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Borgström M, Bergsten A, Tunebjer M, Hedin Skogman B, Nevéus T. Daytime urotherapy in nocturnal enuresis: a randomised, controlled trial. Arch Dis Child 2022; 107:570-574. [PMID: 35074830 PMCID: PMC9125372 DOI: 10.1136/archdischild-2021-323488] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/03/2022] [Indexed: 01/23/2023]
Abstract
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.
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Affiliation(s)
- Malin Borgström
- Center for Clinical Research Dalarna, Falun, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Amadeus Bergsten
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Maria Tunebjer
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Barbro Hedin Skogman
- Center for Clinical Research Dalarna, Uppsala University, Falun, Sweden
- Institution of Medical and Health Sciences, Örebro University, Örebro, Sweden
| | - Tryggve Nevéus
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Aral A, Usta MB, Erguner Aral A. Factors associated with response to simple behavioral intervention in primary enuresis nocturna. Bull Menninger Clin 2022; 86:67-89. [PMID: 35258343 DOI: 10.1521/bumc.2022.86.1.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This 8-week longitudinal study examined predictors of response to simple behavioral intervention in primary enuresis nocturna (PEN). A total of 154 children, aged 8-18 years, diagnosed with PEN were evaluated. The results indicated that lack of constipation, milder enuresis severity, and higher bladder capacity are the primary predictors of good treatment response, and lower family dysfunction is the most robust familial predictor. Lack of constipation is the main predictor with unique variance in multiple regression. Specialists should be aware of conditions that hinder the success of simple behavioral intervention before implementing costly treatments. In treatment-refractory cases, it is important to examine each child for constipation. Family-centered approaches can be helpful if used in parallel with behavioral treatments.
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Affiliation(s)
- Armagan Aral
- Staff physician in the Department of Child and Adolescent Psychiatry, Mental Health Hospital, Samsun, Turkey
| | - Mirac Baris Usta
- Department of Child and Adolescent Psychiatry, Medical Faculty, University of Ondokuz Mayis, Samsun, Turkey
| | - Ayse Erguner Aral
- Psychiatry resident in the Department of Mental Health and Diseases, Medical Faculty, University of Ondokuz Mayis, Samsun, Turkey
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Nevéus T. Problems with enuresis management-A personal view. Front Pediatr 2022; 10:1044302. [PMID: 36405838 PMCID: PMC9671946 DOI: 10.3389/fped.2022.1044302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
Much has happened since the end of the era when enuresis was blamed on the parents or the children themselves. Still, there are large gaps in our knowledge and large parts of modern enuresis management guidelines are (still) not based on firm evidence. In this review I will question the following commonly made assumptions regarding enuresis evaluation and treatment: •It is important to subdivide enuresis according to the presence of daytime symptoms•Voiding charts are crucial in the primary evaluation of the enuretic child•All children with enuresis need to be screened for behavioral or psychiatric issues•Concomittant daytime incontinence needs to be successfully treated before addressing the enuresis•Concomittant constipation needs to be successfully treated before addressing the enuresis•Urotherapy is a first-line treatment against enuresis In this review I will argue that much of what we do with these children is based more on experience and well-meant but poorly supported assumptions than on evidence. Some advice and therapies are probably ineffective whereas for other treatments we lack reliable predictors of treatment response. More research is obviously needed, but awaiting new results enuresis management could be substantially simplified.
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Affiliation(s)
- Tryggve Nevéus
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Eliezer DD, Samnakay N, Starkey MR, Deshpande AV. Effectiveness of standard urotherapy (basic bladder advice) and combination therapies in managing bladder dysfunction in children with treated behavioral disorders: Results of a prospective cohort (DABBED) study. Low Urin Tract Symptoms 2021; 13:490-497. [PMID: 34313379 DOI: 10.1111/luts.12400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 12/15/2022]
Abstract
AIMS We evaluated the efficacy of standard urotherapy and combination therapies in treatment of bladder dysfunction in children with treated behavioral disorders. METHODS Prospective study of children (6-16 years) with bladder dysfunction and behavioral disorders was conducted between March 2018-2020. Eligible children were initially offered standard urotherapy and those with no response at 3 months were offered combination therapies. Symptomatic response, changes in Akbal score and PinQ score were reported at 6 months and outcomes were correlated to behavioral diagnoses and medications. RESULTS Thirty-nine consecutive children (male = 27, mean age [SD] 10.3 [±2.0] years) were recruited, of whom 29 completed the study (five lost to follow-up, three non-compliant to treatment, two excluded). Thirty-four (87%) children had attention deficit/hyperactivity disorder. Monosymptomatic nocturnal enuresis (n = 11) and non-monosymptomatic enuresis (n = 17) were the commonest diagnoses. Following 3-month review, 14 (38%) children continued to receive standard urotherapy, while 15 (41%) children were transitioned to combination therapy. At 6-month review, complete/partial response was seen in 62% (23/37) and no response in 16% (6/37); with 32% (12/37) responding to standard urotherapy alone. Akbal symptom scores (15.9-11.5; P < 0.01) and PinQ scores (26.0-19.5; P = 0.008) improved significantly at 6-month follow-up. Type of underlying behavioral disorder(s) or medications for behavioral disorder did not influence the outcomes. CONCLUSION This study confirms that children with underlying behavioral disorders are able to have a good response to the appropriate therapy for their bladder dysfunction with a third of children responding to standard urotherapy alone.
