Do Holding Exercises or Antimuscarinics Increase Maximum Voided Volume in Monosymptomatic Nocturnal Enuresis? A Randomized Controlled Trial in Children

The efficacy of standard urotherapy in the treatment of nocturnal enuresis in children: A systematic review

INTRODUCTION

Standard urotherapy in children with nocturnal enuresis (NE) is first-line treatment according to the current International Children's Continence Society (ICCS) guidelines. ICCS defines standard urotherapy as information and demystification, instruction in how to resolve lower urinary tract dysfunction, lifestyle advice, registration of symptoms and voiding habits, and support and encouragement. These interventions often are time consuming and some aspects of urotherapy, such as fluid restrictions, can be a frustrating process for a child, which emphasizes the importance of clarifying their relevance. The purpose of this review is to perform a systematic search in literature to evaluate the use of standard urotherapy in the treatment of children with primary NE (PNE).

STUDY DESIGN

A systematic literature search was conducted in MEDLINE, Embase, and CENTRAL based on the key concepts of standard urotherapy and NE. We identified 2,476 studies. After a systematic selection process using the Covidence tool, 39 studies were included. The quality of the studies was assessed by the QualSyst Checklist. Our protocol adheres to the PRISMA statement and was registered in PROSPERO database (CRD42020185611).

RESULTS

Most of the 39 included studies scored low in quality. All studies combined several urotherapy interventions and studied different study populations. Twenty-two randomized controlled trials (RCTs) were included, which reported 0-92% of children being dry after urotherapy treatment. Three RCTs, all individualizing and optimizing drinking and voiding during the day and practicing optimal toilet posture, scored higher in quality based on the QualSyst score, and reported few children experiencing complete resolution of NE (5-33%). Eight studies compared the efficacy of urotherapy to a control group, however, conflicting results were found.

DISCUSSION

This systematic review presents available literature in the field of standard urotherapy in the treatment of children with PNE. One possible explanation for low efficacy rates of urotherapy in NE is the large heterogeneity of the study populations and interventions. Additionally, the intervention period and the intensity of intervention can have an impact on the outcome.

CONCLUSION

The number of clinical studies on standard urotherapy in children with NE is limited and many of them are of poor quality. High quality research in a well-defined NE population is needed to establish the role of standard urotherapy in first-line treatment of children with NE or as an add-on to other first line treatments. We conclude that at present there is insufficient evidence for recommending standard urotherapy to children with PNE as a first line treatment modality.

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.

Evidence of reduced bladder capacity during nighttime in children with monosymptomatic nocturnal enuresis

INTRODUCTION

Bladder capacity in children with nocturnal enuresis is assessed by maximal voided volumes (MVV) obtained through daytime frequency volume (FV) charts. Although a degree of association has been demonstrated, daytime MVV does not consistently correspond with the nocturnal bladder capacity (NBC) in monosymptomatic nocturnal enuresis (MNE). It was hypothesized that isolated reduced NBC is a common phenomenon in children with nocturnal enuresis, despite normal daytime bladder function.

OBJECTIVE

The aim of this study was to evaluate NBC in children with MNE and normal daytime voided volumes. Specifically, it aimed to determine the prevalence and degree of reduced NBC when using nocturnal urine production (NUP) during wet nights as a surrogate estimate of NBC. Furthermore, it aimed to investigate the relationship between NBC and desmopressin response.

MATERIALS AND METHODS

Data from 103 children aged 5-15 years consecutively treated for MNE in a tertiary referral centre and with normal MVV on daytime FV charts were collected for this cohort study. Home recordings were completed for 2 weeks at baseline and during desmopressin dose titration. Estimated nocturnal bladder capacity (eNBC) was assessed separately each night as the total NUP causing a wet night. If NUP during a wet night was less than MVV, it was considered to be reduced eNBC during that particular night.

