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Caldwell PH, Codarini M, Stewart F, Hahn D, Sureshkumar P. Alarm interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2020; 5:CD002911. [PMID: 32364251 PMCID: PMC7197139 DOI: 10.1002/14651858.cd002911.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Patrina Hy Caldwell
- Discipline of Child and Adolescent Health, The Children's Hospital at Westmead Clinical School, University of Sydney, Westmead, Australia
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
| | - Miriam Codarini
- School of Medicine, Western Sydney University, Campbelltown, Australia
| | - Fiona Stewart
- c/o Cochrane Incontinence, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
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Bastos JM, Rondon AV, de Lima GRM, Zerati M, Schneider-Monteiro ED, Molina CAF, Calado ADA, Barroso U. Brazilian consensus in enuresis-recomendations for clinical practice. Int Braz J Urol 2019; 45:889-900. [PMID: 31408290 PMCID: PMC6844333 DOI: 10.1590/s1677-5538.ibju.2019.0080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/06/2019] [Indexed: 01/14/2023] Open
Abstract
Introduction Enuresis, defined as an intermittent urinary incontinence that occurs during sleep, is a frequent condition, occurring in about 10% of children at 7 years of age. However, it is frequently neglected by the family and by the primary care provider, leaving many of those children without treatment. Despite of many studies in Enuresis and recent advances in scientific and technological knowledge there is still considerable heterogeneity in evaluation methods and therapeutic approaches. Materials and Methods The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Enuresis and elaborated a draft of the document. On September 2018 the panel met to review, discuss and write a consensus document. Results and Discussion Enuresis is a multifactorial disease that can lead to a diversity of problems for the child and family. Children presenting with Enuresis require careful evaluation and treatment to avoid future psychological and behavioral problems. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.
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Affiliation(s)
- José Murillo Bastos
- Universidade Federal de Juiz de Fora (UFJF) e Hospital e Maternidade Therezinha de Jesus da Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (HMTJ-SUPREMA), Juiz de Fora, MG, Brasil
| | - Atila Victal Rondon
- Universidade do Estado do Rio de Janeiro (UERJ) e Hospital Federal Cardoso Fontes (HFCF), Rio de Janeiro, RJ, Brasil
| | | | - Miguel Zerati
- Instituto de Urologia e Nefrologia de São José do Rio Preto (IUN) e Faculdade Regional de Medicina(FAMERP), Hospital de Base, São José do Rio Preto, SP, Brasil
| | | | - Carlos Augusto F Molina
- Hospital das Clinicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brasil
| | | | - Ubirajara Barroso
- Universidade Federal da Bahia (UFBA) e Escola Bahiana de Medicina (BAHIANA), Salvador, BA, Brasil
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Song P, Huang C, Wang Y, Wang Q, Zhu W, Yue Y, Wang W, Feng J, He X, Cui L, Wan T, Wen J. Comparison of desmopressin, alarm, desmopressin plus alarm, and desmopressin plus anticholinergic agents in the management of paediatric monosymptomatic nocturnal enuresis: a network meta-analysis. BJU Int 2018; 123:388-400. [PMID: 30216627 DOI: 10.1111/bju.14539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To assess the efficacy of desmopressin, alarm, desmopressin plus alarm, and desmopressin plus anticholinergic agent (AA) therapy in the management of paediatric monosymptomatic nocturnal enuresis (MNE) using a network meta-analysis. MATERIALS AND METHODS We searched the electronic databases PubMed, Cochrane Library, EMBASE and Web of Science from inception to 1 March 2018. Randomized controlled trials (RCTs) that compared desmopressin, alarm, desmopressin plus alarm, and desmopressin plus AAs were identified. The network meta-analysis was conducted with software R 3.3.2 and STATA 14.0. RESULTS Eighteen RCTs with a total of 1 649 participants were included. The meta-analysis results showed that complete response (CR) and success rates with desmopressin plus AAs were higher than with desmopressin or alarm monotherapy. Success rates for desmopressin plus alarm therapy were higher than for alarm monotherapy. No obvious difference was observed between desmopressin plus AAs and desmopressin plus alarm therapy with regard to CR rate and success rate. The relapse rate with alarm monotherapy was much lower than with desmopressin monotherapy. Adverse events seemed to be infrequently and tolerable for all treatments. The ranking probability results were as follows: desmopressin plus AA ranked first for the outcomes of CR and success, desmopressin plus alarm therapy ranked first for mean number of wet nights per week, and alarm therapy had the lowest relapse rate. CONCLUSIONS The network meta-analysis showed that desmopressin had similar efficacy to alarm therapy but a higher relapse rate. Desmopressin plus AA therapy was associated with better efficacy than and a similar relapse rate to desmopressin monotherapy. Desmopressin plus alarm therapy was similar to both desmopressin and alarm monotherapy in efficacy. All treatments, including desmopressin plus AAwere associated with tolerable adverse events; however, additional high-quality studies are needed for further evaluation of these treatments.
