Enuresis

Impaired selective attention in patients with severe primary monosymptomatic nocturnal enuresis: An event-related potential study

Objectives

Primary monosymptomatic nocturnal enuresis (PMNE) is a very common problem in school age children. It is thought that PMNE represents a maturational lag in the central nervous system of those children. We did this case control study to assess the selective attention and resource allocation in those children using the P300 wave of the Event-Related Potentials (ERPs) and its relation to disease severity.

Methods

Forty four patients with PMNE and twenty three healthy controls were included in this study. Patients were diagnosed according to the criteria of international children's continence society and were classified into two groups; patients with frequent wetting (≥4 episodes/week), and patients with infrequent wetting (<4 episodes/week). ERPs were recorded at Fz, Cz, and Pz locations using odd-ball paradigm. N200 and P300 peak latencies (ms), and N200/P300 peak to peak amplitudes (µV) were measured.

Results

We found significant increase of P300 and N200/P300 interpeak latencies, and significant decrease of P300 amplitudes in frequent wetting group "severe" PMNE compared to healthy controls and infrequent wetting group.

Conclusion

Abnormal selective attention and resource allocation were found in patients with severe PMNE. Measures to improve selective attention might be helpful in treatment of patients with severe PMNE.

Significance

Impaired selective attention might play a role in pathogenesis of severe PMNE and the need for the various measures to improve selective attention may be further studied as a therapeutic tool for patients with severe PMNE.

Examining the effectiveness of parental strategies to overcome bedwetting: an observational cohort study

OBJECTIVE

To examine whether a range of common strategies used by parents to overcome bedwetting in 7½-year-old children (including lifting, restricting drinks before bedtime, regular daytime toilet trips, rewards, showing displeasure and using protection pants) are effective in reducing the risk of bedwetting at 9½ years.

DESIGN

Prospective cohort study.

SETTING

General community.

PARTICIPANTS

The starting sample included 1258 children (66.7% boys and 33.2% girls) who were still bedwetting at 7½ years.

OUTCOME MEASURE

Risk of bedwetting at 9½ years.

RESULTS

Using propensity score-based methods, we found that two of the parental strategies used at 7½ years were associated with an increased risk of bedwetting at 9½ years, after adjusting the model for child and family variables and other parental strategies: lifting (risk difference=0.106 (95% CI 0.009 to 0.202), ie, there is a 10.6% (0.9% to 20.2%) increase in risk of bedwetting at 9½ years among children whose parents used lifting compared with children whose parents did not use this strategy) and restricting drinks before bedtime (0.123 (0.021 to 0.226)). The effect of using the other parental strategies was in either direction (an increase or decrease in the risk of bedwetting at 9½ years), for example, showing displeasure (-0.052 (-0.214 to 0.110)). When we re-analysed the data using multivariable regression analysis, the results were mostly consistent with the propensity score-based methods.

CONCLUSION

These findings provide evidence that common strategies used to overcome bedwetting in 7½-year-olds are not effective in reducing the risk of bedwetting at 9½ years. Parents should be encouraged to seek professional advice for their child's bedwetting rather than persisting with strategies that may be ineffective.

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.

Alarm interventions for nocturnal enuresis in children

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.

INTERMITTENT ORAL DESMOPRESSIN THERAPY FOR MONOSYMPTOMATIC PRIMARY NOCTURNAL ENURESIS

PURPOSE

In a prospective study we evaluate the efficacy of intermittent desmopressin (DDAVP) every other day for patients with nocturnal enuresis relapse who need additional therapy.

MATERIALS AND METHODS

Between January 2000 and August 2001, 71 boys and 52 girls 6 to 22 years old (mean age 12.5) were treated with 0.2 mg DDAVP daily for monosymptomatic nocturnal enuresis. After an initial 2 weeks of dose titration the nonresponders were given 0.4 mg DDAVP daily. Those who did not respond to this dose were excluded from study. The remaining patients took desmopressin for 3 months. Patients with persistent enuresis after 3 months of treatment were given intermittent 0.2 or 0.4 mg DDAVP every other day. Followup was performed 6 weeks later.

