Treatment of childhood nocturnal enuresis: an examination of clinically relevant principles

[Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment]

Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment Abstract: Objective: Enuresis and daytime urinary incontinence are common disorders in children and adolescents and are associated with incapacitation and a high rate of comorbid psychological disorders. This interdisciplinary guideline summarizes the current state of knowledge regarding somatic and psychiatric assessment and treatment. We formulate consensus-based, practical recommendations. Methods: The members of this guideline commission consisted of 18 professional associations. The guideline results from current literature searches, several online surveys, and consensus conferences based on standard procedures. Results: According to the International Children's Continence Society (ICCS), there are four different subtypes of nocturnal enuresis and nine subtypes of daytime urinary incontinence. Organic factors first have to be excluded. Clinical and noninvasive assessment is sufficient in most cases. Standard urotherapy is the mainstay of treatment. If indicated, one can add specific urotherapy and pharmacotherapy. Medication can be useful, especially in enuresis and urge incontinence. Psychological and somatic comorbid disorders must also be addressed. Conclusions: The recommendations of this guideline were passed with a high consensus. Interdisciplinary cooperation is especially important, as somatic factors and comorbid psychological disorders and symptoms need to be considered. More research is required especially regarding functional (nonorganic) daytime urinary incontinence.

Clinical management of nocturnal enuresis

Nocturnal enuresis (NE) is a common health problem. Approximately 10% of 7-year-old children wet the bed regularly during sleep. Enuresis can be categorized into monosymptomatic (MEN) and nonmonosymptomatic (NMEN) forms. MEN occurs without any other symptoms of bladder dysfunction. NMEN is associated with dysfunction of the lower urinary tract with or without daytime incontinence. The rate of comorbid gastrointestinal, behavioral, and emotional disorders is elevated depending upon the subtype of NE. A careful clinical history is fundamental to the evaluation of enuresis. Diagnostic procedures include medical history and psychological screening with questionnaires, bladder and bowel diary, physical examination, urinalysis, ultrasound, and examination of residual urine. The mainstay of treatment is urotherapy with information and psychoeducation about normal lower urinary tract function, the underlying cause of MEN, disturbed bladder dysfunction in the child with NMEN and instructions about therapeutic strategies. Alarm therapy and the use of desmopressin have been shown to be effective in randomized trials. Children with NMEN first need treatment of the underlying daytime functional bladder problem before treatment of nocturnal enuresis. In patients with findings of overactive bladder, besides urotherapy, anticholinergic drugs may be useful.

Increased renal concentrating ability after long-term oral desmopressin lyophilisate treatment contributes to continued success for monosymptomatic nocturnal enuresis

OBJECTIVES

To investigate renal concentrating ability after long-term fast-melting oral desmopressin lyophilisate treatment in children with monosymptomatic nocturnal enuresis.

METHODS

The present retrospective study involved 58 children (43 boys, 15 girls; aged 6-12 years) with nocturnal enuresis receiving oral desmopressin lyophilisate. After treatment for 4 weeks with a complete response, patients were placed on a reduced dose of 120 μg on alternate days. Moring urine osmolality was measured using urine samples obtained after medication and non-medication dry nights. Patients who experienced ≥1 wet nights/month during alternate-day oral desmopressin lyophilisate treatment or within 6 months after its cessation were assigned to the relapse group, whereas those who experienced <1 wet night/month were assigned to the continued success group.

RESULTS

The continued success and relapse groups included 41 and 17 patients, respectively. The mean duration of treatment was 18.5 and 18.3 months in the continued success group and relapse group, respectively. There was no significant difference in morning urine osmolality after medication nights between the continued success and relapse groups; however, morning urine osmolality after non-medication nights was significantly higher in the continued success group than in the relapse group (P < 0.0001). Similarly, nocturnal urine volume was significantly higher in the relapse group than in the continued success group (P = 0.046).

CONCLUSIONS

These results suggest that patients receiving long-term oral desmopressin lyophilisate treatment develop increased nocturnal renal concentrating ability, which results in sustained dryness even after treatment cessation.

Structured desmopressin withdrawal improves response and treatment outcome for monosymptomatic enuretic children

PURPOSE

In this national, multicenter, retrospective survey we tested whether structured withdrawal of desmopressin, in which dose frequency rather than dose quantity was gradually decreased, would improve outcome.