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Affiliation(s)
- Pan Song
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Chuiguo Huang
- Department of Urology, Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yan Wang
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Qingwei Wang
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Wen Zhu
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yiwei Yue
- College of Clinical Medicine, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Wancong Wang
- Department of Digest, The fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Jinjin Feng
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Xiangfei He
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Lingang Cui
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Tingxiang Wan
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Jianguo Wen
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
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Kuwertz-Bröking E, von Gontard A. Clinical management of nocturnal enuresis. Pediatr Nephrol 2018; 33:1145-1154. [PMID: 28828529 DOI: 10.1007/s00467-017-3778-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 07/10/2017] [Accepted: 07/13/2017] [Indexed: 01/14/2023]
Abstract
Nocturnal enuresis (NE) is a common health problem. Approximately 10% of 7-year-old children wet the bed regularly during sleep. Enuresis can be categorized into monosymptomatic (MEN) and nonmonosymptomatic (NMEN) forms. MEN occurs without any other symptoms of bladder dysfunction. NMEN is associated with dysfunction of the lower urinary tract with or without daytime incontinence. The rate of comorbid gastrointestinal, behavioral, and emotional disorders is elevated depending upon the subtype of NE. A careful clinical history is fundamental to the evaluation of enuresis. Diagnostic procedures include medical history and psychological screening with questionnaires, bladder and bowel diary, physical examination, urinalysis, ultrasound, and examination of residual urine. The mainstay of treatment is urotherapy with information and psychoeducation about normal lower urinary tract function, the underlying cause of MEN, disturbed bladder dysfunction in the child with NMEN and instructions about therapeutic strategies. Alarm therapy and the use of desmopressin have been shown to be effective in randomized trials. Children with NMEN first need treatment of the underlying daytime functional bladder problem before treatment of nocturnal enuresis. In patients with findings of overactive bladder, besides urotherapy, anticholinergic drugs may be useful.
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Affiliation(s)
- Eberhard Kuwertz-Bröking
- Pediatric Nephrology, University Children's Hospital Münster, Waldeyerstrasse 22, 48149, Muenster, Germany.
| | - Alexander von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, 66421, Homburg, Germany
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Monosymptomatic nocturnal enuresis in pediatric patients: multidisciplinary assessment and effects of therapeutic intervention. Pediatr Nephrol 2017; 32:843-851. [PMID: 27988804 DOI: 10.1007/s00467-016-3510-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 06/06/2016] [Accepted: 09/09/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Few studies manage patients with isolated monosymptomatic enuresis (MNE) with multidisciplinary evaluation and pre- and long-term post-intervention monitoring. METHODS This was a prospective study of MNE patients, aged 6-16 years, diagnosed by multidisciplinary assessment. Of the 140 initial applicants (58.6%) with MNE, 82 were included in the study and randomized for therapeutic intervention in three treatment groups, namely: alarm, desmopressin and alarm + desmopressin. Therapeutic response was evaluated 12 months after treatment withdrawal. RESULTS Of the 82 patients [mean age 9.5 (SD ± 2.6) years, n = 62 males (75.6%)], 91.1% had a family history of nocturnal enuresis (NE) in first-/second-degree relatives, 81.7% had constipation and 40.7% had mild-to-moderate apnea. Prior to randomization, management of constipation and urotherapy led to remission in seven of the 82 patients; 75 patients were randomized to intervention. There were 14/75 (18.7%) dropouts during the intervention, especially in the alarm group (p = 0.00). Initial complete/partial response was achieved in 56.6% of the alarm group, 70% of the desmopressin group and 64% in the combined group (p = 0.26). Continued success occurred in 70% of the alarm group, 84.2% of the desmopressin group and 100% of the combined group (p = 0.21). Recurrence occurred in 3/20 (15%) patients in the alarm group and 1/19 (5.2 %) patients of the desmopressin group. Post-intervention Child Behavior Checklist (CBCL) and PedsQL 4.0 scores showed significant improvement. CONCLUSIONS The three therapeutic modalities were effective in managing MNE with low relapse rates; the alarm group showed the highest dropout rate. Therapeutic success was associated with improvement of behavioral problems and quality of life scores.
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Shepard JA, Poler JE, Grabman JH. Evidence-Based Psychosocial Treatments for Pediatric Elimination Disorders. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2016; 46:767-797. [PMID: 27911597 DOI: 10.1080/15374416.2016.1247356] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Jaclyn A Shepard
- a Department of Psychiatry & Neurobehavioral Sciences , University of Virginia School of Medicine
| | - Joseph E Poler
- a Department of Psychiatry & Neurobehavioral Sciences , University of Virginia School of Medicine
| | - Jesse H Grabman
- a Department of Psychiatry & Neurobehavioral Sciences , University of Virginia School of Medicine
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Sharifiaghdas F, Sharifiaghdas S, Taheri M. Primary Monosymptomatic Nocturnal Enuresis: Monotherapy vs Combination Therapy. Urology 2016; 93:170-4. [DOI: 10.1016/j.urology.2016.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/26/2016] [Accepted: 02/08/2016] [Indexed: 01/29/2023]
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Arda E, Cakiroglu B, Thomas DT. Primary Nocturnal Enuresis: A Review. Nephrourol Mon 2016; 8:e35809. [PMID: 27703953 PMCID: PMC5039962 DOI: 10.5812/numonthly.35809] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 04/30/2016] [Indexed: 01/27/2023] Open
Abstract
Context Nocturnal enuresis or bedwetting is the most common type of urinary incontinence in children. It has significant psychological effects on both the child and the family. Enuresis nocturna is defined as the inability to hold urine during the night in children who have completed toilet training. It is termed as being “primary” if no continence has ever been achieved or “secondary if it follows at least 6 months of dry nights. The aim of this review was to assemble the pathophysiological background and general information about nocturnal enuresis. Evidence Acquisition This review was performed by evaluating the literature on nocturnal enuresis published between 1970 and 2015, available via PubMed and using the keywords “nocturnal enuresis,” “incontinence,” “pediatric,” “review,” and “treatment.” Results Children with nocturnal enuresis produce urine at higher rates during the night, and may have lower bladder capacities. Some children with nocturnal enuresis may also have daytime urgency, frequency, and urinary incontinence. Treatment includes aggressive treatment of accompanying constipation or urinary tract infections, behavioral changes, and medical therapy. Alarm therapy remains the first-line treatment modality for primary nocturnal enuresis. High rates of patient compliance and relapse mean that alternative treatments remain on the agenda. Conclusions Nocturnal enuresis is a common problem that has multifaceted effects on both the child and the family. Due to multiple etiologic factors, nocturnal enuresis is still not clearly defined.
