Assignment of dominant inherited nocturnal enuresis (ENUR1) to chromosome 13q

Bibliometric and visual analysis of nocturnal enuresis from 1982 to 2022

Nocturnal enuresis is a common disorder among children that seriously affects physical and mental health and has become a social problem. Bibliometric analysis is a valid way to examine existing research results, current research hotspots and research frontiers. Current studies on nocturnal enuresis are numerous and complex, but a bibliometric analysis of the existing research on nocturnal enuresis has yet to be published. To better identify the research trends and frontiers in nocturnal enuresis, it is necessary to conduct a comprehensive review and analysis. We used bibliometric and visualization methods to analyze the 1,111 papers published between 1982 and 2022 from the Web of Science core collection. Basic information about the country, institution, and authors was analyzed, which led to a basic understanding of nocturnal enuresis. The United States is the most prolific country, Ghent University is the most influential institution, and Rittig Soren is the most prominent scholar. The frequency of keywords, clustering, and the cited literature were analyzed to understand the hotspots and frontiers of research, and a brief review of the highly cited literature was conducted. The current research hotspots are the treatment modalities for nocturnal enuresis, epidemiological investigations, and the exploration of pathogenesis. Clinical research, adenoidectomy, aquaporin 2, and response inhibition are potential research hotspots. The standardization of terminology in nocturnal enuresis and the pathologies of polyuria and sleep disorder are at the forefront of research. In summary, the results of our bibliometric analysis reveal views on the current situation and the trend of nocturnal enuresis research for the first time. This study may provide guidance for promoting research on nocturnal enuresis.

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.

New insights in treatment of monosymptomatic enuresis

Objective

Nocturnal enuresis (NE) is defined as uncontrollable bed-wetting for at least three consecutive months in children over 5 years. Sleep could be dramatically altered in children with primary nocturnal enuresis (PNE); consequently, this helps to confirm the assumption that PNE appears to modify sleep structure, or it might be the result of an irregular sleep structure itself.

Method

This study conducted on 180 patients with monosymptomatic nocturnal enuresis. Their age was ranged from 6 to 18 years, and they were still having nocturnal enuresis episodes. We record two main points: first, if the child is a regular sleeper or not. The second point if the child is a regular bed wetter or not. This work fully compliant with the STROCCS criteria (Agha et al., 2019).

Result

A total of 180 children were included (Male 122, 67.8%, Female 58, 32.2%). The mean age was 8.9 (±2.4). This study showed that children aged 7–10 years are significantly more inclined to be reported as specific time bed-wetter's, whereas those aged between 11 and 13 are significantly less likely to wet their bed at a specific time (p = 0.001). Children who tend to sleep more often near a specific time each night are 6.74 times more prone to bed-wet around a particular time during their sleep (p < 0.001).

Conclusion

This study can be considered as hypothesis-generating that shed light on the possible correlation between the adherence to sleep at a specific time and its effect on the time of enuresis and the number of bedwetting.

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Nocturnal enuresis is a common compliant among the pediatric age group.

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The incidence of Nocturnal enuresis varies with age.

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There is possible correlation between the adherence to sleep at a specific time and its effect on the time of enuresis and number of bedwetting.

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The majority of children who sleep at a particular time suffer from Nocturnal enuresis at a specific time and are younger than the rest of the children, while children who sleep at an unspecified time suffer from multiple bed wettings at an undetermined time.

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The chronobiology of micturition plays a vital role in the regulation of bedwetting in Monosymptomatic Nocturnal Enuresis (MNE) children.

Effect of DRD4 Receptor -616 C/G Polymorphism on Thalamic GABA Levels in Pediatric Patients With Primary Nocturnal Enuresis

BACKGROUND

The single nucleotide polymorphism (SNP) of dopamine D4 receptor (DRD4) promoter (-616; rs747302) is associated with abnormalities of the thalamus in children suffering from primary nocturnal enuresis (PNE).

PURPOSE

To investigate the effect of DRD4 -616 C/G SNP on thalamic gamma-aminobutyric acid (GABA) levels in PNE children.

STUDY TYPE

Prospective, observational.

SUBJECTS

One hundred and seventy-six children with PNE and 161 healthy control children.

FIELD STRENGTH/SEQUENCE

3 T, three-dimensional T1-weighted turbo field echo sequence and MEscher-Garwood Point RESolved Spectroscopy (MEGA-PRESS) MRS sequence.

ASSESSMENT

The MEGA-PRESS MRS sequence was used to measure thalamic GABA spectra. The thalamic GABA+ level was calculated using the Gannet 3.0 software package for each participant. A questionnaire was used to determine arousal from sleep (AS) scores.

STATISTICAL TESTS

Comparisons of the AS scores and thalamic GABA+ levels were performed using the Mann-Whitney U test between C-allele carriers and GG homozygotes in the PNE and control groups. Spearman correlation analysis was performed to determine the association between AS scores and thalamic GABA levels in PNE children.

RESULTS

Thalamic GABA levels in the PNE group were significantly higher than those in the healthy control group (0.178 (0.169-0.186) vs. 0.154 (0.146-0.164), Z = 8.526, P_corrected  < 0.001). The GABA levels in C-allele carriers were significantly higher than those in GG homozygotes in both the PNE and control groups (0.184 (0.181-0.193) vs. 0.170 (0.165-0.177), Z = 8.683, P_corrected  < 0.001; 0.166 (0.156-0.170) vs. 0.147 (0.141-0.152), Z = 9.445, P_corrected  < 0.001). GABA levels in the thalamus were also significantly and positively correlated with AS scores in C-allele carriers in the PNE group (r = 0.747, P < 0.05).

DATA CONCLUSION

DRD4 -616 C allele may be associated with increased thalamic GABA+ levels, especially in C-allele carrying PNE children.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 3.