RESULTS

Surprisingly, 82% (n = 84) of the children with MNE and normal daytime MVV experienced at least one wet night, with NUP below the daytime MVV indicative of a reduced eNBC. For 84 patients, mean percentage of wet nights with reduced eNBC (NUP below MVV) was 49% (SD ± 31). A total of 11% of children with frequently reduced eNBC (>40% of wet nights with reduced eNBC) responded to desmopressin (Summary Fig.). Of the children with frequently reduced NBC, 91% experienced wet nights, with NUP <65% of expected bladder capacity (EBC).

CONCLUSIONS

A significant proportion of children with MNE and normal MVV during the daytime frequently experienced wet nights, with a NUP well below their MVV and even <65% of EBC. This indicated that bladder reservoir dysfunction during sleep is relatively common in MNE. This abnormality was not reflected on daytime recordings, and thus nighttime data with NUP must be collected. This phenomenon may explain treatment failure to desmopressin, despite adequate antidiuretic response.

Can recording only the day-time voided volumes predict bladder capacity?

Purpose

This study aimed to demonstrate a method to easily assess bladder capacity using knowledge of day-time voided volumes, which can be obtained even from patients with nocturnal enuresis where the first morning void cannot accurately predict the bladder capacity due to bladder emptying overnight.

Materials and Methods

We evaluated 177 healthy children from 7 Korean medical centres entered the study between January 2008 and January 2009. Voided volumes measured for more than 48 hours were recorded in the frequency volume chart (FVC).

Results

Most voided volumes during day-time were showed between 30% and 80% of the maximal voided volume (MVV). The maximal voided volume during day-time (MVVDT) was significantly less than the MVV (179.5±71.1 mL vs. 227.0±79.2 mL, p<0.001). The correlation coefficients with the MVV were 0.801 for the estimated MVV using the MVVDT (MVVDT×1.25), which suggested a fairly strong relationship between the MVVDT×1.25 and the MVV.

Conclusions

The MVV derived from the FVC excluding the FMV was less than if the FMV had been included. When an accurate first morning voided volume cannot be obtained, as in patients with nocturnal enuresis, calculating MVVDT×1.25 allows estimation of the bladder capacity in place of the MVV.

Evidence-Based Psychosocial Treatments for Pediatric Elimination Disorders

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

The biofeedback treatment for non-monosymptomatic enuresis nocturna

AIMS

Enuresis is a child older than 5 years wetting in discrete portions during sleep. It has two subgroups: monosymptomatic enuresis nocturna (MSEN) and non-monosymptomatic enuresis nocturna (NMSEN). In this research, we specifically aimed to examine the effect of biofeedback in NMSEN.

METHODS

We retrospectively analyzed the hospital records of 182 children with NMSEN who were refractory to urotherapy modifications and directed to biofeedback therapies between 2005 and 2010. Enuresis before and after biofeedback therapies was evaluated. One or less enuretic night in a month was defined as success.

RESULTS

There were 118 (64%) girls and 64 (35%) boys. With biofeedback therapy, 117 of 182 patients recovered with a success rate of 64% (P < 0.001), but 65 patients still had enuresis. Seventy-two out of 118 girls recovered with a success rate of 61% (P < 0.001), whereas 45 out of 64 boys recovered with a success rate of 70% (P = 0.001). The NMSEN complaints of daytime incontinence, dysuria, urgency, holding maneuvers, and urgency incontinence disappeared significantly concomitant to the enuresis component, as well (P < 0.05).

CONCLUSIONS

Biofeedback therapy is an effective treatment option for the enuresis component of NMSEN with a 64% success rate.