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Affiliation(s)
- Ersan Arda
- Hisar Intercontinental Hospital, Department of Urology, Istanbul, Turkey
| | - Basri Cakiroglu
- Hisar Intercontinental Hospital, Department of Urology, Istanbul, Turkey
- Corresponding author: Basri Cakiroglu, Hisar Intercontinental Hospital, Department of Urology, Istanbul, Turkey. Tel: +90-2165241300, Fax: +90-2165241323, E-mail:
| | - David T. Thomas
- Maltepe University Medical School, Department of Pediatric Surgery, Istanbul, Turkey
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Abstract
Intermittent incontinence of urine in a sleeping child who has previously been dry for less than 6 months without any other lower urinary tract symptoms is considered to be primary monosymptomatic nocturnal enuresis (PMNE). Although, most children outgrow PMNE with age, the psychological impact on the child warrants parental education and patient motivation and treatment. Motivational therapy, alarm therapy and drug therapy are the mainstay of treatment. Motivational and alarm therapy have better success rates than drug therapy alone. Desmopressin is the commonly used first-line drug and is best for short-term relief. Other drugs such as anti-cholinergics, imipramine and sertraline are used in resistant cases. This review focuses on the assessment and treatment of PMNE.
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Affiliation(s)
- Shikha Jain
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS) , Bhopal, Madhya Pradesh, India
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Ahmed AFAM, Amin MM, Ali MM, Shalaby EAM. Efficacy of an enuresis alarm, desmopressin, and combination therapy in the treatment of saudi children with primary monosymptomatic nocturnal enuresis. Korean J Urol 2013; 54:783-90. [PMID: 24255762 PMCID: PMC3830973 DOI: 10.4111/kju.2013.54.11.783] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 09/06/2013] [Indexed: 11/18/2022] Open
Abstract
Purpose We evaluated and compared the effectiveness of an enuresis alarm, desmopressin medication, and their combination in the treatment of Saudi children with primary monosymptomatic nocturnal enuresis (PMNE). Materials and Methods A total of 136 children with PMNE were randomly assigned to receive an enuresis alarm alone (EA group, n=45), desmopressin alone (D group, n=46), or a combination of both (EA/D group, n=45). Patients were followed weekly during treatment and for 12 weeks after treatment withdrawal. Results During treatment, wetting frequencies were significantly reduced in all groups and remained significantly lower than pretreatment values until the end of follow-up. In the D and EA/D groups, an immediate reduction in wetting frequencies was observed, whereas a longer time was required to reach a significant reduction in the EA group. The full and partial response rates were 13.3% and 37.8% in the EA group, 26.1% and 43.5% in the D group, and 40.0% and 33.3% in the EA/D group. A significant difference was observed only between the EA and EA/D groups (p=0.025). Relapse rates were higher in the D group (66.6%) than in the EA (16.6%) and EA/D (33.3%) groups. A significant difference was observed between the D and EA groups only (p=0.019). Conclusions Desmopressin, an enuresis alarm, and combined therapy are effective in the treatment of Saudi children with PMNE. Desmopressin produced an immediate effect but relapses were common. The enuresis alarm provided gradual effects that persisted posttreatment. The combined therapy was superior to the alarm in achieving an immediate response; however, its effect was not better than that of the alarm long term.
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Affiliation(s)
- Abul-Fotouh Abdel-Maguid Ahmed
- Department of Urology, Al-Azhar University, Cairo, Egypt. ; Department of Urology, Salman Bin Abdul-Aziz University, Al-Kharj, Kingdom of Saudi Arabia
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Rittig N, Hagstroem S, Mahler B, Kamperis K, Siggaard C, Mikkelsen MM, Bower WF, Djurhuus JC, Rittig S. Outcome of a standardized approach to childhood urinary symptoms-long-term follow-up of 720 patients. Neurourol Urodyn 2013; 33:475-81. [DOI: 10.1002/nau.22447] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Accepted: 05/15/2013] [Indexed: 11/12/2022]
Affiliation(s)
- Nikolaj Rittig
- Department of Pediatrics; Aarhus University Hospital, Aarhus University; Aarhus Denmark
| | - Søren Hagstroem
- Institute of Clinical Medicine, Aarhus University; Aarhus Denmark
| | - Birgitte Mahler
- Institute of Clinical Medicine, Aarhus University; Aarhus Denmark
| | - Konstantinos Kamperis
- Department of Pediatrics; Aarhus University Hospital, Aarhus University; Aarhus Denmark
| | - Charlotte Siggaard
- Department of Pediatrics; Aarhus University Hospital, Aarhus University; Aarhus Denmark
| | | | | | - Jens C. Djurhuus
- Institute of Clinical Medicine, Aarhus University; Aarhus Denmark
| | - Søren Rittig
- Department of Pediatrics; Aarhus University Hospital, Aarhus University; Aarhus Denmark
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Meir J, Eggert P. Prepulse inhibition of the startle reflex for differentiation of enuresis in children. Pediatr Nephrol 2011; 26:939-43. [PMID: 21373778 DOI: 10.1007/s00467-011-1817-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 01/28/2011] [Accepted: 01/31/2011] [Indexed: 11/28/2022]
Abstract
Children with enuresis can be classified into those who wet their beds only at night (monosymptomatic enuresis, mE), and those who additionally suffer from daytime symptoms, such as urgency or incontinence (non-monosymptomatic enuresis, nmE). Evidence is growing that enuresis may have a central origin: bedwetting children have lower brainstem reflex control (impaired prepulse inhibition) than normal controls. However, findings on this subject are inconsistent. To date, there has been no study in pediatric patients according to the type of enuresis. With the aim of determining whether mE and nmE children differ in terms of central reflex control, we divided 30 enuretic children into two groups (mE and nmE) based on data recorded in a bladder diary and clinical history (19 with history of diurnal urge, 11 without; age 5-14 years). Prepulse inhibition (PPI) of the startle reflex of the children was measured and compared between groups. A significant difference in PPI was observed between the groups, with the nmE group having a lower median PPI level than the mE group (10 vs. 73%, respectively; p = 0.0002). These findings lead to the assumption that a loss of central control plays a role only in the etiology of nmE. Moreover, they may throw a new light on the classification of enuresis.
