Transcutaneous Electrical Nerve Stimulation in Children with Monosymptomatic Nocturnal Enuresis: A Randomized, Double-Blind, Placebo Controlled Study

Posterior tibial nerve stimulation versus desmopressin in treating children with primary mono-symptomatic nocturnal enuresis. A randomized clinical trial

Objective

Assessment of the efficacy of Posterior Tibial Nerve Stimulation (PTNS) versus Desmopressin in treating Primary Mono-symptomatic Nocturnal Enuresis (PMNE).

Patients and methods

This randomized clinical trial was conducted at the Urology department of Abo Elreesh pediatric hospital, Cairo University on 80 children, aged between 5 and 13 years old, diagnosed to have PMNE between June 2020 and November 2020. Children were divided into two equal groups; those who underwent PTNS (as one session per week for 12 weeks) (Group A) and those who received Desmopressin 0.2 mg. single evening dose for 12 weeks (Group B). Both groups were constructed to adhere to behavioral therapy and were statistically evaluated regarding the frequency of nocturnal enuresis (NE) before, after treatment, and after 1 month of follow-up.

Results

Both groups showed statistically significant improvement in the frequency of NE before and after treatment (p < 0.001), but there were no statistically significant differences between them (p = 0.763). There was a statistically significant relapse of NE frequency after 1 month of follow-up after completion of treatment in both groups (p < 0.001), with no statistically significant differences between the two groups (p = 0.075).

Conclusion

Posterior tibial nerve stimulation and Desmopressin are viable treatment options for children with primary mono-symptomatic nocturnal enuresis. However, relapse in some responders with time suggests the need for maintenance therapy.

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.

At-home use of parasacral transcutaneous electrical nerve stimulation for pediatric voiding dysfunction: a randomized controlled trial to assess its safety and feasibility

Introduction

Treating pediatric voiding dysfunction involves behavioral changes that require significant time or medications that are often avoided or discontinued due to side effects. Using parasacral transcutaneous electrical nerve stimulation (PTENS) has shown to have reasonable efficacy, but the safety and feasibility of its off-label use for pediatric voiding dysfunction are not well-established. Concerns have also been raised over treatment adherence. In-home therapy might improve adherence compared with office-based therapy; however, no studies have evaluated in-home feasibility to date. This study aims to assess the safety and feasibility of off-label use of PTENS for pediatric voiding dysfunction.

Materials and methods

A single-institution prospective, randomized controlled study was conducted from March 2019 to March 2020. Participants aged 6-18 years diagnosed with voiding dysfunction, overactive bladder, or urinary incontinence were eligible for the study. Those with known neurologic disorders, implanted electrical devices, anatomic lower urinary tract abnormality, and recurrent urinary tract infections and those taking bladder medications were excluded. Children with primary monosymptomatic nocturnal enuresis were also excluded due to previous work suggesting a lack of efficacy. Participants were randomly assigned to receive 12 weeks of urotherapy alone (control) or urotherapy plus at-home PTENS treatment. Families were contacted weekly to assess for adverse events (AEs) and treatment adherence. The primary and secondary outcomes were safety, defined as the absence of AEs and treatment adherence, respectively.

Results

A total of 30 eligible participants were divided into two groups, with 15 participants in each arm. The median age was 9.4 years (interquartile range: 7.7-10.6). In total, 60% were male. Baseline demographics and urotherapy compliance were similar between the two groups. With PTENS use, two AEs were reported, including mild pruritus at the pad site and discomfort when removing pads, while no AEs were noted in the control group. In total, 60% of patients completed three 30-min sessions per week, and all participants were able to complete treatment sessions for at least 10 weeks, involving 30 min of PTENS treatment each time.

Conclusion

This randomized controlled study confirms that at-home use of PTENS is feasible with reasonable treatment adherence and minimal AEs. Future collaborative, multi-institutional studies may better determine the efficacy of this treatment modality.

Assessing the outcomes of parasacral transcutaneous electrical nerve stimulation (PTENS) in the treatment of enuresis in children: A systematic review and meta-analysis of randomized control trials

INTRODUCTION

Nocturnal enuresis (NE) is a common pathology in children that can have significant behavioral, emotional, and social impacts on a child's life. Recent studies have assessed PTENS as a potential treatment method for NE, particularly in those who do not respond to initial first-line treatments. Literature has shown varying results with regard to its success. There has been no systematic review and meta-analysis to date assessing outcomes following this treatment.