Simple behavioural interventions for nocturnal enuresis in children

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Treatment for nocturnal enuresis: the current state in Japan

Nocturnal enuresis is common problem in children with a prevalence as high as 20% among children aged 5. Though nocturnal enuresis does not directly impose imminent danger to a patient's life, children with enuresis and their parents can be psychologically suffering in day-to-day life, including in school activities. Therefore, it is important to provide an explanation regarding the cause of nocturnal enuresis, how to approach the disorder, the course, and the outlook leading to the planned treatment. The cause of enuresis is considered to be a mismatch between nocturnal diuresis and nocturnal bladder capacity, nocturnal polyuria due to a lack of circadian change in antidiuretic hormones, and a developmental delay in the voiding mechanisms. Therefore, patients can be classified as the type associated with a large amount of urine at night (polyuria type), the type that is associated with a functionally small bladder capacity (bladder type), the type associated with both the aforementioned (mixed type), or the type that does not fall under any of these (normal type). Based on this logic, although the International Children's Continence Society has issued the standardization document, in which the enuresis alarm and desmopressin therapy are recommended as the first line treatment, a different tack has been taken in Japan, where the therapeutic strategy is plotted depending on the type of enuresis; pharmacotherapy for enuretic children aged 6 years or older includes desmopressin acetate for polyuria type, anticholinergic agents for bladder type, and a combination of these agents for mixed type.

Treatment of primary nocturnal enuresis in children: a review

Primary nocturnal enuresis is a common childhood disorder. Treatment approaches bridge the psychological and medical fields. A substantial body of literature addresses the various ways of treating enuresis, from pharmaceuticals to behavioural interventions. The medical and psychological literatures have proceeded relatively independently from one another and there has been little interconnection between the US and international literatures, resulting in a lack of discourse and integration among researchers investigating treatment outcomes for enuresis. This review examined the evidence base for treatments of primary nocturnal enuresis in children. Psychological, pharmaceutical and multi-component interventions are discussed. This review sought to provide an integrated interdisciplinary and international perspective on treatment efficacy for nocturnal enuresis by expressly gathering publications from psychological and medical fields, as well as US and international sources. The literature supported the urine alarm as the most effective intervention for nocturnal enuresis and demonstrated the benefit of combining the urine alarm with other components, both behavioural and pharmaceutical. In particular, recent literature showed that the urine alarm, when used in conjunction with antidiuretic medication (i.e. desmopressin), leads to more dry nights earlier in the conditioning process. Disparities between the different literatures were discussed.

Structured desmopressin withdrawal improves response and treatment outcome for monosymptomatic enuretic children

PURPOSE

In this national, multicenter, retrospective survey we tested whether structured withdrawal of desmopressin, in which dose frequency rather than dose quantity was gradually decreased, would improve outcome.

MATERIAL AND METHODS

Enrolled in the study were 487 monosymptomatic enuretic patients from a total of 181 centers (The Enuresis Algorithm of Marschall Survey Group). At study outset 41% of patients had 7 wet nights per week, 45% had 3 to 6 and 14% had fewer than 3. All patients were treated with desmopressin, which was abruptly terminated or tapered with analogue by a structured scheme. Response rates were compared in the groups according to International Children's Continence Society guidelines.

RESULTS

The 173 children with abrupt termination had a 51% response rate, including a full and partial response in 44.1% and 27%, respectively, and no response in 22%. The 314 children with tapering had a 72% response rate, including a full and partial response in 66.8% and 24%, and no response in 4% (p <0.0001). Enuresis frequency with abrupt termination decreased from 21 wet nights per month before treatment to 6. The tapering group had 21 wet nights per months before and 2 after treatment (p <0.0001). Followup at 1 month showed fewer than 2 wet nights per month in 57% of cases with abrupt termination and in 80% with tapering (p <0.0001). Pretreatment had no influence. No severe side effects occurred.

CONCLUSIONS

This national, multicenter, retrospective analysis proves that antidiuretic treatment followed by a structured withdrawal program is superior to regular treatment with abrupt termination in enuretic children. Hence, desmopressin followed by structured withdrawal should be the standard. It is also superior to published outcomes of alarm treatment.

