Treatment of nocturnal enuresis with an ultrasound bladder volume controlled alarm device

Wearable-Based Integrated System for In-Home Monitoring and Analysis of Nocturnal Enuresis

Nocturnal enuresis (NE) is involuntary bedwetting during sleep, typically appearing in young children. Despite the potential benefits of the long-term home monitoring of NE patients for research and treatment enhancement, this area remains underexplored. To address this, we propose NEcare, an in-home monitoring system that utilizes wearable devices and machine learning techniques. NEcare collects sensor data from an electrocardiogram, body impedance (BI), a three-axis accelerometer, and a three-axis gyroscope to examine bladder volume (BV), heart rate (HR), and periodic limb movements in sleep (PLMS). Additionally, it analyzes the collected NE patient data and supports NE moment estimation using heuristic rules and deep learning techniques. To demonstrate the feasibility of in-home monitoring for NE patients using our wearable system, we used our datasets from 30 in-hospital patients and 4 in-home patients. The results show that NEcare captures expected trends associated with NE occurrences, including BV increase, HR increase, and PLMS appearance. In addition, we studied the machine learning-based NE moment estimation, which could help relieve the burdens of NE patients and their families. Finally, we address the limitations and outline future research directions for the development of wearable systems for NE patients.

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.

Intelligent autonomous treatment of bedwetting using non-invasive wearable advanced mechatronics systems and MEMS sensors : Intelligent autonomous bladder monitoring to treat NE

Post-void alarm systems to monitor bedwetting in nocturnal enuresis (NE) have been deemed unsatisfactory. The aim of this study is to develop a safe, comfortable and non-invasive pre-void wearable alarm and associated technologies using advanced mechatronics. Each stage of development includes patient and public involvement and engagement (PPI). The early stages of the development involved children with and without NE (and parents) who were tested at a hospital under the supervision of physicians, radiologists, psychologists, and nurses. The readings of the wearable device were simultaneously compared with B-mode images and measurements, acquired from a conventional ultrasound device, and were found to correlate highly. The results showed that determining imminent voiding need is viable using non-invasive sensors. Following on from "proof of concept," a bespoke advanced mechatronics device has been developed. The device houses custom electronics, an ultrasound system, intelligent software, a user-friendly smartphone application, bedside alarm box, and a dedicated undergarment, along with a self-adhesive gel pad-designed to keep the MEMS sensors aligned with the abdomen. Testing of the device with phantoms and volunteers has been successful in determining bladder volume and associated voiding need. Five miniaturised, and therefore more ergonomic, versions of the device are being developed, with an enabled connection to the cloud platform for location independent control and monitoring. Thereafter, the enhanced device will be tested with children with NE at their homes for 14 weeks, to gain feedback relating to wearability and data collection involving the cloud platform. Graphical Abstract Design of the MyPAD advanced mechatronics system.

SENS-U: continuous home monitoring of natural nocturnal bladder filling in children with nocturnal enuresis - a feasibility study

INTRODUCTION

Enuresis is a common problem in children. One treatment option is a wetting alarm that provides an alarm when incontinence occurs. A drawback of this approach is that the child is still awakened by wet sheets. Recently, a wearable, wireless ultrasonic bladder sensor became available, the SENS-U, which has the potential to prevent the enuretic event by waking up the child before the bladder is full. In this first feasibility study, the aim is to perform a night-time, home-based evaluation of the SENS-U in children with monosymptomatic nocturnal enuresis (MNE).

PATIENTS AND METHODS

In this study, children (6-12 years) with MNE were included for a one-night monitoring session. During the night, the SENS-U continuously (i.e. every 30 s) estimated the filling status [notifications were deactivated]. In addition, urine volume was collected in a measurement cup (or diaper weight). The total measured natural nocturnal bladder filling (NNBF) cycles was analyzed by descriptive statistics. Before and after the measurement, sleep behavior was assessed by a selection of the Children's Sleep Habits Questionnaire.

RESULTS

Fifteen patients (boys/girls: 13/2) [mean age: 8.6 ± 1.5 years] have been enrolled. One patient was excluded due to inadequate sensor-to-skin contact. For 14 children, 18 NNBF cycles were recorded (voiding diary) of which three patients (21%) had more than one NNBF cycle. The SENS-U was able to successfully detect 83% of the NNBF cycles. The three missed NNBF cycles had a voided volume ≤30 ml, which was at the lower limit of the sensor's detection range. The SENS-U had no effect on sleeping behavior.