RESULTS

Of 123 patients 92 completed the study. Mean followup after beginning intermittent DDAVP therapy was 9.2 months (range 6 to 18). Of the 92 patients 45 responded to the 0.2 mg daily dose (group 1) and continued treatment for at least 3 months, while the dose was titrated to 0.4 mg for the remaining 47 (group 2). There were 23 patients who did not respond to 0.4 mg DDAVP and they were excluded from the study. After cessation of the drug 21 group 1 patients (46.6%) and 13 group 2 patients (54%) still had enuresis, and they were placed on intermittent therapy. After 6 weeks 15 of these 34 patients had complete and 13 of the remaining 19 had partial response, while the 6 nonresponders continued on daily DDAVP. Overall the complete and partial response rate of intermittent treatment was 20 of 21 group 1 patients (95%) and 8 of 13 group 2 (61.5%).

CONCLUSIONS

For some enuretic patients with relapse after cessation of initial 3-month therapy, intermittent DDAVP may be an effective alternative long-term treatment.

Complex behavioural and educational 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.

OBJECTIVES

To assess the effects of complex behavioural and educational interventions on nocturnal enuresis in children, and to compare them 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 complex behavioural or educational interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and physical behavioural methods, alarms, desmopressin, tricyclics, and miscellaneous other interventions.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Sixteen trials involving 1081 children were identified which included a complex or educational intervention for nocturnal enuresis. The trials were mostly small and some had methodological problems including the use of a quasi-randomised method of concealment of allocation in three trials and baseline differences between the groups in another three.A complex intervention (such as dry bed training (DBT) or full spectrum home training (FSHT)) including an alarm was better than no-treatment control groups (eg RR for failure or relapse after stopping DBT 0.25; 95% CI 0.16 to 0.39) but there was not enough evidence about the effects of complex interventions alone if an alarm was not used. A complex intervention on its own was not as good as an alarm on its own or the intervention supplemented by an alarm (eg RR for failure or relapse after DBT alone versus DBT plus alarm 2.81; 95% CI 1.80 to 4.38). On the other hand, a complex intervention supplemented by a bed alarm might reduce the relapse rate compared with the alarm on its own (eg RR for failure or relapse after DBT plus alarm versus alarm alone 0.5; 95% CI 0.31 to 0.80).There was not enough evidence to judge whether providing educational information about enuresis was effective, irrespective of method of delivery. There was some evidence that direct contact between families and therapists enhanced the effect of a complex intervention, and that increased contact and support enhanced a package of simple behavioural interventions, but these were addressed only in single trials and the results would need to be confirmed by further randomised controlled trials, in particular the effect on use of resources.

REVIEWER'S CONCLUSIONS

Although DBT and FSHT were better than no treatment when used in combination with an alarm, there was insufficient evidence to support their use without an alarm. An alarm on its own was also better than DBT on its own, but there was some evidence that combining an alarm with DBT was better than an alarm on its own, suggesting that DBT may augment the effect of an alarm. There was also some evidence that direct contact with a therapist might enhance the effects of an intervention.

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.

Nocturnal enuresis

Nocturnal enuresis is a benign condition, yet needs treatment to relieve the child and parents of the accompanying anxiety and the stigma attached to it. It is defined as normal nearly complete evacuation of the bladder at a wrong place and time at least twice a month after the fifth year of life. The underlying cause of enuresis is functional and various proposed pathophysiological mechanisms like maturational delay, genetics, role of sleep, antidiuretic hormone, and bladder capacity are discussed. These factors have a bearing on the management. As no treatment plan is ideal, various treatment modalities currently available including good supportive care are elaborated and a plan of management discussed.

Alarm interventions for nocturnal enuresis in children

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.