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Affiliation(s)
- Julia Meir
- Hospital for Children and Adolescents, University Leipzig, Leipzig, Germany
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Desmopressin treatment regimens in monosymptomatic and nonmonosymptomatic enuresis: A review from a clinical perspective. J Pediatr Urol 2011; 7:10-20. [PMID: 20576470 DOI: 10.1016/j.jpurol.2010.04.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2010] [Accepted: 04/13/2010] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate outcomes of desmopressin treatment in monosymptomatic enuresis (ME) and nonmonosymptomatic enuresis (NME). MATERIALS AND METHODS PubMed was searched for all studies investigating enuresis, up to July 2009, in which desmopressin was administered alone or combined with other treatments. Each study was graded according to its respective level of evidence. RESULTS Altogether, 99 studies enrolling 7422 patients were identified as fulfilling the inclusion criteria. In 76 studies, desmopressin was administered as monotherapy; in 29 it was combined with other treatments such as antimuscarinics and enuresis alarm. CONCLUSION Studies incorporating a minor invasive versus a non-invasive diagnostic approach seem to achieve superior long-term success rates. Primary efficacy outcomes following desmopressin treatment are more favourable in ME than NME. Desmopressin administered with adjunct measures achieves superior outcomes compared to monotherapy, especially in NME. Compared to sudden withdrawal, the structured withdrawal programs show better long-term success and lower relapse rates. So far, no superiority has been shown for either time- or dose-dependent structured withdrawal programs. Most studies incorporated only small case series; only 25 studies with level of evidence 1 or 2 have been conducted. The broad range of mono- and adjunct treatments were evaluated according to the evidence based criteria recommended by the European Association of Urology.
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Kwak KW, Park KH, Baek M. The Efficacy of Enuresis Alarm Treatment in Pharmacotherapy-Resistant Nocturnal Enuresis. Urology 2011; 77:200-4. [DOI: 10.1016/j.urology.2010.06.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 06/23/2010] [Accepted: 06/27/2010] [Indexed: 11/16/2022]
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Kwak KW, Lee YS, Park KH, Baek M. Efficacy of desmopressin and enuresis alarm as first and second line treatment for primary monosymptomatic nocturnal enuresis: prospective randomized crossover study. J Urol 2010; 184:2521-6. [PMID: 20961574 DOI: 10.1016/j.juro.2010.08.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE We compared the efficacy of desmopressin and enuresis alarm as first and second line treatment options for monosymptomatic nocturnal enuresis. MATERIALS AND METHODS A total of 104 children with monosymptomatic nocturnal enuresis were randomly assigned to either desmopressin (54) or enuresis alarm (50) as first line treatment. Following 12 weeks of first line treatment children with a full response were evaluated for relapse 12 weeks after withdrawal of treatment. Children with partial or no response were switched to the alternative treatment and then evaluated after 12 weeks of crossover treatment. Relapse was defined as more than 1 episode of bedwetting monthly. RESULTS Following first line treatment 77.8% of the desmopressin group and 82% of the enuresis alarm group achieved a successful result, including full response in 37% and 50% of the groups, respectively (p=0.433). Of the children with a full response 50% in the desmopressin group and 12% in the enuresis alarm group experienced a relapse when treatment stopped (p=0.005). Following second line crossover treatment 71.4% of the enuresis alarm-desmopressin group and 67.8% of the desmopressin-enuresis alarm group achieved a successful result, including full response in 47.6% and 45.2% of the groups, respectively (p=0.961). CONCLUSIONS There was no difference between desmopressin and enuresis alarm during treatment for achieving dryness, but the chance of relapse after treatment stopped was higher following desmopressin. Switching to the alternative treatment following partial or no response provided an additional benefit.