Pathogenesis and brain functional imaging in nocturnal enuresis: A review

Nocturnal enuresis is a common and distressing developmental disease, which may cause various degrees of psychosocial stress and impairment to self-esteem in affected children as well as agitation to their parents or caregivers. Nevertheless, the etiology and pathogenesis of nocturnal enuresis are not understood. Currently, nocturnal enuresis is generally considered a multifactorial disease associated with a complex interaction of somatic, psychosocial, and environmental factors. A variety of postulations have been proposed to explain the occurrence and progression of nocturnal enuresis, including hereditary aberration, abnormal circadian rhythm of antidiuretic hormone secretion during sleep, bladder dysfunction, abnormal sleep, difficulties in arousal, neuropsychological disorders, and maturational delays of the brain. In recent decades, the introduction of functional neuroimaging technologies has provided new approaches for uncovering the mechanisms underlying nocturnal enuresis. The main neuroimaging modalities have included brain morphometry based on structural magnetic resonance imaging (MRI), task-based and event-related functional MRI (fMRI), and resting-state fMRI. The relevant studies have indicated that nocturnal enuresis is associated with functional and structural alterations of the brain. In this review, we briefly summarized the popular hypotheses regarding the pathogenesis of nocturnal enuresis and the current progress of functional neuroimaging studies in examining the underlying mechanisms thereof.

Alarm interventions for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) affects up to 20% of five-year-olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs.

OBJECTIVES

To assess the effects of enuresis alarms for treating enuresis in children.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles.

SELECTION CRITERIA

We included randomised or quasi-randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data.

MAIN RESULTS

We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) -2.68, 95% confidence interval (CI) -4.59 to -0.78; 4 trials, 127 children; low-quality evidence). Low-quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post-treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low-quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD -0.96, 95% CI -2.32 to 0.41; 1 trial, 47 children; very low-quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low-quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post-treatment. Compared with control alarms, code-word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate-quality evidence) but there is probably little to no difference in the number of children remaining dry post-treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate-quality evidence). Very low-quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry-bed training, and star chart plus rewards) (MD -0.81, 95% CI -2.01 to 0.38; low-quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low-quality evidence) and may slightly increase the number of children remaining dry post-treatment (RR 1.39, 95% CI 0.81 to 2.41; low-quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD -0.64, 95% CI -1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low-quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post-treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate-quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post-treatment, because the quality of evidence is very low. Due to very low-quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD -0.88, 95% CI -0.38 to -1.38; 2 trials, 156 children; low-quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low-quality evidence) and the number of children remaining dry post-treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low-quality evidence) compared with desmopressin alone. Alarm plus dry-bed training may increase the number of children achieving a complete response compared to dry-bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low-quality evidence). It is unclear if there is any difference in the number of children remaining dry post-treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low-quality evidence). Due to very low-quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code-word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate-quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate-quality evidence). Very low-quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments.

AUTHORS' CONCLUSIONS

Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately-powered trials with robust randomisation are still needed to determine the full effect of alarm therapy.

Effect of DRD4 receptor -616 C/G polymorphism on brain structure and functional connectivity density in pediatric primary nocturnal enuresis patients

The dopamine D4 receptor (DRD4) promoter (-616; rs747302) has been associated with primary nocturnal enuresis (PNE); however, its relationship with neuroimaging has not been investigated. Therefore, we assessed the effects of the DRD4 -616 C/G single nucleotide polymorphism on the gray matter volume (GMV) and functional connectivity density (FCD) during resting-state functional magnetic resonance imaging in children with PNE using voxel-based morphometry and FCD methods. Genomic and imaging data were obtained from 97 children with PNE and 105 healthy controls. DRD4 -616 C/G was genotyped. Arousal from sleep (AS) was assessed on a scale of 1-8. Both the main effect of genotype and the group (PNE/control)-by-genotype interaction on GMV and FCD were calculated. Our results showed that C-allele carriers were associated with a higher AS, decreased GMV and FCD in the pregenual anterior cingulate cortex; children with PNE carrying the C allele exhibit decreased GMV and FCD in the thalamus; however, controls carrying the C allele exhibit increased FCD in the posterior cingulate cortex. These effects of genetic variation of the DRD4 locus may help us understand the genetic susceptibility of the DRD4 -616 C allele to PNE.

Translational Research for Pediatric Lower Urinary Tract Dysfunction

This review provides a comprehensive view of translational research aimed at elucidating the pathophysiology of pediatric lower urinary tract dysfunction (LUTD). A web search was conducted according to combinations of keywords, and the significance of each article was defined by the author. The dramatic evolution of the mass analysis method of genomes, transcripts, and proteins has enabled a comprehensive analysis of molecular events underlying diseases, and these methodologies have also been applied to pediatric LUTD. In genetic analyses of syndromes underlying daytime incontinence, urofacial (Ochoa) syndrome may be creating a prototype of a new research approach. Nocturnal enuresis has long been studied genetically, and several candidate loci have been reported. However, the pursuit for enuresis genes has been abandoned partly because genetic association and enuresis phenotype (bladder or renal type) could not be linked. Enuresis associated with diabetes insipidus has provided new insights into the etiology of the diseases. A chronobiological approach may shed new light on this area. Posterior urethral valves and neurogenic bladders have attracted the interest of pediatric urologists to the smooth muscle biology of the bladder. Bladder exstrophy and cloacal anomalies are rare but major anomalies caused by defective urorectal development and have recently been studied from a genetic standpoint. Translational studies for pediatric LUTD may be extended to adult bladder disease, or to application of precision medicine for diseased children.

Management of nocturnal enuresis - myths and facts

Nocturnal enuresis often causes considerable distress or functional impairment to patient and their parents necessitating a multidisciplinary approach from paediatrician, paediatric nephrologist, urologists and psychiatrist. Mechanisms of monosymptomatic nocturnal enuresis are mainly nocturnal polyuria, bladder overactivity and failure to awaken from sleep in response to bladder sensations. Goal oriented and etiology wise treatment includes simple behavioral intervention, conditioning alarm regimen and pharmacotherapy with desmopressin, imipramine and anticholinergic drugs. Symptoms often recurs requiring change over or combination of different modes of

treatment.

Association between exclusive maternal breastfeeding during the first 4 months of life and primary enuresis

INTRODUCTION

Although the relationship between enuresis and breastfeeding is still poorly documented in the literature, a possible association is speculated as both are strongly associated with children's development. Therefore, the main objective of this study was to evaluate whether there is an association between primary enuresis and the duration of exclusive breastfeeding.

MATERIAL AND METHODS

This is an observational, case-control study, involving 200 children and adolescents from 6 to 14 years old, who were divided into two groups: the enuresis group (EG), composed of 100 children with primary enuresis; and the control group (CG) of 100 matched children without enuresis. The matching criteria were sex, age, and socioeconomic level. Adults responsible for each infant answered a structured questionnaire to identify biological and behavioral factor, as well as the duration of maternal breastfeeding. Children whose parents could not comprehend the questionnaire or children with neurological or psychiatric disorders or secondary enuresis were not included in the study.

