Reduced anti-diuretic response to desmopressin during wet nights in patients with monosymptomatic nocturnal enuresis

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).

Nocturnal enuresis in children: The role of arginine-vasopressin

Nocturnal enuresis is the involuntary pass of urine during sleep beyond the age of 5 years. It is a common condition in childhood and has an impact on the child's well-being. Research into the pathophysiology of the condition in the last decades has led to a paradigm shift, and enuresis is no longer considered a psychiatric disorder but rather a maturation defect with a somatic background. An excess urine production during sleep is a common finding in children with enuresis and disturbances in the circadian rhythm of arginine-vasopressin (AVP) is found in the majority of children with nocturnal polyuria. Children with enuresis and nocturnal polyuria lack the physiologic increase in AVP levels during sleep and treatment with the AVP analogue desmopressin can restore this rhythm and lead to dry nights. The reasons for this aberrant circadian AVP rhythm are not established. Furthermore, not all children with enuresis and nocturnal polyuria can be successfully treated with desmopressin suggesting that factors beyond renal water handling can be implicated such as natriuresis, hypercalciuria, and sleep-disordered breathing. The advances in the research of the genetic background of the condition may shed further light on the enuresis pathophysiology.

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.

Night-time diuresis pattern in children with and without primary monosymptomatic nocturnal enuresis

INTRODUCTION

Night-time polyuria as the dominating pathophysiological mechanism for primary monosymptomatic nocturnal enuresis (PMNE) has been put in question with nocturnal detrusor overactivity and high arousal thresholds as alternatives. An earlier finding of night-time polyuria in 12% of healthy non-enuretic schoolchildren underscores that excessive night-time diuresis per se is unlikely the major cause of PMNE.

OBJECTIVE

The objective of this study was to compare the night-time diuresis pattern in children with and without PMNE and to evaluate the role of night-time polyuria in provoking enuretic episodes in children with PMNE.

STUDY DESIGN

Night-time diuresis pattern was recorded in 27 children with PMNE, aged 6-15 years, and 29 non-enuretic children, aged 6-13 years. Using a portable ultrasound recorder, the bladder volume was estimated at 15-min intervals for at least three nights with the child sleeping in its own bed at home. The volume of enuretic episodes was controlled using preweighed diapers. All voids were registered by time and volume. Diuresis during night time was estimated from the slope of regression lines fitted to ultrasound recording points. Mean night-time diuresis was calculated from total urine production during the night and time interval from the last void before bedtime to the first morning void.

RESULTS

Night-time bladder filling pattern was recorded from 189 nights, giving 149 interpretable patterns for analysis (77 children with PMNE and 72 dry children). The night-time diuresis pattern was similar for children with or without PMNE, showing large variability between different nights of the same child. Most nights displayed a smooth bladder filling at constant low rate, whereas other nights showed an early phase with high diuresis followed by a longer period of low diuresis with no difference between the two groups.

DISCUSSION

Night-time diuresis has been non-invasively monitored in children while asleep in their own beds at home. The pattern of night-time diuresis varies considerably between different nights of the same child, with no obvious differences in any diuresis parameters between children with or without PMNE.

CONCLUSION

Non-enuretic children have similar diuresis pattern and maximal night-time diuresis values as children with PMNE, making it unlikely that PMNE is caused by night-time polyuria per se (Summary figure). Delayed maturation of sleep mechanisms such as decreased arousability or sleep inhibition of the micturition reflex is more likely to be the main etiology for enuresis.

Clinical management of nocturnal enuresis

Nocturnal enuresis (NE) is a common health problem. Approximately 10% of 7-year-old children wet the bed regularly during sleep. Enuresis can be categorized into monosymptomatic (MEN) and nonmonosymptomatic (NMEN) forms. MEN occurs without any other symptoms of bladder dysfunction. NMEN is associated with dysfunction of the lower urinary tract with or without daytime incontinence. The rate of comorbid gastrointestinal, behavioral, and emotional disorders is elevated depending upon the subtype of NE. A careful clinical history is fundamental to the evaluation of enuresis. Diagnostic procedures include medical history and psychological screening with questionnaires, bladder and bowel diary, physical examination, urinalysis, ultrasound, and examination of residual urine. The mainstay of treatment is urotherapy with information and psychoeducation about normal lower urinary tract function, the underlying cause of MEN, disturbed bladder dysfunction in the child with NMEN and instructions about therapeutic strategies. Alarm therapy and the use of desmopressin have been shown to be effective in randomized trials. Children with NMEN first need treatment of the underlying daytime functional bladder problem before treatment of nocturnal enuresis. In patients with findings of overactive bladder, besides urotherapy, anticholinergic drugs may be useful.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Highly sensitive assay for the determination of therapeutic peptide desmopressin in human plasma by UPLC-MS/MS