OBJECTIVES

Despite multiple studies showing the potential benefits of PTENS in NE, there has been no consensus regarding its efficacy. The aim of this study was to systematically analyze the effects of PTENS on children with NE.

STUDY DESIGN

In September 2021, a search of PubMed, Embase and the Cochrane Library was carried out for studies relating to outcomes following PTENS in children with NE. Studies included were original publication English language randomized controlled trial (RCT's) with at least ten children receiving parasacral transcutaneous electrical nerve stimulation (PTENS). After assessing for relevant studies, data were collated and analyzed from the included studies. Risk of bias was assessed using the Cochrane seven domain assessment. Our primary outcome was response and nonresponse to treatment. These results were combined in a fixed effects meta-analysis model to obtain an overall estimate of the success rate. Information regarding demographics was also collected. There was no external funding for this review.

RESULTS

Of 145 studies found initially, four RCT's (208 children) were included. The weighted mean rate of full response to active PTENS was 10.8% (0%-19%). All studies considered, meta-analysis showed no difference between PTENS and controls (RR: 0.70, 95% confidence interval [CI: 0.37-1.32]). Subgroup analysis of monosymptomatic enuresis showed no effect of PTENS compared to controls (RR = 0.58, 95% CI: [0.24-1.42]). When grouped, studies comparing PTENS to sham/behavioral treatment showed no benefit compared to controls (RR = 0.81, 95% CI: [0.05-12.53]) and those comparing PTENS to biofeedback/interferential current (IFC) showed no difference to controls (RR = 0.69, 95% CI: [0.36-1.33]). There was no evidence of a difference between cases and controls between these latter subgroups (RR = 0.70, 95% CI: [0.37-1.32]).

DISCUSSION/CONCLUSION

Our results suggest that PTENS has no clear benefit in the management of children with NE compared to controls. Subgroup analysis showed that its use in monosymptomatic NE has no clear advantage. However, this review has highlighted the need for further high quality studies. Limitations to this review included a relatively small sample size and the use of prior or concomitant therapies.

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.

Transcutaneous electrical nerve stimulation as add-on therapy in children receiving anticholinergics and/or mirabegron for refractory daytime urinary incontinence: A retrospective cohort study

AIMS

To investigate if children with daytime urinary incontinence (DUI) and overactive bladder (OAB) refractory to standard urotherapy and medicinal treatment, would experience improvement in symptoms after add-on treatment with transcutaneous electrical nerve stimulation (TENS).

METHODS

Children were retrospectively enrolled from tertiary referral centers at Aarhus and Aalborg University Hospitals. All data were retrieved from the patients' journals. All children were prescribed TENS as an add-on treatment to the highest-tolerable dose of medicinal treatment in a standardized regime of 2 h a day for around 3 months. Primary endpoints were the number of wet days per week (WDPW) and incontinence episodes per day. Effect of treatment was defined as greater or equal to 50% reduction in the frequency of DUI episodes. Secondary endpoints were to establish predictive factors for the effect of treatment using logistic regression.

RESULTS

Seventy-six children diagnosed with DUI and OAB refractory to treatment with standard urotherapy and pharmacological treatment, at the age of 5-16 years were included from February 2017 to February 2020. A reduction in WDPW (from 6.31 [5.86-6.61] to 4.27 [3.45-4.90], p < 0.05) and incontinence episodes per day (from 2.45 [1.98-2.91] to 1.43 [1.07-1.80], p < 0.05) was observed. Twelve patients became completely dry. At 6 months follow-up, seven of the 12 complete responders had relapsed while five remained dry. A history of constipation before TENS was a predictor of poor treatment response (p = 0.016).

CONCLUSIONS

TENS as add-on to anticholinergic treatment seems effective in a number of children with treatment-refractory DUI.

An Examination of the Relationship between Urinary Neurotrophin Concentrations and Transcutaneous Electrical Nerve Stimulation (TENS) Used in Pediatric Overactive Bladder Therapy

This article aims to explore changes in urinary concentrations of selected neurotrophins in the course of TENS therapy in children with overactive bladder (OAB). A two-group open-label prospective study was conducted. The intervention group comprised 30 children aged between 5 and 12 years old with OAB refractory to conservative therapy. They received 12 weeks of TENS therapy in a home setting. The urinary neurotrophins, NGF, BDNF, NT3, NT4, were measured by ELISA at baseline and at the end of the TENS therapy. Total urinary neurotrophins levels were standardized to mg of creatinine (Cr). We compared the results with the reference group of 30 participants with no symptoms of bladder overactivity. The results revealed that children with OAB both before and after TENS therapy had higher NGF, BDNF, and NT4 concentrations in total and after normalization to Cr than the reference group in contrast to NT3. The response to the therapy expressed as a decrease of urinary neurotrophins after TENS depended on the age and the presenting symptoms. In conclusion, children older than 8 years of age with complaints of daytime incontinence responded better to TENS.