CONCLUSION

The SENS-U was able to monitor the natural nocturnal bladder filling successfully in children with monosymptomatic nocturnal enuresis at home, without disturbing their sleep. Future research focuses on investigating the usability of the SENS-U for both diagnostic - and treatment purposes.

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.

The amount of urine voided in bed by children with enuresis

INTRODUCTION

Enuretic children wet their beds either because of nocturnal polyuria or nocturnal detrusor overactivity. Polyuric children often respond to desmopressin, whereas children with nocturnal detrusor overactivity are often therapy resistant and may have low daytime voided volumes. It is logical to assume that the enuretic event in children with nocturnal polyuria occurs with a full bladder, i.e. with the enuretic voided volume (EVV) close to the child's expected bladder capacity (EBC) for his/her age. However, the EVV has only rarely been studied, and little is known about how it relates to case history, polyuria, or daytime bladder function. The aim of this study was to look at EVV and relate it to voiding chart data and treatment response.

METHODS

Anamnestic data and voiding charts, including measurement of nocturnal urine production and EVV, in enuretic children with or without concomitant daytime incontinence attending a tertiary center were retrospectively reviewed. The EVV was analyzed and compared to anamnestic data, voiding chart data, and response to therapy in accordance with the guidelines of the International Children's Continence Society.

RESULTS

Data were available for 220 children (age 5-24, median 9), 40 of whom were girls. The prevalence of previous or present daytime incontinence was 42.4%, and 50.5% sometimes experienced urgency. The average EVV was 54.9 ± 32.8% of EBC. EVV correlated highly significantly to nocturnal urine production (p < 0.001). Still, EVV ≥ EBC was observed in only 16 children. EVV was slightly larger in girls (p = 0.013) and in children with urgency (p = 0.034), but there were no significant EVV differences between children responding or not responding to antidiuretic, anticholinergic, or antidepressant therapy. Relevant data are summarized in the Table below.

DISCUSSION

Case history and daytime voiding chart data give very little information about nocturnal bladder function. The EVV is strongly influenced by nocturnal urine production but only rarely reaches up to a level close to or exceeding the EBC. The enuretic event only very rarely represents the emptying of a full bladder. Thus, a component of nocturnal detrusor overactivity can be assumed to be present in almost all enuretic children, even in children with nocturnal polyuria. The value of the EVV is limited in predicting response to therapy.

SENS-U: validation of a wearable ultrasonic bladder monitor in children during urodynamic studies

PURPOSE

Urinary incontinence is a common problem in school-age children. Because many children remain unaware of a full-bladder sensation, the SENS-U^™ Bladder Sensor was developed. The SENS-U is a small, wearable ultrasound sensor, which is positioned on the lower abdomen using a skin-friendly adhesive. The sensor continuously estimates the bladder filling status and informs the user when it is time to go to the toilet. In this study, the clinical performance of the SENS-U is evaluated in children during (video) urodynamics.

MATERIAL AND METHODS

In this study, 30 children (6-12 years) were included who were scheduled for a (video) urodynamic study. During urodynamics, the SENS-U determined the average anterior-posterior (A-P) bladder dimension (every 30 s) to estimate the filling status. The correlation between the average A-P bladder dimension and the infused volume is analyzed by Spearman's correlation.

RESULTS

Thirty patients (boys/girls: 15/15; mean age: 7.9 ± 1.4 years) were included, in whom the SENS-U detected the full bladder before voiding in 90% of the patients (27/30). In the other patients, the bladder was outside the detection area due to either erroneous sensor placement (n = 1) or an (relative) obese abdomen in the upright position (n = 2). There was a strong correlation (median r_s = 0.94) between the average A-P bladder dimension and the infused volume. The detectable maximum bladder volume ranged between 71 and 463 ml.

CONCLUSION

The SENS-U is able to detect a full bladder with a success rate of 90%. When excluding erroneous data due to sensor misplacement or an (relative) obese abdomen, the detection rate may even be higher. Future research will focus on investigating the effect of theSENS-U in incontinence training.