RESULTS AND DISCUSSION

Evaluating the duration of exclusive breastfeeding, 72% of the subjects of the EG and 42% of the CG had been breastfed for less than 4 months (p < 0.001) (Figure). In bivariate analysis, there was a strong association between symptoms of enuresis with a positive family history of enuresis and duration of exclusive breastfeeding (p < 0.001), and also association with full breastfeeding duration (p = 0.044), number of children (p = 0.045), and parents' education (p = 0.045). After logistic regression, primary enuresis continued to be associated with duration of exclusive breastfeeding and family history of enuresis. The proportion of children that had been exclusively breastfed for more than 4 months was significantly higher in the CG 58% (58/100) than in the EG 28% (28/100) (p < 0.001, OR 4.35, 95% CI 1.99-9.50).

CONCLUSIONS

This study confirmed the association between primary enuresis and various factors that have already been studied, with the addition of a new factor, duration of exclusive breastfeeding for less than 4 months, which is strongly associated with primary enuresis.

Tricyclic and related drugs for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) affects up to 20% of five year-olds and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Tricyclics have been used to treat enuresis since the 1960s.

OBJECTIVES

To assess the effects of tricyclic and related drugs compared with other interventions for treating children with enuresis.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (containing trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings), on 30 November 2015, and reference lists of relevant articles.

SELECTION CRITERIA

We included all randomised and quasi-randomised trials comparing a tricyclic or related drug with another intervention for treating enuresis. We also included combination therapies that included tricyclics. We excluded trials for treating daytime wetting.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the quality of the eligible trials, and extracted data. We settled differences by discussion with a third review author.

MAIN RESULTS

Sixty-four trials met the inclusion criteria, involving 4071 children. The quality of many trials was poor, with comparisons addressed by single studies. Minor adverse effects were common, and reported in 30 trials. These included dizziness, headache, mood changes, gastrointestinal discomforts and neutropenia. More serious side-effects can occur but were not reported. Seven trials reported no adverse effects.Tricyclics are more effective than placebo, particularly for short-term outcomes. Compared to placebo, imipramine resulted in one fewer wet nights per week (mean difference (MD) -0.95, 95% confidence interval (CI) -1.40 to -0.50; 4 trials, 347 children), with fewer failing to achieve 14 consecutive dry nights (78% versus 95% for placebo, RR 0.74, 95% CI 0.61 to 0.90; 12 trials, 831 children). Amitriptyline and desipramine were more effective than placebo, but nortriptyline and mianserin showed no difference. Most tricyclics did not have a sustained effect after ceasing treatment, with 96% wetting at follow-up for imipramine versus 97% for placebo.Imipramine combined with oxybutynin is also more effective than placebo, with 33% failing to achieve 14 consecutive dry nights at the end of treatment versus 78% for placebo (RR 0.43, 95% CI 0.23 to 0.78; 1 trial, 47 children) and 45% wetting at follow-up versus 79% for placebo (RR 0.58, 95% CI 0.34 to 0.99; 1 trial, 36 children).There was insufficient evidence to judge the effect between different doses of tricyclics, and between different tricyclics. Treatment outcomes between tricyclic and desmopressin were similar, but were mixed when tricyclic was compared with an anticholinergic. However, when imipramine was compared with desmopressin plus oxybutynin (1 trial, 45 children), the combination therapy was more effective, with one fewer wet nights per week (MD 1.07, 95% CI 0.06 to 2.08) and 36% failing to achieve 14 consecutive dry nights versus 87% for imipramine (RR 2.39, 95% CI 1.35 to 4.25). Tricyclics were also more effective or showed no difference in response when compared to other drugs which are no longer used for enuresis.Tricyclics were less effective than alarms. Although there was no difference in the number of wet nights, 67% failed to achieve 14 consecutive dry nights for imipramine versus only 17% for alarms (RR 4.00, 95% CI 1.06 to 15.08; 1 trial, 24 children). Alarm therapy also had a more sustained effect after ceasing treatment with 100% on imipramine versus 58% on alarms wetting at follow-up (RR 1.67, 95% CI 1.03 to 2.69; 1 trial, 24 children).Imipramine was more effective than simple behavioural therapies during treatment, with one fewer wet nights per week compared with star chart plus placebo (MD -0.80, 95% CI -1.33 to -0.27; 1 trial, 250 children). At follow-up 40% were wet with imipramine versus 80% with fluids and avoiding punishment (RR 0.50, 95% CI 0.28 to 0.89; 1 trial, 40 children). However, imipramine was less effective than complex behavioural therapies, with 61% failing to achieve 14 consecutive dry nights for imipramine versus 33% for the three-step programme (RR 1.83, 95% CI 1.08 to 3.12; 1 trial, 72 children) and 16% for the three-step programme combined with motivational therapy and computer-led education (RR 3.91, 95% CI 2.30 to 6.66; 1 trial, 132 children) at the end of treatment, with similar results at follow-up.Tricyclics were more effective than restricted diet, with 99% failing to achieve 14 consecutive dry nights versus 84% for imipramine (RR 0.84, 95% CI 0.75 to 0.93; 1 trial, 147 children).There was insufficient evidence to judge the effect of tricyclics compared to the other miscellaneous interventions studied.At the end of treatment there were about two fewer wet nights for imipramine plus oxybutynin compared with imipramine monotherapy (MD -2.10, 95% CI -2.99 to -1.21; 1 trial, 63 children) and 48% on imipramine plus oxybutynin failed to achieve 14 consecutive dry nights compared with 74% on imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.92; 2 trials, 101 children). At follow-up, 45% on imipramine plus oxybutynin were wetting versus 83% on imipramine monotherapy (RR 0.55, 95% CI 0.32 to 0.92; 1 trial, 36 children).When imipramine combined with desmopressin was compared with imipramine monotherapy, there was no difference in outcomes. However, when imipramine plus desmopressin was compared with desmopressin monotherapy, the combination was more effective, with 15% not achieving 14 consecutive dry nights at the end of treatment for imipramine plus desmopressin versus 40% for desmopressin monotherapy (RR 0.38, 95% CI 0.17 to 0.83; 1 trial, 86 children). Tricyclics combined with alarm therapy were not more effective than alarm monotherapy, alarm combined with desmopressin or alarm combined with nortriptyline. The addition of a tricyclic to other behavioural therapies did not alter treatment response.