Abnormalities in event-related potential and brainstem auditory evoked response in children with nocturnal enuresis

To evaluate central nervous system functioning involvement in nocturnal enuresis, P300 and N200 event-related brain potentials and brainstem auditory-evoked potentials (BAER) were assessed in a group of 35 enuretic boys aged 7-9 years. The measurements of enuretic group were compared to those of age and sex matched non-enuretics. P300 latency in the enuretic group was significantly longer than in non-enuretic group (420 ms at parietal scalp (Pz), 414 ms at central scalp (Cz) versus 386 ms at Pz, 376 ms at Cz; P < 0.01 and P < 0.01, respectively). Both enuretic and non-enuretic subjects were divided into three subgroups his age. There was no significant difference in terms of both P300 amplitude and N200 latency and N200 amplitude between non-enuretic age subgroups. But, P300 latency over central scalp in 8 years old non-enuretic subgroup was significantly longer than in 9 years old non-enuretic subgroup (P < 0.01). No significant difference was found in latency and amplitude of P300 and N200 latency between enuretic subgroups. However, N200 amplitude at Cz in 8 years old enuretic subgroup was significantly lower than both in 7 years old enuretic subgroup and in 9 years old enuretic subgroup (P < 0.01 and P < 0.01, respectively). There were significant topographical differences in latency and amplitude of P300 and in N200 latency in enuretic age subgroups, only. There was no significant difference in interpeak latencies I-III, I-V and III-V and wave latencies I, III and V of BAERs between enuretic group and non-enuretic subgroup. Longer interpeak and wave latencies of BAERs were found both in 8 years old enuretic subgroup and 8 years old non-enuretic subgroup.

CONCLUSION

Longer P300 latency in primer enuretics compare to non-enuretics is an evidence of a maturational delay of central nervous system functioning.

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.

The effectiveness of desmopressin in the treatment of childhood nocturnal enuresis: predicting response using pretreatment variables

OBJECTIVE

To determine the factors that predict the effectiveness of desmopressin in the treatment of childhood nocturnal enuresis.

PATIENTS AND METHOD

Sixty-six children with monosymptomatic nocturnal enuresis were treated with intranasal or oral desmopressin for a 4-week period. starting with a standard dose of 20 microg (0.2 mg oral) and increasing after 2 weeks where no progress was apparent to 40 microg (0.4 mg oral). Before treatment a range of variables (demographic, situational, enuretic history, physiological, parental attitude and child) were recorded. Three parameters of success acted as dependent variables, with stepwise linear regression models used to determine pretreatment predictors of success with desmopressin.

RESULT

Each outcome variable produced a very similar model of predictors. Success, as assessed by the most dry nights over a 14-night period, was associated with less severe enuresis before treatment, a parental belief that the child's enuresis was unstable and higher birthweight.

CONCLUSION

From the analysis, a model of arginine vasopressin release is proposed and the clinical implications of the findings addressed.

Primary nocturnal enuresis and desmopressin treatment: do psychosocial factors affect outcome?

Twenty-three patients (5 to 15 years of age) with primary nocturnal enuresis were treated with desmopressin (DDAVP) according to a four-step protocol with weekly reductions of daily doses (1 to 0.25 microgram/kg body weight) thus including aspects of behavior-oriented "bladder retention training". The rate of wet nights was significantly reduced while patients were on medication (p < 0.02), but the sample as a whole returned to baseline levels after medication was stopped. Six subjects (26%) were non-responders. A variety of psychological and psychosocial single factors did not significantly affect the outcome. However, a subgroup of seven patients assessed as "psychologically non-distressed" revealed better results both on medication (p < 0.02; reduction 73%) and off medication (p > or = 0.05; reduction 39%) compared to a "distressed" subgroup (N = 16). Both groups showed significant changes in wet nights over the treatment course (p < 0.02 and p > or = 0.002, respectively). There was no clear-cut relationship between laboratory data (urine volume, osmolality, vasopressin) and outcome in wet nights. Data did not suggest a subgroup of patients with particularly low nocturnal vasopressin (AVP) secretion and, thus, high rates of wet nights. Our results corroborated the finding that DDAVP is an effective substance in reducing wet nights in patients with primary nocturnal enuresis. However, with respect to major reductions and long-term results (off medication), these preliminary findings suggest that "psychological distress" seems to be a very important confounding outcome variable. Thus, careful consideration and assessment of psychological and psychosocial aspects of distress are recommended. Eventually, a combination of DDAVP treatment with counseling and/or psychotherapy may significantly improve results for the majority of patients and families.