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Affiliation(s)
- Dilharan D Eliezer
- John Hunter Children's Hospital, New Lambton Heights, New South Wales, Australia.,University of Newcastle, Callaghan, New South Wales, Australia
| | - Naeem Samnakay
- Department of Surgery, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Surgery, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Malcolm R Starkey
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia.,Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Aniruddh V Deshpande
- John Hunter Children's Hospital, New Lambton Heights, New South Wales, Australia.,University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia.,Urology Unit, Department of Surgery, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Bogaert G, Stein R, Undre S, Nijman RJM, Quadackers J, 't Hoen L, Kocvara R, Silay S, Tekgul S, Radmayr C, Dogan HS. Practical recommendations of the EAU-ESPU guidelines committee for monosymptomatic enuresis-Bedwetting. Neurourol Urodyn 2019; 39:489-497. [PMID: 31793066 DOI: 10.1002/nau.24239] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/14/2019] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Guy Bogaert
- Department of Urology, University of Leuven, Leuven, Belgium
| | - Raimund Stein
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University of Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Shabnam Undre
- Department of Pediatric and Adult Urology, East and North Herts NHS Trust, Stevenage, UK
| | - Rien J M Nijman
- Department of Urology and Pediatric Urology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Josine Quadackers
- Department of Urology and Pediatric Urology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Lisette 't Hoen
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Radim Kocvara
- Department of Urology, First Faculty of Medicine in Praha, General Teaching Hospital, Charles University, Prague, Czech Republic
| | - Selcuk Silay
- Division of Pediatric Urology, Department of Urology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Serdar Tekgul
- Division of Pediatric Urology, Department of Urology, Hacettepe University, Ankara, Turkey
| | - Christian Radmayr
- Department of Urology, Medical University of Innsbruck, Innsbruck, Austria
| | - Hasan Serkan Dogan
- Division of Pediatric Urology, Department of Urology, Hacettepe University, Ankara, Turkey
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Marzuillo P, Marotta R, Guarino S, Fedele MC, Palladino F, Capalbo D, Della Vecchia N, Miraglia Del Giudice E, Polito C, La Manna A. 'Frequently recurring' nocturnal polyuria is predictive of response to desmopressin in monosymptomatic nocturnal enuresis in childhood. J Pediatr Urol 2019; 15:166.e1-166.e7. [PMID: 30528650 DOI: 10.1016/j.jpurol.2018.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/18/2018] [Accepted: 11/06/2018] [Indexed: 12/30/2022]
Abstract
INTRODUCTION The nocturnal polyuria is considered a significant predictive value for response to desmopressin. The cutoff value useful to define nocturnal polyuria is still a matter of debate. Moreover, it is current notion that maximal voided volume (MVV) could be used as a predictor for desmopressin response. OBJECTIVE The objective of this study was to assess the impact of different definitions of nocturnal polyuria (and of its frequency) and MVV in predicting the response to desmopressin. STUDY DESIGN A total of 103 patients with frequent monosymptomatic nocturnal enuresis (≥4 wet nights/week) were enrolled. A bladder diary over a 4-day period was collected. The MVV was defined as the highest micturition volume detected at bladder diary. Nocturnal diuresis was measured in 5 wet nights. Then, patients were administered with 120 mcg of sublingual desmopressin. After 2 months, if there was no complete response, the dose was increased to 240 mcg. Nocturnal polyuria was defined as follows: 1.Definition 1: nocturnal urine production >130% of the expected bladder capacity (EBC). 2. Definition 2: >100% EBC. 3. Definition 3: > 20×(age + 9) mL. The primary outcome was 'response to desmopressin' after 3 months of treatment. RESULTS Fifty-three patients responded to desmopressin. Comparing the responses to desmopressin on the basis of the three definitions of nocturnal polyuria, no significant difference was found. There was no cutoff value of nocturnal polyuria expressed as %EBC useful in providing a significant receiver-operating characteristic (ROC) curve. The area under the ROC curve for MVV expressed as %EBC was 0.67 (95% confidence interval [CI], 0.54-0.80; p = 0.01). A MVV >103.1% of EBC had 78.8% (95% CI, 61.1-91.0) sensitivity and 47.5% (95% CI, 31.5-63.9) specificity for predicting response to desmopressin. Among the patients with nocturnal polyuria according to definition 1, a higher percentage of subjects with nocturnal polyuria in 4 out of 5 or 5 out of 5 nights responded to desmopressin, compared with other patients. Patients presenting with nocturnal polyuria according to definition 3 in 5 out of 5 nights showed a 100% of response to desmopressin. At multivariate analysis, the only significant odds ratio (OR) to respond to desmopressin was that of patients with nocturnal polyuria according to definition 1 in >3 nights (OR = 7.1, 95% CI, 1.3-40.3). DISCUSSION AND CONCLUSIONS The presence or absence of nocturnal polyuria-according to all three definitions-in at least one night was not effective in predicting the response to desmopressin. Predictors of desmopressin response were nocturnal polyuria in >3 out of 5 wet nights according to definition 1 and in 5 out of 5 wet nights according to definition 3.