Continuous bladder volume monitoring system for wearable applications

In this research, we propose a bladder volume monitoring system that can be effectively applied for various voiding dysfunctions. Whereas conventional systems lack consecutive measurements, the proposed system can continuously monitor a user's status even during unconscious sleep. For the convenience, we design a simple and comfortable waist-belt-type device by using the body impedance analysis (BIA) technique. To support various measurement scenarios, we develop applications by connecting the device to a smartphone. To minimize motion noises, which are inevitable when monitoring over an extended period, we propose a motion artifact reduction algorithm that exploits multiple frequency sources. The experimental results show a strong relationship between the impedance variation and the bladder volume; this confirms the feasibility of our system.

A prospective study of examining physiological signals for estimating occurrence of nocturnal enuresis

The nocturnal enuresis is challenging due to the increased social activities of the children. This disorder significantly bothers both the children and their parents in psychological, behavioral, social, and financial manners. However, the primary treatments have limitations and further are not able to completely cure the disorder. In order to reduce pain and burdens of patients and their parents, it is important to accurately estimate when the enuretic incident occurs in advance. For the estimation, we have comprehensively investigated various studies of the nocturnal enuresis in the diverse fields. Through the investigations, we have summarized four hypotheses of the physiological signals related to the enuretic moment. In order to conquer the nocturnal enuresis, we design a preliminary framework sensing and investigating the physiological signals with the sensors. Our synthesized approach to understand and estimate the moments of the enuretic incidents can establish a foothold to complete the promising prediction system.

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.

Clinical evaluation of a novel ultrasound-based bladder volume monitor

OBJECTIVE

Bladder volume monitors may be useful for surveillance of bladder volume and urine production in urologic patients. Therefore, we designed an ultrasonic bladder volume monitor and evaluated it in vitro using phantoms and in vivo in one male volunteer. The purpose of this study was to perform a more thorough in vivo evaluation of our monitor in urologic patients to investigate biological effects and variance over a wide range of bladder volumes.

MATERIAL AND METHODS

Thirty urologic patients of either gender were examined using the bladder volume monitor, which is based on seven phased array ultrasonic transducers arranged in a circular pattern to optimize detection of the bladder walls. The monitor was set up to record bladder volume every 30 s during two sequential cystometries with infusion rates of 30 and 60 ml/min. The measured volumes were analyzed using regression analysis to determine volume increments (slopes), offset volume (intercept) and correlation (Pearson's correlation coefficient).

RESULTS

In the male patients, the median correlation coefficient between the infused and measured volumes was 0.97 and the slope was 0.68 ml/ml, thus warranting a correction factor of approximately 1.47 with no general volume offset. In the female patients, small bladders were generally outside the field of view of the monitor. Consequently, the correlation coefficients and slopes were 0.834 (median) and 0.43 (mean), respectively, whereas volume offsets were generally negative.

CONCLUSIONS

For examinations in male patients, the performance of the bladder volume monitor was adequate. However, for examinations in female patients, a minor redesign of the transducer unit is necessary to insure proper operation.

Exploring the differences between mono- and polysymptomatic nocturnal enuresis

OBJECTIVE

Recently the heterogeneity of nocturnal enuresis has been manifest in the distinction between mono- and polysymptomatic forms, based on the absence or presence of bladder overactivity, respectively. Although this classification has important clinical implications, there is a lack of empirical work relating to associated symptom expression and psychological functioning. The aim of this study was to identify variables associated with the two forms of nocturnal enuresis by means of a large population survey.

MATERIAL AND METHODS

From a cohort of 11,021 parents surveyed as part of the Avon Longitudinal Study of Parents and Children when their children were aged 7(1/2) years, 8242 questionnaires were returned, with 7935 children meeting the inclusion criteria. Parents were invited to complete a questionnaire containing items relating to bedwetting, toileting behaviour, day-time wetting, bowel functioning and psychological variables.

RESULTS

A total of 194 children met the Diagnostic and Statistical Manual of Mental Disorders-IV definition of nocturnal enuresis, of whom 133 (68.5%) were classified as monosymptomatic and 61 (31.5%) as polysymptomatic. Those with the polysymptomatic form were significantly more likely to have multiple episodes of bedwetting, to show signs (such as fidgeting) of needing to urinate during the day, to need a reminder to toilet during the day and to have day-time wetting and soiling.