AUTHORS' CONCLUSIONS

There was evidence that tricyclics are effective at reducing the number of wet nights during treatment, but do not have a sustained effect after treatment stops, with most children relapsing. In contrast, there was evidence that alarm therapy has better short- and long-term outcomes. There was some evidence that tricyclics combined with anticholinergics may be more effective that tricyclic monotherapy.

Influence of Orthodontic Rapid Maxillary Expansion on Nocturnal Enuresis in Children

BACKGROUND

The etiology of nocturnal enuresis (NE) is multifactorial and has not been fully explained yet. New ways of treatment are constantly being investigated, including the rapid maxillary expansion (RME).

METHODS

A total of 41 patients diagnosed with NE were divided into two experimental groups: A and B. Group A included 16 children who have been treated with RME. Group B comprised 25 children who have not undertaken orthodontic treatment. Children from both groups have been monitored in monthly intervals, during a 12-month period, towards the intensification of NE. The comparative analysis of both groups has been conducted after 3 years of observation.

RESULTS

Statistical analysis has shown a 4.5 times increase of the probability of reduction of NE in the case of the treated group in comparison with the group of children who have not undergone orthodontic treatment. Unfortunately, the chance of obtaining total dryness diminished proportionally to the higher degree of intensification of enuresis at the beginning of the test.

CONCLUSION

RME can constitute an alternative method of NE treatment in children, irrespective of the occurrence of upper jaw narrowing.

The Time of Spontaneous Resolution of Monosymptomatic Nocturnal Enuresis (MNE) Is Familial

PURPOSE

To investigate whether or not the age of spontaneous resolution of monosymptomatic nocturnal enuresis (MNE) was familial.

PATIENTS AND METHODS

A questionnaire was administered to more than 1,500 people, and 100 appropriate participants were identified from four referral hospitals. We included the participants who had MNE and whose parents also had MNE with spontaneous resolution. Then the association between the spontaneous resolution time of MNE in parents and that in their children was investigated.

RESULTS

The mean ages of spontaneous resolution were 10.7 (10-30 years), 9.4 (6-17 years) and 10.9 (6-18 years) in participants, their mothers and their fathers, respectively. According to the statistical analysis, there was a positive correlation between participants and both their mothers and fathers (p < 0.05). In addition, it was revealed that familial MNE history based on first- and second-degree relatives, in addition to their parents, was also associated with the increased spontaneous resolution age of MNE (p < 0.05). According to our results, gender and parents' education status were not statistically associated with the spontaneous resolution (p > 0.05).

CONCLUSION

As a conclusion, the age of spontaneous resolution of MNE is familial. Although the exact reasons of spontaneous resolution still remain a mystery; further genetic investigations may be able to resolve this mystery.

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.

Nocturnal enuresis

Nocturnal enuresis (NE) is increasingly seen as part of a heterogeneous phenomenon that at times will include daytime lower urinary tract symptoms such as urgency, frequency and wetting - with reduced bladder storage, usually due to an overactive bladder. In turn, these may be associated with constipation and/or faecal soiling. This paper discusses these considerations in the management of NE.

[Primary monosymptomatic enuresis: diagnostics and therapy]

Nocturnal enuresis is one of the most common problems in childhood. In this article a standardized terminology for basic diagnostics additionally to extended diagnostics will be presented. Depending on the findings a specialized therapy can be performed. Besides drug therapy with antidiuretic hormone (ADH) sleep arousal devices can be used and the combination of both approaches also shows excellent results. At the end of therapy a protracted withdrawal shows better results than abrupt cessation.

Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics)

BACKGROUND

Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 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. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis.

OBJECTIVES

To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi-randomised trials. The reference lists of relevant articles were also searched.

SELECTION CRITERIA

All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. 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 review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author.

MAIN RESULTS

A total of 40 randomised or quasi-randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials.For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights.Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects.

AUTHORS' CONCLUSIONS

There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials.

[Evaluation of anthropometric development in patients with enuresis]

INTRODUCTION

An epidemiological study was conducted to assess the anthropometric development in children diagnosed with primary monosymptomatic nocturnal enuresis, depending on the treatment option selected.

PATIENTS AND METHODS

A longitudinal series of cases including 548 children aged 5-10 years. Anthropometric parameters of children were assessed at diagnosis, and after one and two years of treatment.

RESULTS

Children with primary monosymptomatic nocturnal enuresis showed no anthropometric changes when their data were compared to the standard deviation score of height, weight, and body mass index (BMI). Overall, no changes were seen in the above mentioned parameters after two years of treatment for enuresis (except for a weight standard deviation score (SDS) decrease in boys). We only found a decrease in the size and weight in those children undergoing behavioral therapy with or without an alarm, findings that, given the limitations of the study, were not considered significant. The odds ratio for cure after one and two years of treatment was 1.41 (95% CI: 0.85-2.34) and 1.52 (95% CI: 0.86-2.70) for desmopressin (and watchful waiting) as compared to all other options.

CONCLUSIONS

In this study, children had SDS values of height, weight, and BMI similar to healthy children of the same age and sex before and after treatment for primary monosymptomatic nocturnal enuresis. Desmopressin appeared to increase the probability of cure after one and two years of treatment, however these data should be corroborated in future randomized clinical trials.

Behavioural genetics of childhood disorders

After a general introduction into genetic risk factors for child psychiatric disorders, four specific child psychiatric disorders with a strong genetic component, namely, Autism Spectrum Disorders, Attention Deficit / Hyperactivity Disorder, Nocturnal Enuresis, and obesity, are discussed in detail. Recent evidence of linkage, candidate gene, and genome-wide association studies are presented. This chapter ends with a prospectus on further research needs.

Complementary and miscellaneous 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 young adults.

OBJECTIVES

To assess the effects of complementary interventions and others such as surgery or diet on nocturnal enuresis in children, and to compare them with other interventions.

SEARCH METHODS

We searched PubMed (1950 to June 2010), EMBASE (1980 to June 2010), the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) (1984 to June 2010), Chinese Biomedical Literature Database (CBM) (1975 to June 2010), China National Knowledge Infrastructure (CNKI) (1979 to June 2010), VIP database (1989 to June 2010), and the reference lists of relevant articles, all last searched 26 June 2010. No language restriction was used.

