enuresis in children.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles.

SELECTION CRITERIA

We included randomised or quasi-randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data.

MAIN RESULTS

We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) -2.68, 95% confidence interval (CI) -4.59 to -0.78; 4 trials, 127 children; low-quality evidence). Low-quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post-treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low-quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD -0.96, 95% CI -2.32 to 0.41; 1 trial, 47 children; very low-quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low-quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post-treatment. Compared with control alarms, code-word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate-quality evidence) but there is probably little to no difference in the number of children remaining dry post-treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate-quality evidence). Very low-quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry-bed training, and star chart plus rewards) (MD -0.81, 95% CI -2.01 to 0.38; low-quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low-quality evidence) and may slightly increase the number of children remaining dry post-treatment (RR 1.39, 95% CI 0.81 to 2.41; low-quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD -0.64, 95% CI -1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low-quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post-treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate-quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post-treatment, because the quality of evidence is very low. Due to very low-quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD -0.88, 95% CI -0.38 to -1.38; 2 trials, 156 children; low-quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low-quality evidence) and the number of children remaining dry post-treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low-quality evidence) compared with desmopressin alone. Alarm plus dry-bed training may increase the number of children achieving a complete response compared to dry-bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low-quality evidence). It is unclear if there is any difference in the number of children remaining dry post-treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low-quality evidence). Due to very low-quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code-word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate-quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate-quality evidence). Very low-quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments.

AUTHORS' CONCLUSIONS

Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately-powered trials with robust randomisation are still needed to determine the full effect of alarm therapy.

Supporting parents of children aged 2-13 with toileting difficulties: Group-based workshops versus individual appointments

INTRODUCTION

Toileting is a key activity of daily living and an important milestone in children's development. Difficulties with this process can cause stress to both child and parents and negatively affect their wellbeing. This study compared the perceived parental competence and child wellbeing of families attending a group-based workshop on toileting issues with families attending an individual appointment at a continence clinic.

METHODS

All parents attending the workshops and attending the clinic between July 2016 and December 2017 were invited to participate in the study. The children were aged between 2 and 13 years. Three measures were used: 1) Parenting Sense of Competence Scale; (2) the Revised Quality of Life Questionnaire for Children (KINDLR) and (3) Parent self-assessment of information and support needs. Participants completed all measures at three points: prior to intervention, 1 week and 1 month post-intervention.

RESULTS

Data were collected from 89 parents attending the workshops and 46 parents attending the clinic. Children were not assessed. Non-parametric tests were used to examine between group differences. Within group changes overtime were examined using Friedman's two-way analysis of variance. Parents who attended the workshop showed significant increases in parenting sense of competence and perceived child quality of life post-intervention. Although there were significant differences between and pre- and post-measures for workshop attendees, there were no significant differences found between the two groups indicating that both forms of intervention had beneficial results.

CONCLUSION

These results suggest that group-based workshops can positively impact parents' perceived competence in managing their child's toileting issues and wellbeing. Further research is recommended to explore the relationship between parenting competence and child wellbeing and to determine which aspects of the workshops were most beneficial.

Study of the profile of behavioral problems and quality of life indexes in a pediatric cohort of monosymptomatic enuresis

OBJECTIVE

To evaluate and correlate, before and after the therapeutic intervention, the behavioral problem scores evaluated by the CBCL/6-18 questionnaire and the quality of life indexes evaluated by the PedsQL™ 4.0 in patients with monosymptomatic nocturnal enuresis.

METHOD

After the initial evaluation and completion of the CBCL/6-18 questionnaire, a multidisciplinary evaluation and completion of the PedsQL™ 4.0 questionnaire was performed. Of the initially evaluated 140 children and adolescents aged 6-16 years, 58 were excluded due to non-monosymptomatic enuresis or associated comorbidities. Of the initially included 82 patients, who were randomized to three treatment groups, 59 completed the CBCL/6-18 and PedsQL™ 4.0 questionnaires at the end of the treatment and were included in this study. The α error was set at 5% for ruling out the null hypothesis.

RESULTS

Of the total of 59 participants, 45.8% responded with total success, 23.7% were partially successful, 23.7% did not reach the improvement criteria, and 6.8% gave up the treatment. There was a significant increase in quality of life indexes and a reduction of post-intervention behavioral problem scores, in the three proposed modalities, in patients who had a total or partial response to treatment. There was no correlation between higher scores of pre-treatment behavior problems and therapeutic failure.