Electrical nerve stimulation therapy in refractory primary monosymtomatic enuresis - A sistematic review

OBJECTIVE

To analyze the effect of electrical nerve stimulation on urinary symptoms in pediatric patients with monosymptomatic primary enuresis refractory to conventional treatment.

METHODS

Three databases (Medline, Embase, and Cochrane) were searched and 160 studies were identified by July 15, 2020. After establishing and applying the inclusion and exclusion criteria, a step-by-step analysis was performed using the title, abstract and full text. The Cochrane Collaboration Tool was then used to analyze the biases of the selected studies.

RESULTS

Of the 160 articles found, 03 were selected for this systematic review. In 02 studies there was a significant reduction in the number of wet nights/week after electrical nerve stimulation. Urodynamic pattern was evaluated in 01 study, with improvement of maximum cystometric capacity in the intervention group. About maximum voided volume, there was no improvement in 01 study, but in other, there was increase in the intervention group.

CONCLUSION

Electrical nerve stimulation might promote improvement in partial and total response scores over the number of dry nights, with no improvement in urodynamic parameters, and could be considered as an feasible option in the management of refractory monosymptomatic primary enuresis. However, it is worth emphasizing the need to conduct more RCTs with a larger sample for better evaluation of the role of neurostimulation.

Dysfunctional voiding: update on evaluation and treatment

PURPOSE OF REVIEW

This review will be covering dysfunctional voiding, its diagnosis, and treatment options. This will focus primarily on dysfunctional voiding rather than all lower urinary tract dysfunction and we will focus on some of the newer findings and progress within this disease.

RECENT FINDINGS

Dysfunctional voiding is the inappropriate sphincter and pelvic floor constriction during voiding in an otherwise neurologically normal child. This has a wide spectrum of symptoms and can lead to a number of complications such as chronic kidney disease and poor quality of life if not appropriately addressed. Dysfunctional voiding is diagnosed with a careful examination and history with further imaging including a renal ultrasound and uroflowmetry to confirm the diagnosis. Urotherapy and biofeedback are the first and second-line treatments respectively and lead to significant improvement or cure in the majority of patients. For refractory patients, additional therapy options include use of α-blockers, botulinum injection, and electroneurostimulation, though the majority of the literature surrounding the use of these therapies consists of small studies with heterogenous causes of voiding dysfunction.

SUMMARY

Dysfunctional voiding is a common urologic complaint that has many excellent options for improving the patient's voiding issues and should be considered in patients with voiding dysfunction.

"Posterior Tibial Nerve" or "Tibial Nerve"? Improving the reporting in health papers

AIMS

The primary objective of this study is to identify which term is the most appropriate to use according to anatomical nomenclature: "posterior tibial nerve" or "tibial nerve." Furthermore, this paper intends to show how the use of these terms in papers indexed in important health databases is numerous and to describe the anatomical characteristics of such nerve, to improve future scientific publications.

METHODS

This is a descriptive study about the importance of standardizing the use of the terms "posterior tibial nerve" and "tibial nerve" and its anatomy. It comprises three phases: the first is a search in the main databases to identify the use of the terms "posterior tibial nerve" and "tibial nerve." The second phase refers to the consultation of international anatomical terminology to identify the most appropriate term to refer to the nerve, while the third phase is related to the study of the anatomy of this nerve.

RESULTS

The term "tibial nerve" is more commonly used, but the use of the term "posterior tibial nerve" is still very substantial. According to international anatomical terminology, the correct term is "tibial nerve," which is a branch of the sciatic nerve.

CONCLUSIONS

"Tibial nerve" is the term standardized by international anatomical terminology. The use of terms in accordance with Terminologia Anatomica is important to facilitate the process of teaching and learning, as well as to improve the reporting and interpretation of papers regarding health, and the evidence-based clinical practice.