SELECTION CRITERIA

All randomised or quasi-randomised trials of complementary and other miscellaneous interventions for nocturnal enuresis in children were included except those focused solely on daytime wetting. Comparison interventions could include no treatment, placebo or sham treatment, alarms, simple behavioural treatment, desmopressin, imipramine and miscellaneous other drugs and interventions.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

In 24 randomised controlled trials, 2334 children were studied, of whom 1283 received a complementary intervention. The quality of the trials was poor: 5 trials were quasi-randomised, 5 showed differences at baseline and 17 lacked follow up data.The outcome was better after hypnosis than imipramine in one trial (relative risk (RR) for failure or relapse after stopping treatment 0.42, 95% confidence interval (CI) 0.23 to 0.78). Psychotherapy appeared to be better in terms of fewer children failing or relapsing than both alarm (RR 0.28, 95% CI 0.09 to 0.85) and rewards (RR 0.29, 95%CI 0.09 to 0.90) but this depended on data from only one trial. Medicinal herbs had better results than desmopressin in one trial (RR for failure or relapse after stopping treatment 0.35, 95% CI 0.14 to 0.85). Acupuncture had better results than sham control acupuncture (RR for failure or relapse after stopping treatment 0.67, 95% CI 0.48 to 0.94) in a further trial. Active chiropractic adjustment had better results than sham adjustment (RR for failure to improve 0.76, 95% CI 0.60 to 0.95). However, each of these findings came from small single trials, and must be verified in further trials. The findings for diet and faradization were unreliable, and there were no trials including homeopathy or surgery.

AUTHORS' CONCLUSIONS

There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture, chiropractic and medicinal herbs but it was provided in each case by single small trials, some of dubious methodological rigour. Robust randomised trials are required with efficacy, cost-effectiveness and adverse effects clearly reported.

Family history of nocturnal enuresis and urinary incontinence: results from a large epidemiological study

PURPOSE

Nocturnal enuresis is a common, genetically heterogeneous disorder. Family, twin and segregation analyses have demonstrated a high heritability. Molecular genetic linkage studies have identified several loci on different chromosomes. Much less is known about the genetics of daytime urinary incontinence. In this study we identify familial patterns in a large, representative sample of children with nocturnal enuresis and daytime urinary incontinence.

MATERIALS AND METHODS

Participants were a cohort of more than 8,000 children enrolled in the population based Avon Longitudinal Study of Parents and Children, a prospective longitudinal study of an original birth cohort of nearly 14,000 children. Parents completed postal questionnaires asking about their own nocturnal enuresis and urinary incontinence. At the age of 7½ years extensive data on nocturnal enuresis and urinary incontinence of their children were obtained.

RESULTS

At the age of 7½ years the prevalence of nocturnal enuresis was 15.5%. Infrequent nocturnal enuresis affected 12.8% of children and severe nocturnal enuresis (2 or more episodes weekly) affected 2.6%. The prevalence of urinary incontinence was 7.8%, and 6.8% had infrequent and 1.0% had severe daytime urinary incontinence. Of the 11,650 mothers who provided data on their own nocturnal enuresis and urinary incontinence 8.8% had nocturnal enuresis and 0.7% had daytime urinary incontinence. Of the 7,897 fathers 9.6% had nocturnal enuresis and 0.3% had daytime urinary incontinence. There were significant associations between parental and child nocturnal enuresis, and parental and child urinary incontinence. Specifically the odds ratios for severe child nocturnal enuresis were 3.63 times higher in maternal and 1.85 times higher in paternal nocturnal enuresis. The odds ratios for severe child urinary incontinence were 3.28 times higher in maternal and 10.1 times higher in paternal urinary incontinence. The associations were less pronounced between parental nocturnal enuresis and child urinary incontinence, as well as between parental urinary incontinence and child nocturnal enuresis.

CONCLUSIONS

Formal genetic risks exist for nocturnal enuresis and urinary incontinence, especially in severe incontinence. The magnitude of effects for child nocturnal enuresis and urinary incontinence is comparable. While the heritability of nocturnal enuresis is well-known, the familiarity of urinary incontinence has been underestimated.

Rs 6313 polymorphism in 5-hydroxytryptamine receptor 2A gene association with polysymptomatic primary nocturnal enuresis

BACKGROUND

Tricyclic antidepressants (TCA) were used to treat nocturnal enuresis (NE) for decades of years although their real mechanisms are unknown. Recently, some case studies demonstrated the efficacy of selective serotonin reuptake inhibitors (SSRI) in the treatment of NE. Both TCA and SSRI have similar influences on serotonin transmission. This study was aimed at evaluating whether 5-hydroxytryptamine receptor 2A (5HTR2A) gene is associated with NE.

METHODS

We analyzed rs6313 polymorphism in 5HTR2A gene of 213 Taiwanese children (116 NE cases and 97 healthy control subjects) using polymerase chain reaction-restriction fragment length polymorphism.

RESULTS

There were no significant differences when comparing the genotypes and allelic frequencies of rs6313 polymorphism in 5HTR2A gene between patients with NE and control subjects. However, when subsequently comparing 5HTR2A genotypes and allelic frequencies in NE child with different phenotypes, genotypes TT and TC appeared higher risks of polysymptomatic NE compared with CC (odds ratio (OR)=10.71, 95% confidence interval (CI)=2.66-43.12; OR=2.68, 95% CI=0.67-10.75, respectively; P=0.0002); and allele T also revealed higher frequencies of polysymptomatic NE compared with allele C (OR=3.7, 95% CI=2.01-6.79, P=0.000015).

CONCLUSIONS

This is the first study that shows the association between 5HTR2A gene polymorphisms and polysymptomatic NE. These results provide further evidence suggesting that genetic variations at 5HTR2A may influence NE treatment response.

Correlations between enuresis in children and nocturia in mothers

OBJECTIVE

To demonstrate a relationship between enuresis and nocturia.

MATERIAL AND METHODS

The study investigated 250 mothers (average age 34.6 +/- 3.3 years) whose children attended the Department of Pediatrics of the Second University of Naples because they suffered from enuresis. Data were collected by self-reported questionnaire and personal interview. All women provided written informed consent with guarantees of confidentiality. Both the presence of nocturia in adulthood and enuresis in childhood were taken into account.