CONCLUSIONS

The proportion of mono- to polysymptomatic nocturnal enuresis was 2:1. Children with the polysymptomatic form had a number of associated bladder and bowel problems. Clinically it is important to distinguish between the two types of nocturnal enuresis in order to identify the most appropriate treatment intervention.

An exploration of outcome criteria in nocturnal enuresis treatmentThe way forward

This paper is a review of outcome definitions and criteria for nocturnal enuresis treatment. A search of the literature published between 1991 and 2001 highlighted 97 papers. Although the International Children's Continence Society and the World Health Organization have published outcome criteria, different, often idiosyncratic, outcome criteria and/or definitions have been adopted in published research on treatment for nocturnal enuresis in recent years. There remains a debate as to what constitutes successful treatment and how to document improvement. Lack of an agreed definition of outcome reduces confidence in comparing studies, with serious clinical and research implications. This paper reviews aspects of importance in determining outcome, including a suggestion to focus on the establishment of dry nights rather than the reduction of wet nights. A new set of criteria is suggested, consisting of a banding system referred to as a "dryness scale", which focuses on the percentage of dry nights accomplished at a point in time, thus eliminating the need to compare current levels of dryness with a baseline.

Enuresis alarm treatment

OBJECTIVE

Treatment for childhood nocturnal enuresis emphasizes either a psychological or pharmacological approach. The enuresis alarm, in comparative studies, has emerged as the most effective psychological treatment. In this review we investigate both outcome rates and influential factors from recently published studies.

MATERIAL AND METHODS

A search of papers published between 1980 and 2002 in the English language involving at least 10 children in which the enuresis alarm was employed as a stand-alone intervention revealed 38 studies.

RESULTS

Heterogeneity in terms of inclusion and outcome parameters made comparison between studies problematic. The most frequently adopted definitions were "wet at least 3 times a week" in terms of severity at inclusion, "14 consecutive dry nights" as a success criterion and "> 1 wet night a week" as a relapse criterion. Success rates across all studies ranged from 30% to 87% and were influenced by the type of enuresis, the treatment duration and the success criteria adopted. In an homogenous subset of 20 studies, 65% success with alarm treatment was found. Further analysis revealed equivalence between different forms of alarm, pre- and within-treatment predictors of outcome and possible mode of action. Relapse rates (ranging between 4% and 55%) were reported in 20 studies, with an homogeneous subset indicating that 42% of children relapsed following alarm treatment.

CONCLUSIONS

The enuresis alarm is an effective intervention for children with nocturnal enuresis. There are a number of factors, both pre- and within-treatment, that appear to influence its effectiveness and may assist clinical decisions concerning its appropriateness for any particular child.

Design and evaluation of an ultrasound-based bladder volume monitor

Ultrasonic bladder volume monitors have successfully been used in the diagnosis and treatment of various urological disorders. Ultrasonic bladder monitors have been developed but they have either been too bulky or too simple and inaccurate. A new, wearable ultrasonic bladder volume monitor has been designed for urological patients. The instrument consists of seven phased-array ultrasonic transducers ergonomically arranged in a circular pattern to optimise detection of the bladder walls perpendicular to the abdominal wall. A Bluetooth radio link was used to transmit data to a laptop computer, where the main signal processing was performed. After detection of bladder surface points, a three-dimensional convex hull representing the bladder was generated, and the volume was estimated. Accuracy, precision, drift over time, temperature dependency and dynamic performance were evaluated using ultrasound phantoms. Furthermore, the system was tested on one volunteer using magnetic resonance imaging (MRI) as reference. The apparatus showed no significant drift, systematic error or temperature effects. Percentage error during static volume measurements had a 95% central prediction interval of +/-7.5% and mean absolute percentage error of 2.9%. The dynamic performance analysis showed linearity in the analysed volume interval. The in vivo study showed a high degree of correlation (R2= 0.99) between the volume measured using MRI and that measured with the apparatus.