MATERIAL AND METHODS

Enrolled in the study were 487 monosymptomatic enuretic patients from a total of 181 centers (The Enuresis Algorithm of Marschall Survey Group). At study outset 41% of patients had 7 wet nights per week, 45% had 3 to 6 and 14% had fewer than 3. All patients were treated with desmopressin, which was abruptly terminated or tapered with analogue by a structured scheme. Response rates were compared in the groups according to International Children's Continence Society guidelines.

RESULTS

The 173 children with abrupt termination had a 51% response rate, including a full and partial response in 44.1% and 27%, respectively, and no response in 22%. The 314 children with tapering had a 72% response rate, including a full and partial response in 66.8% and 24%, and no response in 4% (p <0.0001). Enuresis frequency with abrupt termination decreased from 21 wet nights per month before treatment to 6. The tapering group had 21 wet nights per months before and 2 after treatment (p <0.0001). Followup at 1 month showed fewer than 2 wet nights per month in 57% of cases with abrupt termination and in 80% with tapering (p <0.0001). Pretreatment had no influence. No severe side effects occurred.

CONCLUSIONS

This national, multicenter, retrospective analysis proves that antidiuretic treatment followed by a structured withdrawal program is superior to regular treatment with abrupt termination in enuretic children. Hence, desmopressin followed by structured withdrawal should be the standard. It is also superior to published outcomes of alarm treatment.

Investigating the three systems approach to complex childhood nocturnal enuresisMedical treatment interventions

OBJECTIVE

Nocturnal enuresis is a heterogeneous condition with various treatment options of both pharmacological and psychological origin. The three systems model previously proposed by us suggests a framework to facilitate understanding, identify a child's needs and specify the appropriate treatment option. In this study we sought to investigate the model in clinical practice in a group of children with severe nocturnal enuresis, with particular reference to pharmacological treatment.

MATERIAL AND METHODS

A total of 66 children were assessed using a schedule for identifying mono- and non-monosymptomatic nocturnal enuresis, and were administered either desmopressin (0.4 mg) or anticholinergic medication (5-10 mg), respectively. Children were assessed at 4 weeks, with those failing to meet the success criterion being offered combination treatment for a further 4 weeks.

RESULTS

Success rates for monotherapy were 49% and 33% for desmopressin and anticholinergic medication, respectively, with an overall success rate of 74.5%, including those who went on to combination treatment. Good clinical signs were identified for those successfully treated with anticholinergic medication.

CONCLUSIONS

This study endorses the three systems approach in clinical practice.

Exploring the differences between mono- and polysymptomatic nocturnal enuresis

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Enuresis alarm treatment

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Is second-line enuretic alarm therapy after unsuccessful pharmacotherapy superior to first-line therapy in the treatment of monosymptomatic nocturnal enuresis?

INTRODUCTION

We aimed at comparing the success rates of primary enuretic alarm therapy with those of secondary alarm therapy after failed pharmacotherapy in the treatment of monosymptomatic nocturnal enuresis (MNE).

PATIENTS AND METHODS

We randomly applied enuretic alarm therapy in 35 MNE patients (group 1) and desmopressin therapy in 49 MNE patients (group 2). The success and rebound rates after 3 and 6 months were determined. We also applied enuretic alarm therapy as a secondary treatment in 19 group 2 patients with complete rebound after 6 months (group 3). The success rates of patients who have received primary and secondary enuretic alarm therapy were compared.

RESULTS

The success rates for groups 1 and 2 were 82.65 and 81.63%, respectively (p = 0.885), at 3 months and 54.28 and 26.53%, respectively (p = 0.007), at 6 months. The success rates in group 3 were 84.21 and 52.63%, respectively, at 3 and 6 months. When these success rates were compared between groups 1 and 3, no statistically significant difference was found (p = 1.000).

CONCLUSION

Prior pharmacotherapy did not increase success rates of alarm therapy in our MNE patients.

Nocturnal enuresis: behavioral treatments

Nocturnal enuresis is a common problem. Physiologic and environmental factors are thought to have a role in the etiology and treatment of this condition. This article discusses the association between enuresis and behavioral or emotional problems. Common behavioral treatments are described, and evidence for their efficacy is reviewed. A brief discussion of hypnosis and acupuncture is included.

Enuresis alarm treatment as a second line to pharmacotherapy in children with monosymptomatic nocturnal enuresis

PURPOSE

We evaluate the effectiveness of enuresis alarm as second line therapy for partial or nonresponders to pharmacotherapy.