An analytical method based on ultra-performance liquid chromatography with positive ion electrospray ionization (ESI) coupled with tandem mass spectrometry detection (UPLC–MS/MS) was developed and validated for the determination of therapeutic peptide desmopressin in human plasma. A desmopressin stable labeled isotope (desmopressin d₈) was used as an internal standard. Analyte and the internal standard were extracted from 200 µL of human plasma via solid-phase extraction technique using Oasis WCX cartridges. The chromatographic separation was achieved on an Aquity UPLC HSS T3 column by using a gradient mixture of methanol and 1 mM ammonium formate buffer as the mobile phase. The calibration curve obtained was linear (r²≥0.99) over the concentration range of 1.01–200 pg/mL. Method validation was performed as per FDA guidelines and the results met the acceptance criteria. The results of the intra- and inter-day precision and accuracy studies were well within the acceptable limits. The proposed method was successfully applied to pharmacokinetic studies in humans.

Evaluation of the effect of 3-month bladder basic advice in children with monosymptomatic nocturnal enuresis

INTRODUCTION

Advice (BBA) into the standards of patients' care in both monosymptomatic and non-monosymptomatic nocturnal enuresis. Although the idea of this recommendation was clear and reflects clinical experience, duration and efficacy have not been definitely established. Recent data have demonstrated the lack of efficacy of BBA and a fierce discussion has ensued. The present study was aimed to assess the efficacy of BBA in a group of previously untreated children with primary monosymptomatic nocturnal enuresis (MNE).

STUDY DESIGN

The study was a prospective interventional multicenter trial in a cohort of previously untreated MNE patients. Forty-nine children (36 males, 13 females, mean age 7.2 years) were included in the analysis. The treatment efficacy was assessed at the 30th, 60th, and 90th days of BBA.

RESULTS

We discovered that the mean number of wet nights decreased significantly (p < 0.001) only after 3 months of BBA from 8.9 to 5.9 episodes every 2 weeks. BBA was fully successful in 2% o the children after 30 day, 12% after 60 days, and 18% after 90 days (Figure). Partial response (by ICCS) was assessed for 8%, 20%, and 34% of the patients. We noted a relatively high rate of non-responders that decreased from 90% to 47% after 90 days. We detected no differences in BBA efficacy between children with night-time polyuria or decreased maximal voided volume. A lower number of wet nights initially predicted the response to the BBA.

DISCUSSION

Our study confirmed rather limited efficacy of BBA, similarly to previous observations, but provided more information on isolated MNE, because of a more specific study group and longer period of observation. The limitation of the study was lack of randomization.

CONCLUSION

Our study revealed that in treatment-naïve children with monosymptomatic enuresis basic bladder training had a low (18%) and late effect, mostly pronounced after the third month of therapy. It seems that only if the patient presents with a favorable profile of bedwetting, occasionally and with a high maximum voided volume, it is worth maintaining BBA for a longer period of up to 3 months before initiating second-line therapy. In an unfavorable initial profile desmopressin or an alarm may be introduced much earlier.

Increased renal concentrating ability after long-term oral desmopressin lyophilisate treatment contributes to continued success for monosymptomatic nocturnal enuresis

OBJECTIVES

To investigate renal concentrating ability after long-term fast-melting oral desmopressin lyophilisate treatment in children with monosymptomatic nocturnal enuresis.

METHODS

The present retrospective study involved 58 children (43 boys, 15 girls; aged 6-12 years) with nocturnal enuresis receiving oral desmopressin lyophilisate. After treatment for 4 weeks with a complete response, patients were placed on a reduced dose of 120 μg on alternate days. Moring urine osmolality was measured using urine samples obtained after medication and non-medication dry nights. Patients who experienced ≥1 wet nights/month during alternate-day oral desmopressin lyophilisate treatment or within 6 months after its cessation were assigned to the relapse group, whereas those who experienced <1 wet night/month were assigned to the continued success group.

RESULTS

The continued success and relapse groups included 41 and 17 patients, respectively. The mean duration of treatment was 18.5 and 18.3 months in the continued success group and relapse group, respectively. There was no significant difference in morning urine osmolality after medication nights between the continued success and relapse groups; however, morning urine osmolality after non-medication nights was significantly higher in the continued success group than in the relapse group (P < 0.0001). Similarly, nocturnal urine volume was significantly higher in the relapse group than in the continued success group (P = 0.046).

CONCLUSIONS

These results suggest that patients receiving long-term oral desmopressin lyophilisate treatment develop increased nocturnal renal concentrating ability, which results in sustained dryness even after treatment cessation.