RESULTS

The overall prevalence of nocturia was 38% (n = 95). There was a history of childhood bedwetting in eight mothers (5%) without nocturia and in 61 mothers (65%) with nocturia; the difference was significant (chi(2) p < 0.01). Moreover, among the 110 enuretic children of nocturic mothers, 69 (62%) suffered from non-monosymptomatic nocturnal enuresis (NMNE), and 34 (56%) of their mothers suffered from NMNE in childhood. Nocturic mothers suffering from non-monosymptomatic enuresis during their childhood had offspring with a higher risk of developing non-monosymptomatic enuresis (odds ratio 4.3 95%, confidence interval 2.6-7.1, p < 0.01).

CONCLUSIONS

These findings enabled a close connection between nocturia in adulthood and enuresis in childhood to be hypothesized. Furthermore, this analysis provided evidence of the link between suffering from nocturia, and previously from enuresis, and having children affected by enuresis.

Nocturnal enuresis: a suggestive endophenotype marker for a subgroup of inattentive attention-deficit/hyperactivity disorder

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) and enuresis co-occur at a higher rate than expected; the cause for this is unclear.

STUDY DESIGN

Diagnostic and demographic variables were compared in 344 children ages 6 to 12 years, with and without enuresis, recruited in an ADHD genetic study. Sleep variables were investigated in a subgroup of 44 enuretic children with age- and sex-matched nonenuretic controls. The association of enuresis with single nucleotide polymorphisms located in regions reported in linkage with enuresis was explored.

RESULTS

The prevalence rate of nocturnal enuresis was 16.9% for the entire cohort. There were no differences in sex, age, socioeconomic status, intelligence quotient, medication treatment, or comorbidities. The enuresis group had a higher likelihood of inattentive symptoms than the nonenuretic group. Night wakings and ability of children to wake themselves in the morning were both significantly decreased in children with enuresis compared with control children in the Child Sleep Habits Questionnaire Night Wakings subscale. No significant association was found with chromosomal regions previously reported in linkage with enuresis.

CONCLUSIONS

Deficits in arousal may contribute to both enuresis and inattentive ADHD. Nocturnal enuresis may be a useful clinical marker in identifying a subgroup of the inattentive phenotype in ADHD genetic studies.

Prevalence of nocturnal enuresis, risk factors, associated familial factors and urinary pathology among school children in Iran

AIM

To estimate the prevalence of enuresis in school-age children in Iran and determine associated factors.

MATERIALS AND METHODS

A total of 7562 children, aged 5-18 years, enrolled in this cross-sectional study. Using a standard questionnaire, data on demographic characteristics, and familial and physical conditions were obtained from the parents by interview. The ICD-10 definition of enuresis was used. In the case of enuretics, a detailed history was taken, and physical and ultrasonographic examinations, urinalysis and urine culture were performed.

RESULTS

The overall prevalence of enuresis was 6.8%. A significant relationship was found between the prevalence of enuresis and age (P=0.001), educational level of parents (P=0.001), number of family members (P=0.028), positive family history of enuresis (P=0.001), parenting methods (P=0.001), and deep sleep (P=0.001). Birth weight (P=0.07), monthly income (P=0.322), employment status of parents (P=0.08), ethnic differences (P=0.09), delayed development (P=0.062), drinking (P=0.072) or urination habit before sleep (P=0.06), and stool incontinence (P=0.062) were not significantly associated with enuresis. Prevalence of urinary tract pathology was 2.9% in enuretics.

CONCLUSIONS

This study provides a quantitative estimate of the prevalence and main risk factors for enuresis in Iranian children.

Family and segregation studies: 411 Chinese children with primary nocturnal enuresis

BACKGROUND

The aim of the present paper was to determine the incidence of primary nocturnal enuresis (PNE) among relatives of Chinese children with PNE, the inheritance pattern, and to identify the characteristics of PNE with positive family history.

METHODS

From July 2003 to June 2004, an epidemiological survey on PNE children was carried out by self-administered questionnaires to parents of 5-18-year-old Chinese students in Henan Province, central China. A detailed family history was recorded in order to determine the presence of familial PNE as defined as any close relative with PNE beyond the age of 5 years.

RESULTS

The response rate was 88% (10 383/11 799), and 411 children (235 boys and 176 girls) with PNE were identified. A positive family history was found in 94 families (22.87%) of 411 probands with PNE, including 48.94% of fathers, 8.51% of mothers, 6.38% of both parents, 6.38% of the siblings and 29.79% of grandfathers or (and) mothers. Among the probands the ratio of male to female was 1.3:1 excluding sex-linked inheritance. Autosomal dominant inheritance was in 14.60%, and autosomal recessive inheritance was consistent in 1.46% of families. In PNE children with positive family history, the proportion of adolescents, with associated daytime symptoms, marked PNE and seeking professional help were significantly higher than those in PNE children without positive family history.

CONCLUSIONS

PNE has a significant family clustering, and all modes of inheritance can occur in different families on the basis of a formal genetic analysis. Those with positive family history often manifest marked PNE, and have daytime symptoms.

Prevalence and associated factors of enuresis in turkish children

OBJECTIVE

Enuresis, which is frequently diagnosed amongst schoolchildren, is an important psychosocial problem for both parents and children. In the present study we aimed to determine the prevalence and associated factors of enuresis in Turkish children and to identify common methods for its management.

MATERIALS AND METHODS

A cross sectional epidemiological study was performed among primary school children living in Ankara, Turkey. A self-administered questionnaire was prepared for this study and distributed to the parents of 1,500 schoolchildren whom aged 6-12 years.

RESULTS

Of the 1,500 questionnaires distributed, 1,339 (89%) were completed. The overall prevalence of nocturnal and diurnal enuresis were 17.5%(n=234) and 1.9% (n=25), respectively. Although male gender, low age, history of enuresis among parents, low educational level of the parents, deep sleep, increased number of siblings, increased number of people sleeping in the child's room, history of enuresis among siblings, poor school performance and history of recurrent urinary tract infections (UTI) were significantly associated with enuresis, but not with severe enuresis. The percentage of children with enuresis seen by physician for treatment was 17.2%. The most preferred treatment option for enuresis was medications (59.5%), whereas alarm treatment was the least preferred (2.4%).

CONCLUSIONS

Our results with enuresis prevalence and associated factors were comparable to other epidemiologic studies from various countries. Furthermore we demonstrated that families in Turkey do not pay sufficient attention to enuresis and most of enuretic children do not receive professional treatment.