Stress and age at menarche of mothers and daughters

The hypothesis that psychological stress during early childhood leads to advanced reproductive maturation was assessed using data from the California Childhood Health and Development Study. Regression analyses failed to indicate that bed wetting, nightmares or thumb-sucking at age 5 predict age at menarche, regardless of controls for mother's age at menarche. Among socioeconomic variables suggested as contextual stressors measured at age 9-11 only mother's education was a significant predictor of daughter's age at menarche, though its effect is trivial compared to mother's age at menarche. Path analysis on a subsample of the subjects failed to demonstrate the hypothesised indirect effect of mother's age at menarche on daughter's age at menarche acting through early marriage and marital dissolution. These results cast doubt on the theory that early childhood stress is the key to divergent reproductive strategies among females based on the timing of reproductive maturation.

Isotope renography in childhood enuresis

A retrospective review was performed of 100 enuretic children who underwent isotope renography during the period 1981-1989. Studies performed were Tc99mDMSA studies for renal size and to detect renal scarring and renography using Tc99mDTPA or MAG3 to evaluate excretion and detect vesicoureteric reflux. Fifty-five children had microbiological evidence of urinary tract infection (UTI), and 16 (29%) of these had abnormalities on their isotope studies. Forty-five had sterile urine and all had normal isotope studies. Thus despite recent reports of urodynamic abnormalities and increased incidence of reflux in patients with enuresis, our findings indicate that standard nuclear medicine renal studies show few abnormalities in patients with monosymptomatic enuresis. The 29% incidence of abnormal studies in patients with enuresis and UTIs suggests that the presence of infection should be an indication for further investigation in this subgroup of enuretic children.

The value of videourodynamics in the investigation of neurologically normal children who wet

Videourodynamic studies were performed on 57 wet children, 35 of whom were assessed retrospectively and 22 prospectively. Thirty-two studies (56%) were abnormal; detrusor instability or reduced compliance was found in 26, increased bladder sensitivity in 3, detrusor sphincter dyssynergia in 2 and sphincter weakness incontinence in 1. A detailed micturition history sheet and the results of routine preliminary investigations (mid-stream urine and ultrasonography) were used in an attempt to predict the outcome of urodynamics. Since only 5 of the 25 normal studies and 18 of the 32 abnormal studies were correctly predicted, it was concluded that accurate prediction was not possible. Urodynamic investigations are therefore required to identify the underlying cause of wetting and to guide appropriate treatment.

Behavioral management of toilet training, enuresis, and encopresis

Toileting problems are a matter of great concern to parents and are a frequent source of family discord, but proper handling of toilet training as well as enuresis and encopresis can ameliorate any untoward effects of these problems. Both the pediatrician and the pediatric psychologist can play a major role in this area.

Primary nocturnal enuresis: current concepts about an old problem

In summary, all children and families who present with nocturnal enuresis should be offered education, reassurance, and ongoing support as a premier component of any treatment regimen. At the same time, the family should be informed about all the treatment options that exist with a goal of tailoring the specific treatment to the individual patient. In most cases, this approach will lead to child, family, and physician satisfaction.

A 6 year follow-up of childhood enuresis: prevalence in adolescence and consequences for mental health

Recent studies have shown an association between enuresis and behavioural or emotional problems. The direction or causality of the association and its duration, however, remain unclear. This study followed a large group of children from ages 11 to 15 years and reported the prevalence of enuresis to age 13 years. The enuretic status of the sample at age 11 years was established relative to the history of enuresis at age 9 years. At age 11 years a significant association was found between enuresis and measures of psychopathology. This association was particularly evident for those children with secondary enuresis, and those who had a history of enuresis but had ceased to wet the bed. Current primary enuresis was not significantly associated with disorder. Similar associations were found between enuresis at age 11 and later disorder at age 13. At age 15 years no significant associations between enuresis and disorder were found. These findings have implications for parents of children with enuresis and for clinicians dealing with the disorder.