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Affiliation(s)
- Kyung Won Kwak
- Department of Urology, Sungkyunkwan University School of Medicine, Samsung Changwon Hospital, Changwon, Korea
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Vogt M, Lehnert T, Till H, Rolle U. Evaluation of different modes of combined therapy in children with monosymptomatic nocturnal enuresis. BJU Int 2009; 105:1456-9. [PMID: 19764973 DOI: 10.1111/j.1464-410x.2009.08872.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the efficacy of different modes of combined therapy in children with monosymptomatic nocturnal enuresis (MNE). PATIENTS AND METHODS A randomized prospective study was performed to compare the order of two types of combined therapy in children with MNE. Group A was treated with primary desmopressin treatment that was combined with alarm treatment after 3 months, while group B was treated with primary alarm treatment that was combined with desmopressin after 3 months. RESULTS Within a period of 18 months, 43 previously untreated children fulfilled the inclusion criteria. Thirteen children achieved dryness after initial monotherapy or discontinued the study. Group A consisted of 16 children and group B of 14 children. After the standardized treatment course of 6 months, 11/16 children in group A and 11/14 children in group B became dry (<3 wet nights/month). Altogether, 22/30 (73%) children were dry after combined treatment, consisting of 12/18 boys and 10/12 girls. Of the children with a normal maximum voided volume, 79% (19/24) achieved dryness, whereas only three of six children with small maximum voided volumes became dry. In all, 13/19 (68%) children with nocturnal polyuria and nine of 11 without nocturnal polyuria became dry. Only one child relapsed (group A). CONCLUSIONS Combined therapy proved effective in children with MNE after 6 months, with no statistically significant differences between the two different orders of treatment.
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Affiliation(s)
- Mandy Vogt
- Department of Paediatric Surgery, University of Leipzig, Leipzig, Germany
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Abstract
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.
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Affiliation(s)
- Richard J Butler
- Clinical Psychology Department, Child and Adolescent Mental Health Services, East Leeds Primary Care Trust, Leeds, UK.
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Tuncel A, Mavituna I, Nalcacioglu V, Tekdogan U, Uzun B, Atan A. Long-term follow-up of enuretic alarm treatment in enuresis nocturna. ACTA ACUST UNITED AC 2009; 42:449-54. [PMID: 18609270 DOI: 10.1080/00365590802095678] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the long-term success of the enuretic alarm device in patients with monosymptomatic primary nocturnal enuresis. MATERIAL AND METHODS Sixty-two patients who had significant monosymptomatic primary nocturnal enuresis were included. They used an enuretic alarm for 3 months. At the end of the treatment, 15 of the patients did not have benefit from the enuretic alarm. Overall, 47 patients benefited from the enuretic alarm. The long-term follow-up was conducted prospectively. RESULTS The mean age was 9.3 (range 5-16) years and mean follow-up time was 19.2 (range 12-30) months. In the follow-up period, relapse was observed in 46.8% (n = 22/47) of these patients. Twenty-two patients reused the enuretic alarm device for 3 months after relapse occurrence and 13 patients (59%) recovered. Although re-relapse was observed in seven of them in the 6 months, six patients had a full response. In total, 65.9% of the patients (n = 31/47) maintained a full response after enuretic alarm treatment in the long-term follow-up. Thirty-one of the 62 patients underwent combination treatment (enuretic alarm plus medical therapy) for unsuccessful enuretic alarm treatment. The overall full response rate for combination treatment was 16.1%. CONCLUSION In the long-term follow-up, the enuretic alarm device provided an acceptable full response rate in patients with primary nocturnal enuresis.
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Affiliation(s)
- Altug Tuncel
- Third Department of Urology, Ministry of Health, Ankara Numune Research and Training Hospital, Ankara, Turkey.
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The efficacy of the addition of short-term desmopressin to alarm therapy in the treatment of primary nocturnal enuresis. Int Urol Nephrol 2008; 40:583-6. [DOI: 10.1007/s11255-008-9355-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2008] [Accepted: 02/11/2008] [Indexed: 10/22/2022]
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Kamperis K, Hagstroem S, Rittig S, Djurhuus JC. Combination of the enuresis alarm and desmopressin: second line treatment for nocturnal enuresis. J Urol 2008; 179:1128-31. [PMID: 18206924 DOI: 10.1016/j.juro.2007.10.088] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2007] [Indexed: 02/07/2023]
Abstract
PURPOSE We sought to evaluate the combination of the enuresis alarm and desmopressin in treating children with enuresis. MATERIALS AND METHODS A retrospective analysis was performed on data from 423 children treated at our clinics with the enuresis alarm during the years 2000 to 2004. Frequency volume charts and desmopressin titration facilitated characterization of the participants using the current International Children's Continence Society standardization. Children were treated with the enuresis alarm as monotherapy before the addition of desmopressin, which commenced after 6 weeks in patients exhibiting inadequate response to alarm or after 2 weeks in patients experiencing multiple enuretic episodes per night or showing no indication of improvement. RESULTS Of the initial population 315 children (74%) were treated only with alarm, of whom 290 became dry. A total of 108 children (26%) were treated with a combination of alarm and desmopressin, with 80 being cured. Children dry on alarm therapy were not different from those needing the addition of desmopressin in terms of demographics. Children dry on desmopressin plus alarm had higher average nocturnal urine production on wet nights (303 +/- 12 ml compared to 269 +/- 5 ml, p <0.001). Maximum voided volume before treatment corrected for age was not different between children dry on alarm and those dry on combination therapy (0.84 +/- 0.02 compared to 0.86 +/- 0.05, not significant). CONCLUSIONS Children needing the addition of desmopressin have a higher nocturnal urine production on wet nights but do not seem to differ in terms of bladder reservoir function characteristics.
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Affiliation(s)
- Konstantinos Kamperis
- Clinical Institute, University of Aarhus and Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark.