Optimizing response to desmopressin in patients with monosymptomatic nocturnal enuresis

Most patients with monosymptomatic nocturnal enuresis can be effectively treated with an enuresis alarm or antidiuretic therapy (desmopressin), depending on the pathophysiology of the condition in the individual patient. Desmopressin is first-line therapy for enuresis caused by nocturnal polyuria, an excessive urine output during the night. However, in a recent study, around one-third of patients thought to be resistant to desmopressin were subsequently treated effectively with desmopressin monotherapy in a specialist centre. The aim of this article is to review best practice in selecting patients for desmopressin treatment, as well as outline eight recommendations for maximizing the chances of treatment success in patients receiving desmopressin. The roles of formulation, dose, timing of administration, food and fluid intake, inter-individual variation in response, body weight, adherence, withdrawal strategies and combination therapies are discussed in light of the most recent research on desmopressin and enuresis. Possible reasons for suboptimal treatment response are explored and strategies to improve outcomes in patients for whom desmopressin is an appropriate therapy are presented. Through optimization of the treatment plan in primary and specialist care centres, the hope is that fewer patients with this distressing and often embarrassing condition will experience unnecessary delays in receiving appropriate care and achieving improvements.

The pathophysiology of monosymptomatic nocturnal enuresis with special emphasis on the circadian rhythm of renal physiology

Nocturnal polyuria in monosymptomatic nocturnal enuresis (MNE) has so far mainly been attributed to a disturbed circadian rhythm of renal water handling. Low vasopressin levels overnight correlate with absent maximal concentrating activity, resulting in an increased nocturnal diuresis with low urinary osmolality. Therefore, treatment with desmopressin is a rational choice. Unfortunately, 20 to 60 % of children with monosymptomatic enuresis are desmopressin-resistant. There is increasing evidence that other disturbed circadian rhythms might play a role in nocturnal polyuria. This review focuses on renal aspects in the pathophysiology of nocturnal polyuria in MNE, with special emphasis on circadian rhythms. Articles related to renal circadian rhythms and enuresis were searched through the PubMed library with the goal of providing a concise review.

CONCLUSION

Nocturnal polyuria can only partially be explained by blunted circadian rhythm of vasopressin secretion. Other alterations in the intrinsic renal circadian clock system also seem to be involved, especially in desmopressin-resistant enuresis.

WHAT IS KNOWN

• Disturbance in the circadian rhythm of arginine vasopressin secretion is related to nocturnal polyuria in children with enuresis. • Desmopressin is recommended as a treatment for monosymptomatic nocturnal enuresis, working as a vasopressin analogue acting on V2 receptors in the collecting ducts of the kidney. What is New: • Other renal circadian rhythms might play a role in nocturnal polyuria, especially in desmopressin-resistant case.

Primary Nocturnal Enuresis: A Review

Context

Nocturnal enuresis or bedwetting is the most common type of urinary incontinence in children. It has significant psychological effects on both the child and the family. Enuresis nocturna is defined as the inability to hold urine during the night in children who have completed toilet training. It is termed as being “primary” if no continence has ever been achieved or “secondary if it follows at least 6 months of dry nights. The aim of this review was to assemble the pathophysiological background and general information about nocturnal enuresis.

Evidence Acquisition

This review was performed by evaluating the literature on nocturnal enuresis published between 1970 and 2015, available via PubMed and using the keywords “nocturnal enuresis,” “incontinence,” “pediatric,” “review,” and “treatment.”

Results

Children with nocturnal enuresis produce urine at higher rates during the night, and may have lower bladder capacities. Some children with nocturnal enuresis may also have daytime urgency, frequency, and urinary incontinence. Treatment includes aggressive treatment of accompanying constipation or urinary tract infections, behavioral changes, and medical therapy. Alarm therapy remains the first-line treatment modality for primary nocturnal enuresis. High rates of patient compliance and relapse mean that alternative treatments remain on the agenda.

Conclusions

Nocturnal enuresis is a common problem that has multifaceted effects on both the child and the family. Due to multiple etiologic factors, nocturnal enuresis is still not clearly defined.

The Time of Spontaneous Resolution of Monosymptomatic Nocturnal Enuresis (MNE) Is Familial

PURPOSE

To investigate whether or not the age of spontaneous resolution of monosymptomatic nocturnal enuresis (MNE) was familial.

PATIENTS AND METHODS

A questionnaire was administered to more than 1,500 people, and 100 appropriate participants were identified from four referral hospitals. We included the participants who had MNE and whose parents also had MNE with spontaneous resolution. Then the association between the spontaneous resolution time of MNE in parents and that in their children was investigated.

RESULTS

The mean ages of spontaneous resolution were 10.7 (10-30 years), 9.4 (6-17 years) and 10.9 (6-18 years) in participants, their mothers and their fathers, respectively. According to the statistical analysis, there was a positive correlation between participants and both their mothers and fathers (p < 0.05). In addition, it was revealed that familial MNE history based on first- and second-degree relatives, in addition to their parents, was also associated with the increased spontaneous resolution age of MNE (p < 0.05). According to our results, gender and parents' education status were not statistically associated with the spontaneous resolution (p > 0.05).

CONCLUSION

As a conclusion, the age of spontaneous resolution of MNE is familial. Although the exact reasons of spontaneous resolution still remain a mystery; further genetic investigations may be able to resolve this mystery.