MRI assessment of the influence of body position on the shape and position of the urinary bladder

OBJECTIVE

Continuous surveillance of patients' bladder volume may be of benefit during the treatment of various urologic disorders. In order to design optimal bladder volume monitoring equipment, information about the shape and position of the bladder, not at least in relation to posture, is crucial. The purpose of this study was consequently to evaluate the influence of body position on the change in shape and position of the bladder.

MATERIAL AND METHODS

MRI was performed in three young volunteers during posture changes. MRI scans in the transverse, frontal and sagittal planes were recorded in bladders of various sizes. The position of the bladder midpoint in the three planes was determined. Moreover, to account for its shape, the compactness of the cross-section of the bladder was calculated on the basis of its perimeter and area.

RESULTS

For the medial-lateral and cranial-caudal positions, the maximal displacements were 4 and 5 mm, respectively. In the ventral-dorsal direction the displacement varied, but was <18 mm. The compactness changed maximally by 11%, indicating a minimal change in shape.

CONCLUSION

In young subjects, the position and shape of the bladder only change modestly for different body positions, thus eliminating the need for special correction measures when designing bladder volume monitoring equipment.

Simple behavioural and physical interventions for nocturnal enuresis in children

BACKGROUND

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% 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 can be great. Simple behavioural methods of treating bedwetting 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.

OBJECTIVES

To assess the effects of simple behavioural interventions on nocturnal enuresis in children, and to compare these with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (searched 18 September 2003). The reference list of a previous version of this review was also searched.

SELECTION CRITERIA

All randomised or quasi-randomised trials of simple behavioural interventions for nocturnal enuresis in children up to the age of 16. Trials focused solely on daytime wetting were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials and extracted data.

MAIN RESULTS

Thirteen trials met the inclusion criteria, involving 702 children of whom 387 received a simple behavioural intervention. However, within each comparison each outcome was addressed by single trials only, precluding meta-analysis. In single small trials, reward systems (e.g. star charts), lifting and waking were each associated with significantly fewer wet nights, higher cure rates and lower relapse rates compared to controls. There was not enough evidence to evaluate retention control training (bladder training), whether compared with controls or dry bed training, or used as a supplement to alarms, or versus desmopressin. Cognitive therapy may have lower failure and relapse rates than star charts, but this finding was based on one small trial only. One small trial of poor quality suggested that star charts were initially less successful than amitriptyline but this difference did not persist after the treatments stopped. Another suggested that imipramine was better than fluid deprivation and avoidance of punishment.

REVIEWERS' CONCLUSIONS

Simple behavioural methods may be effective for some children, but further trials are needed, in particular in comparison with treatments known to be effective, such as desmopressin, tricyclic drugs and alarms. However, simple methods could be tried as first line therapy before considering alarms or drugs, because these alternative treatments may be more demanding and may have adverse effects.

Simple behavioural and physical interventions for nocturnal enuresis in children

BACKGROUND

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% 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 can be great. Simple behavioural methods of treating bedwetting 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.

OBJECTIVES

To assess the effects of simple behavioural interventions on nocturnal enuresis in children, and to compare these with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register. The reference list of a previous version of this review was also searched. Date of the most recent search: December 2001.

SELECTION CRITERIA

All randomised or quasi-randomised trials of simple behavioural interventions for nocturnal enuresis in children up to the age of 16. Trials focused solely on daytime wetting were excluded.

DATA COLLECTION AND ANALYSIS

In a previous version of this review, trials up to 1997 were independently assessed by two reviewers. Previous trials were re-assessed, and further trials were assessed for quality, and data were extracted by another reviewer.

MAIN RESULTS

Twelve reliable trials met the inclusion criteria, involving 748 children of whom 365 received a simple behavioural intervention. However, within each comparison each outcome was addressed by single trials only, precluding meta-analysis. In single small trials, reward systems (e.g. star charts), lifting and waking were each associated with significantly fewer wet nights, higher cure rates and lower relapse rates compared to controls. There was not enough evidence to evaluate retention control training (bladder training), whether compared with controls or dry bed training, or used as a supplement to alarms, or versus desmopressin. Cognitive therapy may have lower failure and relapse rates than star charts, but this finding was based on one small trial only. One small trial of poor quality suggested that star charts were initially less successful than amitriptyline but this difference did not persist after the treatments stopped.