CONCLUSIONS

Only the participants who successfully responded to interventions showed improvement in quality of life and behavioral problems, which indicates that enuresis is a primary problem that has a negative impact on these parameters. The authors suggest that it is possible to achieve success in the treatment of monosymptomatic enuresis, even in patients with high pre-intervention behavioral problem scores.

The impact of bowel and bladder problems on children's quality of life and their parents: A scoping review

BACKGROUND

Functional bladder and bowel problems are common in children and have a serious psychological as well as physical impact. The objective of this scoping review was to synthesise evidence on the impact of such conditions both on children's quality of life (QOL) and their parents.

METHODS

The scoping review followed Arksey and O'Malley's framework. Relevant studies were identified by a comprehensive search of scientific databases. Inclusion criteria focused on children with bladder and bowel dysfunction, their QOL, and impact on parents. Studies were analysed for aims, study populations, measures, and results.

RESULTS

A total of 783 records were retrieved with 30 meeting the criteria. Most studies found that QOL was reduced in children with nocturnal enuresis, day bladder dysfunction, bowel dysfunction, and combined bladder and bowel dysfunction. Parents' QOL and social-emotional functioning were also negatively affected.

CONCLUSIONS

Functional bladder and bowel problems should be identified and treated as early as possible to minimise negative impacts on QOL of children and their carers. Future research should focus on how to best provide early and effective intervention in the most accessible manner.

Urinary disorders and bladder-bowel dysfunction in children: approaches to diagnosis, treatment and prevention

Pediatric urinary disorders manifested as urinary incontinence, compelling urges to urinate, etc. remain an important problem of contemporary healthcare. In spite of being extensively covered in the literature, urinary disorders, including enuresis, still present a diagnostic challenge to the physicians of primary healthcare facilities. Based on the findings of our retrospective study that revealed discrepancies between referral and final diagnoses of pediatric urinary disorders, we give recommendations to both physicians of primary healthcare facilities and their inpatient care colleagues that will help them to arrive at the correct diagnosis of a urinary disorder or concomitant bladder-bowel dysfunction using the proposed diagnostic algorithm.

Systematic Review and Meta-analysis of Alarm versus Desmopressin Therapy for Pediatric Monosymptomatic Enuresis

This study is to compare the efficacy of enuresis alarm and desmopressin therapy in managing pediatric monosymptomatic enuresis. We performed systematic literature searches on different databases from inception until April 2017 without language restriction. All randomized control trials comparing an enuresis alarm and desmopressin in managing children with monosymptomatic enuresis were included. A total of 15 studies with 1502 participants (aged 5 to 16 years) were included for pooled analysis. Overall, an enuresis alarm outperformed desmopressin in achieving at least a partial response (>50% reduction in wet nights) in per-protocol analysis (OR: 1.53, 95% CI 1.05 to 2.23) but not in intention-to-treat analysis (OR: 0.97, 95% CI 0.73 to 1.30) as the alarm was hampered by a high dropout rate (OR: 2.20, 95% CI 3.41 to 4.29). However, alarm therapy yielded a better sustained response (OR: 2.89, 95% CI 1.38 to 6.04) and lower relapse rate (OR: 0.25, 95% CI 0.12 to 0.50). In the intention to treat analysis, the results revealed that alarm and desmopressin therapy are comparable in efficacy with regards to achieving >50% reduction in baseline wet nights in enuretic children. However, enuresis alarms offer a superior treatment response and a lower relapse rate in well-motivated children.

Comparison of desmopressin, alarm, desmopressin plus alarm, and desmopressin plus anticholinergic agents in the management of paediatric monosymptomatic nocturnal enuresis: a network meta-analysis

OBJECTIVE

To assess the efficacy of desmopressin, alarm, desmopressin plus alarm, and desmopressin plus anticholinergic agent (AA) therapy in the management of paediatric monosymptomatic nocturnal enuresis (MNE) using a network meta-analysis.

MATERIALS AND METHODS

We searched the electronic databases PubMed, Cochrane Library, EMBASE and Web of Science from inception to 1 March 2018. Randomized controlled trials (RCTs) that compared desmopressin, alarm, desmopressin plus alarm, and desmopressin plus AAs were identified. The network meta-analysis was conducted with software R 3.3.2 and STATA 14.0.

RESULTS

Eighteen RCTs with a total of 1 649 participants were included. The meta-analysis results showed that complete response (CR) and success rates with desmopressin plus AAs were higher than with desmopressin or alarm monotherapy. Success rates for desmopressin plus alarm therapy were higher than for alarm monotherapy. No obvious difference was observed between desmopressin plus AAs and desmopressin plus alarm therapy with regard to CR rate and success rate. The relapse rate with alarm monotherapy was much lower than with desmopressin monotherapy. Adverse events seemed to be infrequently and tolerable for all treatments. The ranking probability results were as follows: desmopressin plus AA ranked first for the outcomes of CR and success, desmopressin plus alarm therapy ranked first for mean number of wet nights per week, and alarm therapy had the lowest relapse rate.