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Affiliation(s)
- P Marzuillo
- Department of Woman, Child and of General and Specialized Surgery, Università Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - R Marotta
- Department of Woman, Child and of General and Specialized Surgery, Università Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - S Guarino
- Department of Woman, Child and of General and Specialized Surgery, Università Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy.
| | - M C Fedele
- Department of Woman, Child and of General and Specialized Surgery, Università Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - F Palladino
- Department of Woman, Child and of General and Specialized Surgery, Università Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - D Capalbo
- Department of Woman, Child and of General and Specialized Surgery, Università Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - N Della Vecchia
- Department of Woman, Child and of General and Specialized Surgery, Università Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - E Miraglia Del Giudice
- Department of Woman, Child and of General and Specialized Surgery, Università Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - C Polito
- Department of Woman, Child and of General and Specialized Surgery, Università Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
| | - A La Manna
- Department of Woman, Child and of General and Specialized Surgery, Università Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Napoli, Italy
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Maternik M. Understanding of and misconceptions around monosymptomatic nocturnal enuresis: findings from patient and physician surveys. J Pediatr Urol 2019; 15:37.e1-37.e8. [PMID: 30340929 DOI: 10.1016/j.jpurol.2018.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/18/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Monosymptomatic nocturnal enuresis (MNE) is a common paediatric condition, caused by the interaction of multiple physiological mechanisms. The condition can lead to psychiatric comorbidities that are detrimental to quality of life but is under-recognised and misunderstood by society and healthcare providers. OBJECTIVE The objective of this study was to gather information from non-specialist physicians on their understanding of enuresis in selected European countries and from patients about the prevalence of MNE, its relationship with comorbidities and the burden of the condition. MATERIALS AND METHODS Between June 2016 and March 2017, physicians and patients in Alpe-Adria, Italy, Romania, Russia, Serbia and Slovakia were asked to complete different surveys on their understanding of the medical condition, its impact on the lives of patients and the prevalence of comorbidities. Surveys were translated into local languages. Survey responses were collated, and data were presented descriptively. RESULTS Overall, 261 physicians (paediatricians comprising nearly two-thirds) and 340 patients (approximately two-thirds were male) completed their respective surveys. Most physicians (67%) believed MNE to be caused by circadian variation of antidiuretic hormone but also mentioned psychological factors as a cause (48%). The most common explanation for MNE given by patients was psychological factors (26%), but 17% gave no explanation. For patients, difficulties related to enuresis were often behavioural (77%), including difficulties at school (61%) and with sleeping (40%). Physicians perceived low self-esteem (32%), anxiety (24%) and embarrassment (17%) as having the greatest impact on patients. There was disagreement among physicians about which discipline is best placed to treat MNE. Favoured treatments were not necessarily consistent with evidence-based guidelines, with lifestyle changes and pharmacological interventions cited most frequently. DISCUSSION The findings of these complementary surveys illustrate that the causes and best treatment of MNE are subject to misconceptions on the part of both the physician and the patient's caregiver. Overall, MNE is perceived as a psychological condition, rather than having a multifactorial pathophysiological basis with a substantial psychological impact. Educational initiatives for healthcare practitioners and the public should help to optimise the understanding of MNE and care of patients.
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Affiliation(s)
- M Maternik
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Dębinki 7, 80-211, Gdansk, Poland.
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Hascicek AM, Kilinc MF, Yildiz Y, Yuceturk CN, Doluoglu OG. A new checklist method enhances treatment compliance and response of behavioural therapy for primary monosymptomatic nocturnal enuresis: a prospective randomised controlled trial. World J Urol 2018; 37:1181-1187. [DOI: 10.1007/s00345-018-2478-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/04/2018] [Indexed: 10/28/2022] Open
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