REVIEWER'S CONCLUSIONS

Simple behavioural methods may be effective for some children, but further trials are needed, in particular in comparison with treatments known to be effective, such as desmopressin, tricyclic drugs and alarms. However, simple methods could be tried as first line therapy before considering alarms or drugs, because these alternative treatments may be more demanding and may have adverse effects.

Enuresis and encopresis: ten years of progress

OBJECTIVE

To review the progress made over the past decade with regard to the treatment of enuresis and encopresis, as well as advances in the understanding of etiological mechanisms.

METHOD

Separate computerized literature (English language only) searches of Medline and PsycINFO databases were conducted under the parameter of enuresis and children-adolescents, as well as encopresis and children-adolescents.

RESULTS

There has been a substantial decrease in published research concerning the use of imipramine to treat enuresis compared with the prior two decades, accompanied by a corresponding increase in the number of papers concerning desmopressin acetate (DDAVP), which has become the primary pharmacological treatment. Genetic studies of large pedigrees have further confirmed the importance of heritable factors. With regard to encopresis, the research has focused primarily on pathophysiological factors related to the colon and anal sphincter.

CONCLUSIONS

The widespread use of DDAVP has been the primary addition to treatment strategies over the past decade. The bell-and-pad method of conditioning, the only major treatment that has enduring benefit after being withdrawn, is the most cost-effective and appears to be underutilized. Research into etiological mechanisms has focused primarily on the mechanism of action of DDAVP and advances in the understanding of genetic factors. Advances in the treatment and etiological understanding of encopresis have been less impressive.

Is routine urinary tract investigation necessary for children with monosymptomatic primary nocturnal enuresis?

OBJECTIVES

To investigate in a prospective study the role of bladder function and to compare the results of urinary tract ultrasonography and urinalysis in children with and without primary nocturnal enuresis because, although this is a common problem in children, the etiology and mechanisms of the disorder have not been elucidated.

METHODS

The study included 106 children with monosymptomatic primary nocturnal enuresis and a control group of 57 children with no history of voiding dysfunction, aged 5 to 19 years. All children underwent urinalysis, bladder and upper urinary tract ultrasonography, and uroflowmetry. The bladder capacity, bladder wall thickness, and postvoid residual volume were measured using ultrasonography. The findings were compared between the enuresis and control groups according to age: 5 to 9 years, 10 to 14 years, and 15 to 19 years.

RESULTS

The mean age was 9.6 +/- 3.1 years in the nocturnal enuresis group and 9.4 +/- 3.3 years in the control group (P = 0.727). The mean number of defecations per week was significantly lower statistically in the enuresis group than in the control group in the age categories of 5 to 9 years and 10 to 14 years (P = 0.038 and P = 0.018, respectively), and the mean number of urinations per day was significantly higher statistically in the enuresis group than in the control group in the age groups of 5 to 9 years and 10 to 14 years (P = 0.002 and P = 0.001, respectively). The bladder capacity, bladder wall thickness, postvoid residual volume, uroflowmetry maximal flow rate, and average flow rate were not significantly different statistically between the children with primary nocturnal enuresis and the control group in the three age brackets. Urinary infection was detected in 2 children (1.88%) in the nocturnal enuresis group and none of the children in the control group (P = 0.547). Upper urinary tract abnormalities detected by ultrasonography were seen in 3 children (2.83%) in the nocturnal enuresis group and 1 child (1.75%) in the control group, revealing no statistical significance (P = 0.671).

CONCLUSIONS

Our findings show that the ultrasonographic and uroflowmetry findings on bladder function and the upper urinary system and the incidence of urinary infection are similar in children with and without nocturnal enuresis. Obtaining a voiding and elimination diary in conjunction with a good history may be beneficial in children with monosymptomatic primary nocturnal enuresis. In addition, routine urinalysis may be unnecessary in the evaluation of children with monosymptomatic primary nocturnal enuresis after obtaining a careful and complete history of the voiding dysfunction.

Paediatric voiding dysfunction and enuresis

Urinary incontinence and nocturnal enuresis are frequently encountered problems in children. In this review some aspects will be highlighted. Especially the different types of monosymptomatic nocturnal enuresis as well as some recent developments in children with dysfunctional voiding will be discussed.