The genetic basis of inherited primary nocturnal enuresis: A UAE study

OBJECTIVE

Nocturnal enuresis is defined as involuntary emptying of the bladder in the absence of an organic cause in a child aged 5 years or older. Primary nocturnal enuresis (PNE) is the term used if the child has never been dry. Of several factors implicated in the etiology of PNE, genetic factors appear to be the strongest. In about 75% of affected children, there is a strong family history. The purpose of this study was to examine the genetic basis of nocturnal enuresis among children in the United Arab Emirates (UAE).

METHODS

Chromosomes 12 and 13 were genotyped in all family members of 10 affected children in four large families. Linkage to earlier reported microsatellite markers on these two chromosomes was examined.

RESULTS

In the four families examined, we did not find evidence for linkage to the two loci reported previously.

CONCLUSIONS

Among UAE children examined, no linkage was found between PNE and the loci reported previously on chromosomes 12 and 13, indicating further genetic heterogeneity in PNE.

Attention-deficit/hyperactivity disorder (ADHD) as a risk factor for persistent nocturnal enuresis in children: a two-year follow-up study

AIMS

A previous prevalence study indicated that the prevalence of ADHD is highly increased in enuretic children. In the current 2-y follow-up study we investigate the relationship between both disorders further. Our goal is to determine whether the ADHD diagnoses can be reconfirmed and whether children with ADHD are more at risk for difficult-to-cure enuresis. Moreover, we explore the effect of medical enuresis parameters on the course of the voiding problem.

METHODS

Eighty-six children with enuresis were screened twice on the presence of ADHD with a 2-y interval. A multi-method, multi-informant assessment of ADHD was used, the child's medical file was consulted, and a parent questionnaire on the child's current voiding problems was completed.

RESULTS

Although 73% of all children with a 2-y-old diagnosis of ADHD still meet the disorder's criteria, only 66% of all subtype diagnoses can be reconfirmed. The odds that a child with ADHD still has voiding problems after 2 y are 3.17 times higher than for a child without ADHD. Although a slightly increased number of prescribed therapies in the ADHD group was noticed, no other significant differences in enuresis treatment methods were found between the groups. The medical parameters were not associated with treatment outcome.

CONCLUSION

Since 73% of ADHD diagnoses can be reconfirmed, the data suggest that the prevalence of the ADHD syndrome rather than reactive ADHD symptomatology is increased in enuretic children. Children with ADHD are at risk for persistent enuresis. Two-year-old medical enuresis parameters seem to have little effect on the current presence/absence of enuresis.

Epidemiology of enuresis among school-age children in Thailand

Enuresis is a very common developmental problem in young children. The aims of this study were to estimate the prevalence of enuresis in school-age children, to determine the factors associated with nocturnal enuresis, and to evaluate the parental strategies for managing enuresis. A randomly selected cross-sectional population-based study was conducted in eight elementary schools in Bangkok, Thailand. A total of 3453 parents of children aged 5 through 15 years completed the questionnaires. The overall response rate to the questionnaire was 70%. The prevalence of enuresis was 4.2% and that of nocturnal enuresis was 3.9%. The prevalence declined with increasing age from 10%, 5.3%, 3%, and 1.2% at ages 5, 7, 10, and 12 years, respectively. There was no enuretic child at ages 13 through 15 years. The prevalence of bed-wetting was slightly more frequent in females than males. Nocturnal enuresis was also found to be significantly associated with the history of encopresis and positive family history of enuresis. There was no significant associated with parental education, birth order, socioeconomic status, diaper use, toilet training, and behavioral and school problems. Behavioral techniques mostly used by parents for management of their children with bed-wetting were ensuring that the child voids before bedtime (72.9%), waking the child up at night to void (61.8%), and evening water intake restriction (28.5%). The overall prevalence rate of nocturnal enuresis in Bangkok school-age children is lower than that of many previous studies reported from other countries. The significant differences in the prevalence reported by other countries' studies attributed to the criteria selection for ranges of age, definition of enuresis, genetic predisposition, and traditional and cultural background.

Genetics of normal and pathological sleep in humans

The complexity of sleep-wake regulation, in addition to the many environmental influences, includes genetic predisposing factors, which begin to be discovered. Most of the current progress in the study of sleep genetics comes from animal models (dogs, mice, and drosophila). Multiple approaches using both animal models and different genetic techniques are needed to follow the segregation and ultimately to identify 'sleep genes' and molecular bases of sleep disorders. Recent progress in molecular genetics and the development of detailed human genome map have already led to the identification of genetic factors in several complex disorders. Only a few genes are known for which a mutation causes a sleep disorder. However, single gene disorders are rare and most common disorders are complex in terms of their genetic susceptibility, environmental factors, gene-gene, and gene-environment interactions. We review here the current progress in the genetics of normal and pathological sleep and suggest a few future perspectives.

Complementary and miscellaneous 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 young adults.

OBJECTIVES

To assess the effects of complementary interventions and others such as surgery or diet on nocturnal enuresis in children, and to compare them with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 22 November 2004), the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) (January 1984 to June 2004) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials of complementary and other miscellaneous interventions for nocturnal enuresis in children were included except those focused solely on daytime wetting. Comparison interventions could include no treatment, placebo or sham treatment, alarms, simple behavioural treatment, desmopressin, imipramine and miscellaneous other drugs and interventions.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

In 15 randomised controlled trials, 1389 children were studied, of whom 703 received a complementary intervention. The quality of the trials was poor: four trials were quasi-randomised, five showed differences at baseline and ten lacked follow up data. The outcome was better after hypnosis than imipramine in one trial (relative risk (RR) for failure or relapse after stopping treatment 0.42, 95% confidence interval (CI) 0.23 to 0.78). Psychotherapy appeared to be better in terms of fewer children failing or relapsing than both alarm (RR 0.28, 95% CI 0.09 to 0.85) and rewards (0.29, 95% 0.09 to 0.90) but this depended on data from only one trial. Acupuncture had better results than sham control acupuncture (RR for failure or relapse after stopping treatment 0.67, 95% CI 0.48 to 0.94) in a further trial. Active chiropractic adjustment had better results than sham adjustment (RR for failure or relapse after stopping treatment 0.74, 95% CI 0.60 to 0.91). However, each of these findings came from small single trials, and need to be verified in further trials. The findings for diet and faradization were unreliable, and there were no trials including homeopathy or surgery.