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21
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Tuygun C, Eroglu M, Bakirtas H, Gucuk A, Zengin K, Imamoglu A. Is second-line enuretic alarm therapy after unsuccessful pharmacotherapy superior to first-line therapy in the treatment of monosymptomatic nocturnal enuresis? Urol Int 2007; 78:260-3. [PMID: 17406138 DOI: 10.1159/000099349] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Indexed: 12/12/2022]
Abstract
INTRODUCTION We aimed at comparing the success rates of primary enuretic alarm therapy with those of secondary alarm therapy after failed pharmacotherapy in the treatment of monosymptomatic nocturnal enuresis (MNE). PATIENTS AND METHODS We randomly applied enuretic alarm therapy in 35 MNE patients (group 1) and desmopressin therapy in 49 MNE patients (group 2). The success and rebound rates after 3 and 6 months were determined. We also applied enuretic alarm therapy as a secondary treatment in 19 group 2 patients with complete rebound after 6 months (group 3). The success rates of patients who have received primary and secondary enuretic alarm therapy were compared. RESULTS The success rates for groups 1 and 2 were 82.65 and 81.63%, respectively (p = 0.885), at 3 months and 54.28 and 26.53%, respectively (p = 0.007), at 6 months. The success rates in group 3 were 84.21 and 52.63%, respectively, at 3 and 6 months. When these success rates were compared between groups 1 and 3, no statistically significant difference was found (p = 1.000). CONCLUSION Prior pharmacotherapy did not increase success rates of alarm therapy in our MNE patients.
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Affiliation(s)
- Can Tuygun
- Department of Urology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey.
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22
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Abstract
Nocturnal enuresis (NE) is one of the most frequent paediatric pathologies. The prevalence of primary nocturnal enuresis (PNE) is around 9% in children between 5 and 10 years of age and about 40% of them have one or more episodes per week. Still for too long, PNE has not been recognised as a pathological condition, particularly by the medical community; as a consequence, there was no specific education at medical school, and a poor involvement by the practitioners. Enuretic children have a sense of social difference and isolation; some of them do express a low self-esteem. Also, self-esteem is improved by the management NE even if this management fails to cure the condition. Primary monosymptomatic nocturnal enuresis (PMNE) is an heterogeneous condition for which various causative factors have been identified such as: nocturnal polyuria, sleep disturbances, reduced bladder capacity or bladder dysfunction, upper airway obstruction. The positive diagnosis of PMNE is based on a complete questionnaire and a careful physical examination. A drinking and voiding chart is an essential non-invasive tool: first, to collect information about the initial drinking and voiding habits of the child, then to reassess the accuracy of the diagnosis. Only motivated patients should receive a specific treatment for their NE and the treatment should be proposed based on the type of PMNE. PMNE associated with nocturnal polyuria should be treated with desmopressin, which reduces nighttime urine production. For PMNE with a reduced bladder capacity alarms should be the first-line treatment. Oxybutinin, a drug with anticholinergic properties, is not theoretically indicated for the treatment of PMNE except for a very small subgroup of patients who have an overactive bladder only during sleep. In cases refractory to monotherapy, NE is probably the result of an association of different physiopathological factors (e.g. both a nocturnal polyuria together with a small bladder capacity) some of them are still unknown. In these patients, a combination of treatments may be more effective than monotherapy. Various combination therapies can be proposed to improve the cure rates.
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Affiliation(s)
- H B Lottmann
- Paediatric Urology Unit, Service de Chirurgie Viscerale Pediatrique, Hôpital Necker-Enfants Malades, Paris, France.
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23
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Gil G, Lim JS, Kim H. Study Results of Enuresis Medical Treatment according to When Medication was Started. Korean J Urol 2006. [DOI: 10.4111/kju.2006.47.10.1069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Geon Gil
- Department of Urology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae Sung Lim
- Department of Urology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hongsik Kim
- Department of Urology, Chungnam National University College of Medicine, Daejeon, Korea
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24
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Glazener CMA, Evans JHC, Peto RE. Alarm interventions for nocturnal enuresis in children. ACTA ACUST UNITED AC 2006. [DOI: 10.1002/ebch.4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Naitoh Y, Kawauchi A, Yamao Y, Seki H, Soh J, Yoneda K, Mizutani Y, Miki T. Combination therapy with alarm and drugs for monosymptomatic nocturnal enuresis not superior to alarm monotherapy. Urology 2005; 66:632-5. [PMID: 16140092 DOI: 10.1016/j.urology.2005.03.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2004] [Revised: 02/16/2005] [Accepted: 03/04/2005] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate the effectiveness of alarm-based combination therapy using desmopressin and imipramine for primary monosymptomatic nocturnal enuresis. METHODS Of the 105 patients, 37 were treated with alarm monotherapy (monotherapy group), 35 were treated with desmopressin combined with an alarm (desmopressin group), and 33 were treated with imipramine combined with an alarm (imipramine group). The therapeutic effects were evaluated at 3 and 6 months. The relapse rates and predictive factors of the therapies were also studied. RESULTS No significant differences were found in the changes in the frequency of wet nights among the three groups, although the frequencies in all three groups decreased significantly with the therapeutic duration. Although the improvement rates at 3 months did not differ among the three groups, the improvement rate of 80% in the desmopressin group and 79% in the imipramine group at 6 months were greater than the 59% rate in the monotherapy group. After cure, no patients relapsed in the monotherapy group, and 3 (43%) each did so in the desmopressin and imipramine groups. In comparing the improved cases in each group, no significant differences were found in background factors. CONCLUSIONS Desmopressin and imipramine combined with an alarm was no more effective than alarm monotherapy. As for alarm monotherapy, other therapeutic modalities should be considered if it has not proved effective after 3 months. In such a situation, combination therapy may be effective as a second choice. No predictive factors for the therapeutic effects in the three modalities were found.