MATERIALS AND METHODS

We recommended enuresis alarm treatment for 67 partial or nonresponders to pharmacotherapy for monosymptomatic nocturnal enuresis. Of these patients 28 were evaluable by inclusion and exclusion criteria. We analyzed the effectiveness of enuresis alarm therapy using the response criteria defined by the reduction rate of wet nights, defined as complete response (greater than 90%), partial response (50% to 90%) and no response (less than 50%). We defined initial and lasting cure when patients showed persistent full response for 4 weeks and 6 months after cessation of all treatments, respectively.

RESULTS

After pharmacotherapy partial responders showed a mean response of 81.2%. On the other hand, nonresponders exhibited a mean response of 26.4% with more than 20 wet nights in 4 weeks. After using second line enuresis alarm treatment 90.5% (19 of 21) of partial responders became full responders and 71.4% (15 of 21), 61.9% (13 of 21) of partial responders showed initial and lasting cure, respectively. In addition, 71.4% (5 of 7) of nonresponders became full responders and 57.1% (4 of 7) exhibited initial and lasting cure.

CONCLUSIONS

Enuresis alarm as second line therapy for monosymptomatic nocturnal enuresis is effective for lasting cure as well as high initial full response rate in partial and nonresponders to pharmacotherapy. Therefore, enuresis alarm is a reasonable second line therapeutic option for partial or nonresponders to pharmacotherapy.

SODIUM FRACTION EXCRETION RATE IN NOCTURNAL ENURESIS CORRELATES WITH NOCTURNAL POLYURIA AND OSMOLALITY

PURPOSE

We verify the sodium fraction excretion rate (FE Na) and potassium fraction excretion (FE K) rates in monosymptomatic nocturnal enuresis. We also correlate FE Na and FE K to urinary osmolality, nocturnal polyuria and vasopressin in the same population.

MATERIALS AND METHODS

A total of 438 children 6 to 15 years old (mean age 9.7) presenting with monosymptomatic nocturnal enuresis were recruited from different centers. Inclusion criteria were 3 or greater wet nights a week, no daytime incontinence and no treatment in the previous 2 months. Exclusion criteria were cardiopathy, endocrinopathy, psychiatric problems and urinary tract abnormalities. Micturition chart, diurnal (8 am to 8 pm) and nocturnal (8 pm to 8 am) urine collection, including separate diuresis volumes, (Na, K and Ca) electrolytes and osmolality were evaluated, as well as serum electrolytes, creatinine and nocturnal (4 am) vasopressin. Diurnal and nocturnal FE K and FE Na were calculated. ANOVA test, chi-square test, Student's t test and Pearson correlation test were used for statistical analysis.

RESULTS

: Nocturnal polyuria (diurnal to nocturnal diuresis ratio less than 1) was found in 273 children (62.3%, group 1 and nocturnal urine volumes were normal in 165 with enuresis (37.7%, group 2). Nocturnal FE Na was abnormal in 179 children (40.8%), including 118 in group 1 (43.2%) and 61 in group 2 (36.9%) (chi-square not significant). FE Na was also increased in nocturnal versus daytime diuresis (Student's t test p <0.001). In group 1 nocturnal FE Na correlated with nocturnal diuresis (Pearson correlation p = 0.003, r = +0.175), while daytime FE Na and nocturnal FE Na correlated with diurnal diuresis (Pearson correlation p = 0.001, r = +0.225 and Pearson correlation p = 0.001, r = +0.209, respectively). In group 2 nocturnal FE Na did not correlate with diuresis (Pearson correlation p = 0.103, r = +0.128) but correlated with vasopressin values (Pearson correlation p = 0.042, r = -0.205). Urine osmolality was reduced in 140 children (31.9%) and correlated with nocturnal diuresis (Pearson correlation p = 0.003, r = -0.321). Vasopressin was decreased in 332 children (75.8%, 62.6% in group 1 and 13.2% in group 2). No significant difference was found between sexes and age of enuretic subgroups.

CONCLUSIONS

Nocturnal FE Na correlates with nocturnal diuresis, whereas daytime FE Na does not. FE K in daytime and nighttime diuresis does not statistically differ in nocturnal polyuric and nonpolyuric enuretic groups. Osmolality correlates with nocturnal diuresis, and vasopressin at 4 am was lower in the nocturnal polyuric group. The hypothesis of a subset of enuretic patients presenting with nocturnal polyuria associated with high nocturnal natriuria and low vasopressin values has been confirmed.

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.