CONCLUSIONS

The network meta-analysis showed that desmopressin had similar efficacy to alarm therapy but a higher relapse rate. Desmopressin plus AA therapy was associated with better efficacy than and a similar relapse rate to desmopressin monotherapy. Desmopressin plus alarm therapy was similar to both desmopressin and alarm monotherapy in efficacy. All treatments, including desmopressin plus AAwere associated with tolerable adverse events; however, additional high-quality studies are needed for further evaluation of these treatments.

The optimal duration of alarm therapy use in children with primary monosymptomatic nocturnal enuresis

BACKGROUND

The prevalence of primary monosymptomatic nocturnal enuresis (PMNE) has a range of 1.6-5.3% in adolescents and 7.5-12.4% in children of 5-10 years. Alarm intervention has been well known for more than 30 years. This method is a reliable and safe means of treating primary monosymptomatic nocturnal enuresis, being effective in 60-80% of cases.

OBJECTIVE

The objective of this study was to determine the efficacy of alarm intervention prolongation after the cure in order to reduce the risk of disease recurrence.

STUDY DESIGN

Two hundred ninety-four boys and 161 girls (455 persons in total) of age 9-14 years (average 11.4 years) took part in the prospective randomized study. After preselection and establishing diagnosis, all patients were randomly divided in three groups. In group А (n = 139) alarm system treatment was carried out within 12 weeks, in group В (n = 136) 16 weeks, and in group С (n = 139) 20 weeks.

RESULTS

The percentage of patients who no longer wet the bed (for 2 weeks or more) immediately after treatment in groups B (80.7%) and C (85.5%) was higher than in group A (67.4%) if the probability of error is p_B/A < 0.05; p_C/A < 0.05. There was no statistically significant difference in treatment success between groups B and C immediately after treatment. The percentage of patients who no longer wet the bed 3 months after the end of treatment in groups B (71.2%) and C (77.1%) was higher than in the group A (45.9%) if the probability of error is p_B/A < 0.05; p_C/A < 0.05. There was no statistically significant difference in treatment success between groups B and C 3 months after treatment. During the year this ratio did not change.

DISCUSSION

These data suggest that the effective duration of alarm intervention is found in the range 16-20 weeks and involves an uninterrupted course of treatment. Perhaps this range of time is optimal for the formation of a neuroreflexive mechanism that creates a habit for independent awakening in children with primary monosymptomatic nocturnal enuresis.

CONCLUSION

The effective duration of alarm intervention is likely to be 16-20 weeks of an uninterrupted course of treatment. This time interval ensures the maximum effectiveness of treatment and the stability of long-term results.

Pediatric chronic patients at outpatient clinics: a study in a Latin American University Hospital

OBJECTIVE

To describe the characteristics of children and adolescentes with chronic diseases of outpatient clinics at a tertiary university hospital.

METHODS

A cross-sectional study was performed with 16,237 patients with chronic diseases followed-up in one year. The data were collected through the electronic system, according to the number of physician appointments in 23 pediatric specialties. Patients were divided in two groups: children (0-9 years) and adolescents (10-19 years). Early (10-14 years) and late (15-19 years) adolescent groups were also analyzed.

RESULTS

Of the total sample, 56% were children and 46% were adolescents. The frequencies of following pediatric specialties were significantly higher in adolescents when compared with children: cardiology, endocrinology, hematology, nephrology/renal transplantation, neurology, nutrology, oncology, palliative and pain care, psychiatry, and rheumatology (p<0.05). The frequencies of emergency service visits (30% vs. 17%, p<0.001), hospitalizations (23% vs. 11%, p<0.001), intensive care unit admissions (6% vs. 2%, p<0.001), and deaths (1% vs. 0.6%, p=0.002) were significantly lower in adolescents than in children. However, the number of physician appointments (≥13) per patient was also higher in the adolescent group (5% vs. 6%, p=0.018). Further analysis comparison between early and late adolescents revealed that the first group had significantly more physician appointments (35% vs. 32%, p=0.025), and required more than two pediatric specialties (22% vs. 21%, p=0.047). Likewise, the frequencies of emergency service visits (19% vs. 14%, p<0.001) and hospitalizations (12% vs. 10%, p=0.035) were higher in early adolescents.