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Affiliation(s)
- Yasuyuki Naitoh
- Department of Urology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
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26
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Abstract
BACKGROUND Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults. OBJECTIVES To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions. SEARCH STRATEGY We searched the Cochrane Incontinence Group specialised trials register (searched 22 November 2004) and the reference lists of relevant articles. SELECTION CRITERIA All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the quality of the eligible trials, and extracted data. MAIN RESULTS Fifty five trials met the inclusion criteria, involving 3152 children of whom 2345 used an alarm. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95% CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (4/22 (18%) vs 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69). Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94). AUTHORS' CONCLUSIONS Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.
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Affiliation(s)
- C M A Glazener
- Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZD.
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Fai-Ngo Ng C, Wong SN. Comparing alarms, desmopressin, and combined treatment in Chinese enuretic children. Pediatr Nephrol 2005; 20:163-9. [PMID: 15605283 DOI: 10.1007/s00467-004-1708-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2003] [Revised: 09/03/2004] [Accepted: 09/10/2004] [Indexed: 11/28/2022]
Abstract
The objective of this multicenter randomized controlled trial was to compare the efficacy of enuresis alarms, oral desmopressin, and combined treatment in Chinese children with monosymptomatic primary nocturnal enuresis. We assigned 105 children aged 7-15 years to receive alarms (group 1, 35 patients), oral desmopressin 400 mug (group 2, 38 patients), or combined therapy (group 3, 32 patients) for 12 weeks; patients were then followed for 12 weeks after treatment. The wetting frequency decreased during treatment by 46%, 52%, and 73% in groups 1, 2, and 3, respectively. In groups 2 and 3, but not in group 1, there was rebound post treatment, but significant improvements persisted at 12 weeks. The complete and partial response rates were 22.9% and 20%, respectively in group 1, 42% and 10.5% in group 2, and 62.5% and 15.6% in group 3. By Kaplan-Meier analysis, group 1 had a significantly poorer response than groups 2 and 3. Of the responders, 20%, 60%, and 40% in groups 1, 2, and 3, respectively, relapsed after stopping treatment. In conclusion, enuresis alarms and/or oral desmopressin were less efficacious in Chinese than in Western societies. Desmopressin produced an immediate effect but relapses were common. Alarms took several weeks to produce a benefit, which was persistent on follow-up.
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Affiliation(s)
- Cherry Fai-Ngo Ng
- Department of Pediatrics and Adolescent Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
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29
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Abstract
Nocturnal enuresis is a common problem. Physiologic and environmental factors are thought to have a role in the etiology and treatment of this condition. This article discusses the association between enuresis and behavioral or emotional problems. Common behavioral treatments are described, and evidence for their efficacy is reviewed. A brief discussion of hypnosis and acupuncture is included.
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Affiliation(s)
- Nathan J Blum
- Division of Child Development and Rehabilitation, Children's Seashore House of The Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, 3405 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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30
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Woo SH, Park KH. Enuresis alarm treatment as a second line to pharmacotherapy in children with monosymptomatic nocturnal enuresis. J Urol 2004; 171:2615-7. [PMID: 15118432 DOI: 10.1097/01.ju.0000113036.13536.29] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We evaluate the effectiveness of enuresis alarm as second line therapy for partial or nonresponders to pharmacotherapy. MATERIALS AND METHODS We recommended enuresis alarm treatment for 67 partial or nonresponders to pharmacotherapy for monosymptomatic nocturnal enuresis. Of these patients 28 were evaluable by inclusion and exclusion criteria. We analyzed the effectiveness of enuresis alarm therapy using the response criteria defined by the reduction rate of wet nights, defined as complete response (greater than 90%), partial response (50% to 90%) and no response (less than 50%). We defined initial and lasting cure when patients showed persistent full response for 4 weeks and 6 months after cessation of all treatments, respectively. RESULTS After pharmacotherapy partial responders showed a mean response of 81.2%. On the other hand, nonresponders exhibited a mean response of 26.4% with more than 20 wet nights in 4 weeks. After using second line enuresis alarm treatment 90.5% (19 of 21) of partial responders became full responders and 71.4% (15 of 21), 61.9% (13 of 21) of partial responders showed initial and lasting cure, respectively. In addition, 71.4% (5 of 7) of nonresponders became full responders and 57.1% (4 of 7) exhibited initial and lasting cure. CONCLUSIONS Enuresis alarm as second line therapy for monosymptomatic nocturnal enuresis is effective for lasting cure as well as high initial full response rate in partial and nonresponders to pharmacotherapy. Therefore, enuresis alarm is a reasonable second line therapeutic option for partial or nonresponders to pharmacotherapy.