Influence of pelvic floor muscle exercises on full spectrum therapy for nocturnal enuresis

PURPOSE

We investigated the effect of pelvic floor muscle training on the efficacy of full spectrum therapy and maximal voided volume in children with nocturnal enuresis. We also determined factors predicting treatment outcome, full spectrum therapy duration and the relapse rate. Full spectrum therapy is a combination of alarm, reward, timed voiding and drinking, over learning and pelvic floor muscle training.

MATERIALS AND METHODS

A total of 63 consecutive children were referred to the physiotherapy department for full spectrum therapy to resolve nocturnal enuresis, including 32 in the experimental group who underwent full spectrum therapy with pelvic floor muscle training and 31 in the control group who underwent full spectrum therapy without training.

RESULTS

There was no significant difference in treatment outcome, duration, maximal voided volume and relapse between the 2 groups. Of all children 89% became dry within 6 months. During the year after treatment 33.3% and 37.9% of the experimental and control groups relapsed, while the relapse rate at 1 year was 7.4% and 20.7%, respectively. Age and child motivation were associated with the duration of success (p = 0.04 and <0.01, respectively). Secondary enuresis and psychosocial problems were factors significantly related to relapse (each p <0.01).

CONCLUSIONS

There is no beneficial effect of including pelvic floor muscle training in full spectrum therapy. Older children and those with better motivation experienced more rapid success. Factors predicting relapse were secondary enuresis and psychosocial problems.

Desmopressin for the treatment of primary nocturnal enuresis

Primary nocturnal enuresis (PNE) affects a large proportion of children aged 5 years and over, and can persist into adolescence if left untreated. To patients and families, the condition is extremely distressing and embarrassing, as well as inconvenient owing to the increased washing of bedclothes required, and the difficulties surrounding socializing, such as planning sleepovers or holidays. PNE is caused by a mismatch between the capacity of the bladder to store urine and the volume of urine produced at night, which is frequently excessive in children with PNE. Excessive urine production at night can be caused by an impairment of the circadian rhythm of antidiuretic hormone secretion. Treatment for PNE is primarily by means of behavioral conditioning or pharmacological therapy. Desmopressin is a synthetic analogue of naturally occurring antidiuretic hormone, and is the only pharmacological therapy with a Grade A, level 1 recommendation from the International Consultation on Incontinence as a first-line treatment for PNE. Desmopressin is a well-established and generally well-tolerated treatment for nocturnal enuresis. The only potentially serious adverse effect of desmopressin is hyponatremia, which is rare and has predominantly been observed with the intranasal form of the drug – this formulation has now been withdrawn for the PNE indication in most countries. This review will explore the pharmacology, clinical efficacy and tolerability of desmopressin and its oral formulations in PNE, including the tablet and the more recent oral lyophilisate.

Diagnosis and management of nocturnal enuresis

PURPOSE OF REVIEW

To highlight recent advances in enuresis research.

RECENT FINDINGS

Many discoveries have distanced us from the time when bedwetting was considered a psychiatric disorder. Instead, it is now agreed that nocturnal polyuria, detrusor overactivity, and high arousal thresholds are, in various combinations, central to enuresis pathogenesis. All three mechanisms have been further elucidated during the last year. It has been found that solute diuresis, and not just free-water diuresis due to vasopressin deficiency, may be causative. Sonographical bladder wall measurements have been shown to have prognostic value in detrusor-dependent enuresis, and fascinating proof for the interplay between the bladder and the sleeping brain has been put forward. And, ironically, sleep research has caused psychiatry to make a slight comeback, as studies have indicated that enuretic children may suffer from cognitive problems due to suboptimal sleep. Less has been achieved regarding treatment, but some evidence has finally supported the experience that anticholinergics may be effective in therapy-resistant enuresis.

SUMMARY

During the last years, increased insight has been gained into the multifaceted pathogenesis of enuresis, but there is still an irritating lack of proven effective therapies.