CONCLUSIONS

This study evaluated a large population in a Latin American hospital and suggested that early adolescents with chronic diseases required many appointments, multiple specialties and hospital admissions.

Effect of comprehensive nursing intervention on constipation in patients with prenatal hemorrhage due to central placenta previa

AIM

To evaluate the effect of comprehensive nursing intervention on constipation in patients with prenatal hemorrhage due to central placenta previa.

METHODS

A total of 60 patients with constipation and prenatal hemorrhage due to central placenta previa treated at Xinchang County People's Hospital from February 2015 to February 2018 were selected and divided into a control group (30 cases) and an observation group (30 cases). Both groups were given routine nursing intervention, and the observation group was additionally given comprehensive nursing intervention. The constipation symptom and efficacy evaluation scale was used to evaluate the improvement of constipation symptoms before and after nursing. The Patient Assessment of Constipation Symptom (PAC-SYM) was used to evaluate the self-perception of both groups before and after nursing. The Patient-Assessment of Constipation Quality Of Life (PAC-QOL) was used to evaluate the quality of life before and after care in the two groups of patients, and to compare the effect of nursing care on the relief of constipation symptoms.

RESULTS

After nursing, the scores of defecation, excessive bowel movement, stool characteristics, defecation time, frequency of defecation, bloating, falling, and indefiniteness after nursing were significantly lower in both groups than the scores before nursing (P < 0.05). The constipation symptoms in the observation group and the improvement of curative effect were significantly better than that of the control group (P < 0.05). The PAC-SYM scores of fecal traits, rectal symptoms, and abdominal symptoms in both groups were lower than the scores before nursing (P < 0.05). The improvement of PAC-SYM score was significantly better in the observation group than in the control group (P < 0.05). The PAC-QOL scores of post-care physiology, anxiety, social psychology, and satisfaction were significantly lower in both groups than the scores before care (P < 0.05). The PAC-QOL scores after nursing care were significantly lower in the observation group than in the control group (P < 0.05).

CONCLUSION

Comprehensive nursing intervention can effectively relieve constipation symptoms in patients with prenatal hemorrhage due to central placenta previa and improve their quality of life.

Incontinence affects health-related quality of life in children and adolescents with spina bifida

PURPOSE

Despite devoting many resources to managing urinary and fecal incontinence (UI and FI) in children with spina bifida (SB), it remains unclear whether either is associated with lower health-related quality of life (HRQOL). We sought to determine the impact of UI and FI on HRQOL in this population.

MATERIALS AND METHODS

Children with SB (8-17 years) living in the United States were surveyed online and in SB clinics (2013-15). We evaluated incontinence over the previous 4 weeks using a UI dry interval (<4 h, ≥4 h), FI clean interval (<1 week, ≥ 1 week), and self-reported amount of UI and FI (for each: a lot, medium, a little, none). HRQOL was assessed with QUALAS, a validated SB-specific instrument. Linear regression was used.

RESULTS

The mean age of 298 children was 12.5 years (52.0% male). Overall, 73.1% had UI, 52.3% had FI, and 43.6% had both. Adjusting for concurrent UI and FI, any UI was associated with lower HRQOL in 14-17 year olds (p < 0.0001) and 10-13 year olds (p = 0.048), but not 8-9 year olds (p = 0.98) (Figure). All age groups reported lower HRQOL with FI (p ≤ 0.0001). On multivariate analysis, UI and FI incontinence intervals were not associated with lower HRQOL for any age group (p ≥ 0.58 and p ≥ 0.10, respectively). Higher quantities of UI were associated with ever-lower HRQOL, particularly in 14-17 year olds (p ≤ 0.02). Any quantity of FI was associated with lower HRQOL in all ages. The findings did not change significantly on exploratory analysis correcting for demographic and clinical variables.

DISCUSSION

We report the first evidence that incontinence matters to children and adolescents with SB. Being a cross-sectional study, we were unable to track HRQOL over time. A prospective study is required to assess if HRQOL impact of UI indeed changes as a child grows up and if improving incontinence with treatments improves HRQOL. Findings are similar to those reported in adults with SB and suggest that the concept of "social continence" based on time interval has no HRQOL relevance in children, adolescents or adults with SB.

CONCLUSIONS

UI is negatively associated with HRQOL in children with SB in an age-dependent fashion: starting in 10 year olds and increasing until 14 years. FI correlates with lower HRQOL regardless of age. Similar to findings in adults with SB, HRQOL is lower with increasing amounts of UI and not the length of a dry interval. FI impacts HRQOL uniformly, regardless of frequency or amount.

Recent advances in managing and understanding enuresis

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