Studies of enuresis. IX. Evidence of a mild form of compensated detrusor hyperreflexia in enuretic children

Evaluation of the enuretic child

Nocturnal enuresis is a symptom of environmental, physical, and psychosocial factors. In addition to a physical examination, the initial workup of the enuretic child should include a careful voiding, psychosocial, and family history. Studies have shown that the parents of enuretic children often have a history of enuresis. An increased incidence of enuresis has also been demonstrated in children from large families and lower socioeconomic groups. Daytime voiding symptoms (e.g., frequency, urgency, or enuresis) suggest the possibility of underlying voiding dysfunction. A complete urinalysis and urine culture also should be performed to exclude urinary infection and certain metabolic or nephrologic disorders. Finally, it is important that the treating physician understand the attitudes of both the child and the family concerning enuresis. Parents who feel that the child is at fault need to be educated and reassured. A careful, complete evaluation will allow the physician to tailor treatment to the individual child and family.

Role of detrusor instability in primary enuresis

We studied 50 enuretic boys and girls by supine cystometry. Detrusor instability was found in 74 percent of the cases. The mean threshold volume at which detrusor instability was demonstrated was 200 mL. The mean bladder capacity of age-matched nonenuretic children was 325 mL. We consider detrusor instability at this reduced threshold volume to be the main cause of primary enuresis.

Terodiline in the treatment of nocturnal enuresis in children

The effect of terodiline was investigated in 17 children with nocturnal enuresis. Twelve of them were evaluated urodynamically before treatment and 6 of these were proved to have detrusor instability with or without provocation. Terodiline in a daily dose of 12.5 mg was administered for 4 weeks. After treatment the number of wet nights per week has significantly decreased. Urodynamically, maximum cystometric capacity has statistically increased and in 2 patients involuntary contraction has disappeared. During these periods no serious side effects were encountered. Terodiline could improve urodynamic parameters in nocturnal enuresis. These changes appear to be favourable in clinical improvement.

Treatment of primary nocturnal enuresis by oral androgen mesterolone. A clinical and cystometric study

A double-blind clinical study of 30 boys, six to ten years of age, with primary nocturnal enuresis was undertaken to assess the role of androgens in treating enuresis. The oral synthetic androgen mesterolone was selected because of its minimal potential toxic effects. Twenty boys were treated with mesterolone and 10 received placebo. Fourteen boys (70%) became dry during treatment (20 mg daily for 14 days), and 5 (25%) remained dry for a follow-up period of four months. Increased cystometric bladder capacity and disappearance of uninhibited detrusor contractions were noticed in a significant number of cases after treatment. No side effects were recorded. Mesterolone has probably modulated the autonomic innervation of the vesical musculature with correction of the defective neural mechanism which is believed to be implicated in the pathogenesis of nocturnal enuresis.

Screening of urinary tract abnormalities among day and nightwetting children

In order to detect possible urinary tract abnormalities among wetters, assessments of previous history completed by ultrasonography of the urinary tract and uroflowmetry were obtained for 145 wetting children and a random sample of 156 sex-matched non-wetting children drawn from a population of 3,375 seven-year-olds. Ultrasonography revealed abnormalities, including both morphological ones and cases with incomplete bladder emptying, in 5 out of 73 nightwetters (6.8%, 95% confidence limit, CL, 1.1-12.6), 10 out of 72 day and day and nightwetters (hereafter daywetters) (13.9%, CL 5.9-21.9) and 4 controls (2.6%, CL 0.1-5.0), the figure for the daywetters differing significantly from that for the controls (p less than 0.01). A fractioned voiding curve was recognized in 1 nightwetter (1.4%, CL -1.3-4.0), 7 daywetters (9.7%, CL 2.9-16.6) and 7 controls (4.5%, CL 1.2-7.7) the difference between the nightwetters and daywetters being significant (p less than 0.05). Depending on the previous history and abnormal findings in ultrasonography or uroflowmetry, examinations were continued with intravenous pyelography, voiding cystography, cystoscopy and/or by cystometry. Finally, marked structural or functional disorders of the urinary tract were detected in 11 out of 72 daywetters (15.3%, CL 7.0-23.6), 1 out of 73 pure nightwetters and 1 out of 156 control children. It is concluded that imaging of the urinary tract is not necessary for pure nightwetters, while ultrasonography or uroflowmetry and more sophisticated radiological or urological methods should be focused on those children with daytime wetting and clinical symptoms of voiding disturbances.

Nocturnal enuresis: epidemiology, evaluation, and currently available treatment options

Treatment of childhood enuresis must begin with a careful history, physical examination, urinalysis, and urine culture to determine if one is dealing with uncomplicated or complicated enuresis. The majority of patients will have uncomplicated enuresis; there are several treatment options available to the physician that can be tailored to the individual patient. Parental support, empathy, and patience are key elements in any successful plan of management of the child with enuresis. Likewise, reassurance, periodic feedback, and encouragement of the parents and child by the physician are necessary for optimal results.