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

BACKGROUND AND AIMS

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

A randomised, double-blind, placebo-controlled clinical trial assessing the efficacy of bedtime buddy® for the treatment of nocturnal enuresis in children

BACKGROUND

Nocturnal enuresis (NE), or 'bedwetting', is a form of night-time urinary incontinence occurring in younger children. A diagnosis of NE can be socially disruptive and psychologically stressful for a child. The most common strategies used by parents to manage NE are waking the child during the night to use the bathroom and limiting the child's water intake before going to bed. Behavioural or educational therapies for NE such as urotherapy or bladder retraining are widely accepted and considered as a mainstream treatment option for non-neurogenic lower urinary tract dysfunction in children. Pharmacotherapy also plays an ancillary role. However, there is no gold standard therapy or intervention to effectively manage NE.

METHODS

This study aims to determine the efficacy of a herbal combination in the treatment of NE in children. The target population for this study is 80 children aged between 6 and 14 years old (males and females) who have primary nocturnal enuresis ≥3 per week (wet nights). The active group will receive one or two capsules per day containing 420 mg of a proprietary blend of Urox® (Seipel Group, Brisbane, Australia) containing Cratevox™ (Crataeva nurvala L; Capparidaceae; Varuna) stem bark extract standardised for 1.5% lupeol: non-standardised Equisetum arvense L. (Equisetaceae; Horsetail) stem extract; and, non-standardised Lindera aggregata Sims. The primary outcome for this study is the frequency of nocturia. Secondary outcomes include safety, quality of life, and daytime incontinence. Each participation will be involved in the trial for 32 weeks including contact with the research team every 2 weeks for the first 8 weeks and then every 8 weeks until trial completion.

DISCUSSION

This study examines a novel treatment for an under-researched health condition affecting many children. Despite the availability of several therapies for NE, there is insufficient evidence to support the use of any one intervention and as such this randomised placebo-controlled phase II trial will be an important contribution to understanding potential new treatments for this condition.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registration Number: 12618000288224.

PROTOCOL

23 February 2018, version 1.1.

The efficacy of electrical stimulation in treating children with nocturnal enuresis: A systematic review and meta-analysis

AIM

We performed a systematic review and meta-analysis to evaluate the efficacy of electrical stimulation (ES) in treating children with nocturnal enuresis (NE).

METHODS

Randomized controlled trials (RCTs) of the use of ES for the treatment of NE in children were searched using EMBASE, MEDLINE, and the Cochrane Controlled Trials Register. The references of related articles were also searched. The systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-analyses.

RESULTS

Four RCTs involving 171 patients were studied. We found that there was statistically significant difference in the wet nights per week (mean difference [MD], -0.70; 95% confidence interval [CI], -0.89 to -0.51; P < .00001), the number of patients with clinical response (MD, 26.88; 95% CI, 11.16 to 64.74; P < .00001), and bladder capacity (MD, -0.70; 95% CI -0.89 to -0.51; P < .00001) in the ES group compared with the placebo group with the exception of maximum voided volume (MVV) (MD, 19.48; 95% CI, -9.18 to 48.14; P = .18).

CONCLUSIONS

The study provides a significant improvement in statistics in the wet nights per week, the number of patients with clinical response and bladder capacity for children with NE compared with the placebo group with the exception of MVV.

Effectiveness of Intra-anal Biofeedback and Electrical Stimulation in the Treatment of Children With Refractory Monosymptomatic Nocturnal Enuresis: A Comparative Randomized Controlled Trial

Purpose

To compare the effects of intra-anal biofeedback (BF) and intra-anal electrical stimulation (ES) on pelvic floor muscles (PFMs) activity, nocturnal bladder capacity, and frequency of wet night episodes in children with refractory primary monosymptomatic nocturnal enuresis (PMNE).

Methods

Ninety children of both sexes aged 8–12 years with refractory PMNE participated in this study. They were randomly assigned to 3 groups of equal number: control group (CON) that underwent behavioral therapy and PFM training, and 2 study groups (BF and ES) that underwent the same program in addition to intra-anal BF training and intra-anal ES, respectively. PFMs activity was assessed using electromyography, nocturnal bladder capacity was evaluated by measuring the first morning voided volume, and a nocturnal enuresis diary was used for documenting wet night episodes before treatment and after 3 months of treatment.

Results

After training, all groups showed statistically significant improvements in all measured outcomes compared to their pretreatment findings. The ES group showed significantly greater improvements in all measured outcomes than the CON and BF groups.

Conclusions

Both intra-anal BF training and ES combined with behavioral therapy and PFMs training were effective in the treatment of PMNE, with intra-anal ES being superior to BF training.

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.