AUTHORS' CONCLUSIONS

There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture and chiropractic but it was provided in each case by single small trials, some of dubious methodological rigour. Robust randomised trials are required with efficacy, cost-effectiveness and adverse effects carefully monitored.

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.

Genes for normal sleep and sleep disorders

Sleep and wakefulness are complex behaviors that are influenced by many genetic and environmental factors, which are beginning to be discovered. The contribution of genetic components to sleep disorders is also increasingly recognized as important. Point mutations in the prion protein, period 2, and the prepro-hypocretin/orexin gene have been found as the cause of a few sleep disorders but the possibility that other gene defects may contribute to the pathophysiology of major sleep disorders is worth in-depth investigations. However, single gene disorders are rare and most common disorders are complex in terms of their genetic susceptibility, environmental effects, gene-gene, and gene-environment interactions. We review here the current progress in the genetics of normal and pathological sleep.

Enuresis prevalence and accompanying factors in schoolchildren: a questionnaire study from southeast Anatolia

INTRODUCTION

The aims of this study were to establish the prevalence of enuresis, to determine accompanying factors, and to identify common methods in the management of enuresis in Turkish children aged between 6 and 11 years living in eastern Anatolia.

METHODS

The parents of 3,527 schoolchildren aged between 6 and 11 years completed a self-administered questionnaire. The questionnaire asked about sociodemographic data, enuresis data, physical or psychological disorders, and family stressors. Descriptive statistics and chi2 test were used for data analysis.

RESULTS

The response rate was 88%. The overall prevalence of reported enuresis was 12.96%, and the prevalence of marked enuresis (at least weekly) was 9.8%. Enuresis was notably more common in boys (male:female ratio 1.6), and the prevalence rates decreased by age without gender bias. Of all enuretic children, 21% had also daytime bed-wetting. The rate of a positive family history was 42% for siblings only and 66% for the other family members. Significantly more of the dry children woke up spontaneously at night to void as compared with the enuretic children (p < 0.001). The parental concern level was not high, and only 15% of the children visited a physician for the management of enuresis. Low socioeconomic status, unfavorable perinatal or postnatal history, and unsatisfactory familial characteristics were significantly more frequent in the enuretic group (p < 0.05). The enuretic children had also higher rates of poor school performance and poor social adaptation as compared with nonenuretic children (p < 0.001).

CONCLUSIONS

These results suggest that the prevalence of enuresis in eastern Anatolia is similar to that reported from western Anatolia and from most other countries. Turkish families did not report a high-level concern about enuresis, and the problem was managed primarily within the family.

Childhood nocturnal enuresis: Developing a conceptual framework

Nocturnal enuresis has been described as the most prevalent and chronic of all childhood problems. The experience, particularly for the older child, can be extremely distressing and limiting. It is now thought that psychological distress (emotional, behavioural, and self-esteem) arises as a consequence of bedwetting, and reaches clinical importance in only a minority who are vulnerable. Many aetiological theories have been proposed with the cause of nocturnal enuresis now regarded as heterogeneous. Based on empirical findings, a new model, termed 'the three systems,' has facilitated a greater clinical understanding of the problem and identification of the appropriate intervention. The model proposes bedwetting results from excessive nocturnal urine production and/or nocturnal bladder overactivity coupled with an inability to arouse to bladder sensations. Effective treatment arises from identification of the child's particular need and application of the appropriate psychological and pharmacological approach. Treatment methods are reviewed in terms of the new model, the mode of action, effectiveness, and application in combination.

Practice parameter for the assessment and treatment of children and adolescents with enuresis

Enuresis is a symptom that is frequently encountered in child psychiatric evaluations. Careful assessment is required to identify specific urologic, developmental, psychosocial, and sleep-related etiologies. For most children with enuresis, however, a specific etiology cannot be determined. Treatment then involves supportive approaches, conditioning with a urine alarm, or medications--imipramine or desmopressin acetate. The psychosocial consequences of the symptom must be recognized and addressed with sensitivity during the evaluation and treatment of enuresis.

Nocturnal enuresis: medical management

Nocturnal enuresis is a problem that affects many children and their families. The etiology seems to be multifactorial and may include a combination of genetic factors,abnormal urodynamics, alterations in vasopressin secretion, sleep factors, psychologic factors, organic disease, and maturational delay. Generally, a complete history and physical examination, with a specific focus on the genitourinary, gastrointestinal, and neurologic systems, is all is that is needed in the evaluation of a patient with enuresis.Currently, the mainstays of medical therapy are DDAVP, imipramine, and oxybutynin. Medications can help to control the symptoms of enuresis, but they generally do not provide a cure; therefore, behavioral therapy is often recommended in conjunction with pharmacotherapy.

Treating Nocturnal Enuresis in Children

BACKGROUND

Childhood nocturnal enuresis (bedwetting) affects many families. Although it has a high rate of spontaneous remission, bedwetting may bring social and emotional stigma, stress, and inconvenience to both the child with enuresis and his or her family.

DESIGN

Summary of systematic reviews of treatment for nocturnal enuresis in children, published in the Cochrane Library, using evidence only from randomized and quasi-randomized trials to compare interventions. Interventions included behavioral, alarm, and pharmacologic treatments.

SETTING AND METHODS

Six Cochrane Reviews contributed evidence to this review: simple behavioral interventions, alarms, complex behavioral or educational interventions, desmopressin, tricyclics and related drugs, and other drugs.

SUBJECTS

The participants were children (usually up to the age of 16).

RESULTS

Much of the available evidence was of poor quality, and there were few direct comparisons between different types of intervention. Simple behavioral Interventions, such as reward systems, are widely used as standard first-line treatment, but they require a high level of parental involvement. There is currently little evidence to show that these interventions work, but they may be worth trying because they have only a few adverse effects. The use of an alarm intervention reduced nighttime bed wetting in a majority of children both during and after treatment. Overlearning or dry-bed training may reduce the relapse rate. Before embarking on alarm treatment, families need to be made aware of both the time and the high level of parental involvement necessary to attain success. Drug therapy, such as desmopressin and tricyclics, reduced the number of wet nights per week compared with placebo but only while the drug was used. Patients and their families need to be warned about possible side effects of some of the drugs.

CONCLUSIONS

Alarms are the most effective treatment for nocturnal enuresis in children, but desmopressin may be considered for temporary relief.