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Affiliation(s)
- Seung-Hyo Woo
- Department of Urology, Eulji Medical University Hospital, Daejeon, Korea
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31
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Affiliation(s)
- Linda S Nield
- Department of Pediatrics, West Virginia University, Morgantown, WV, USA
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Gibb S, Nolan T, South M, Noad L, Bates G, Vidmar S. Evidence against a synergistic effect of desmopressin with conditioning in the treatment of nocturnal enuresis. J Pediatr 2004; 144:351-7. [PMID: 15001941 DOI: 10.1016/j.jpeds.2003.12.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To test the hypothesis that desmopressin facilitates acquisition of continence, we aimed to establish whether, in children with nocturnal enuresis who are desmopressin nonresponders, adjunct desmopressin increases the rate of sustained continence after treatment with a conditioning alarm. Study design Patients with nocturnal enuresis (n=358; age range, 6-16 years) completed a 4-week "run-in" course of intranasal desmopressin (20-40 microg). Of these, 207 defined as nonresponders (<50% reduction in wet nights) were randomly assigned to receive either desmopressin (n=101) or placebo (n=106) nasal spray, together with conditioning alarm therapy for 8 weeks. Principal outcome measures were remission (28 continuous dry nights) and relapse (>2 wet nights in 2 weeks after having achieved remission). RESULTS Remission rates were similar in both groups (51.5% desmopressin, 48.1% placebo; 95% CI on difference, -10%, 17%; P=.63), and relapse rates were not significantly different (13.5% vs 5.9%; 95% CI on difference, -3.7%, 19%; P=.19). Although remission rates were similar, children treated with desmopressin had significantly more dry nights during treatment than those in the placebo group. CONCLUSIONS Desmopressin did not act synergistically with alarm treatment to achieve remission. Therefore, we infer that in partial or nonresponders, desmopressin does not enhance learning.
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Affiliation(s)
- Susie Gibb
- Departments of General Medicine and Outpatient Services, Royal Children's Hospital Melbourne, University of Melbourne School of Population Health, Melbourne, Australia
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Abstract
BACKGROUND 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. OBJECTIVES To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions. SEARCH STRATEGY We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles. Date of the most recent searches: December 2002. SELECTION CRITERIA All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the quality of the eligible trials, and extracted data. MAIN RESULTS Fifty three trials met the inclusion criteria, involving 2862 children. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.36, 95% CI 0.31 to 0.43). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (RR 4/22 (18%) vs 16/24 (67%),RR 0.27, 95% CI 0.11 to 0.69). Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94). REVIEWER'S CONCLUSIONS Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm) and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.
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Affiliation(s)
- C M Glazener
- Health Services Research Unit (Foresterhill Lea), University of Aberdeen, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZD.
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34
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Abstract
BACKGROUND 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 to the children can be great. OBJECTIVES To assess the effects of desmopressin on nocturnal enuresis in children, and to compare desmopressin with other interventions. SEARCH STRATEGY The following electronic databases were searched: MEDLINE to June 1997; AMED; ASSIA; BIDS; BIOSIS Previews (1985-1996); CINAHL; DHSS Data; EMBASE (1974 to June 1997); PsycLIT and SIGLE. Organisations, manufacturers, researchers and health professionals concerned with enuresis were contacted for information. The reference sections of obtained studies were also checked for further trials. Date of the most recent search: July 1997. SELECTION CRITERIA All randomised trials of desmopressin for nocturnal enuresis in children were included in the review. Trials were eligible for inclusion if: children were randomised to receive desmopressin compared with placebo, other drugs or other conservative interventions for nocturnal bedwetting; participants with organic causes for their bedwetting were excluded; and baseline assessments of the level of bedwetting were reported. 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 Twenty one randomised trials involving 948 children treated with desmopressin, met the inclusion criteria. The quality of many of the trials was poor. Desmopressin was compared with a tricyclic drug in two trials, and with alarms in one. Desmopressin was effective in reducing bedwetting in a variety of doses and forms. Each dose of desmopressin reduced bedwetting by at least one night per week during treatment (eg 20microg: 1.56 fewer wet nights per week, 95% CI -1.94 to -1.19). Participants on desmopressin were 4.6 times more likely to achieve 14 consecutive dry nights (95% CI 1.38 to 15.02) compared with placebo. However, there was no difference after treatment was finished. There was no apparent dose-related effect of desmopressin, but the evidence was limited. Data which compared oral and nasal administration were too few to be conclusive. Desmopressin and imipramine (a tricyclic drug) were equally effective in one small trial. Amitriptyline (another tricyclic) was not consistently better than desmopressin either alone or when used as a supplement. In a single trial, desmopressin was initially superior to using an alarm in reducing the number of wet nights per week: WMD -1.7 (95% CI: -2.96 to -0.45), but this result was not sustained; after three months of treatment, patients using the alarm had 1.4 fewer wet nights per week than with desmopressin: (95% CI: 0.14 to 2.65). Participants receiving the alarm intervention were also nine times less likely to relapse than those given desmopressin: RR 9.2 (95% CI: 1.28 to 65.9). Combining alarm and drug therapy was found to be superior to alarm treatment alone. The addition of desmopressin to an alarm schedule resulted in one less wet night per week: (95% CI: -1.55 to -0.45). REVIEWER'S CONCLUSIONS Desmopressin rapidly reduced the number of wet nights per week, but there was some evidence that this was not sustained after treatment stopped. Comparison with alternative treatments suggested that desmopressin and tricyclics had similar clinical effects, but that alarms produced more sustained benefits. However, based on the available evidence, these conclusions can only be tentative. There was some evidence of minor side effects of desmopressin in the included trials, such as nasal irritation and nose bleeds. However, the risk of water intoxication associated with over-drinking before bedtime has been reported. Patients and their families need to be warned of potential adverse effects and advise
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Affiliation(s)
- C M Glazener
- Health Services Research Unit (Flea), University of Aberdeen, Foresterhill Lea, Foresterhill, Aberdeen, Aberdeenshire, UK, AB25 2ZD.
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