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

Effectiveness of bladder retraining programme on bedwetting frequency and relapse rate of children with nocturnal enuresis

BACKGROUND OF THE STUDY

Nocturnal enuresis, or bedwetting, is a prevalent and emotionally challenging condition that has a significant impact on the behavior, psychological well-being, and social lives of school-aged children.

AIM

This study aimed to assess the effectiveness of bladder retraining programme on bedwetting frequency and relapse rate among children with nocturnal enuresis.

METHODS

The study was conducted in two phases. The Phase I included a survey questionnaire to identify the prevalence of nocturnal enuresis among school children studying in Grade I to Grade X of 3 selected schools in Nashik, India. Out of 2150 prevalence questionnaires, 1900 filled in questionnaires were received back. 226 children were found to be positive for monosymptomatic nocturnal enuresis. A total of 160 children were selected from which 80 samples were included in experimental group and 80 were in control group. A three-step bladder retraining program was provided for parents and children in the experimental group. The parents and children from experimental group were called on the 15th day to reinforce the interventions. Posttests were conducted at 1st month (Posttest I), 3rd month (Posttest II), and 6th month (Posttest III/Relapse) for both experimental and control group.

RESULTS

The total prevalence of nocturnal enuresis among 1900 school age children aged 6 years-15 years is found to be 11.89%. Out of the 226 enuretic children, majority 101 (44.69%) wet their beds 1-3 times per week while 48 (21.23%) children wet their beds Every night. Comparison of bedwetting frequency in both groups during Pretest, Posttest I, Posttest II and Posttest III using chi-square test showed that: In pretest there was no significant difference between children in experimental and control group as indicated by the non-significant P value 0.43. Whereas in posttest I, II & III, P value 0.001 indicates highly significant difference in bedwetting frequency of children in both the groups. Children in experimental group had a relapse rate of 3.75% and 100% relapse was observed in control group during posttest III (at 6th month).

DISCUSSION

The study findings revealed a statistically significant reduction in bedwetting frequency within the experimental group (p = 0.001), contrasting with the control group's non-significant change (p = 0.17). Additionally, the relapse rate was markedly lower in the experimental group (3.75%) compared to the control group (100%). This aligns with Garcia-Fernandez and Petros' (2020) findings, where a squatting-based pelvic floor rehabilitation method demonstrated a significant reduction in bedwetting frequency, curing 86% of children. Van Kampen et al.'s (2009) study also supported the efficacy of pelvic floor muscle training in reducing relapse rates, providing further validation for the current study's findings.

CONCLUSION

The 3 step bladder retraining programme was found to be very effective in reducing the bedwetting frequency and relapse rate among children. This study provides evidence supporting effectiveness of such tailored bladder retraining interventions in managing monosymptomatic nocturnal enuresis in school-aged children.

Autonomic nervous system dysregulation in children with monosymptomatic nocturnal enuresis

AIM

To investigate the role of autonomic nervous system in subpopulations of children with enuresis.

METHODS

We included 35 children with enuresis, divided in children with (17) and without nocturnal polyuria (18) and 43 healthy controls. For all participants hormones and neurotransmitters were measured. Patients and controls wore a sleep tracker device and children with enuresis underwent a 24 h blood pressure monitoring, nocturnal urine output measurement and uroflowmetry.

RESULTS

Children with enuresis had lower than controls copeptin and aldosterone, with the latter being more prominent in patients without nocturnal polyuria. Dopamine was lower in patients without nocturnal polyuria compared with patients with nocturnal polyuria. Children without polyuria experienced episodes only during NREM sleep, whereas in children with polyuria episodes occurred in both REM and NREM sleep. Children with enuresis experienced a non-dipping phenomenon during sleep which was more prominent in the group without polyuria.

CONCLUSION

In patients with nocturnal polyuria, nocturnal enuresis is associated with sympathetic hyperactivity which results in pressure polyuria and significantly lower systolic dipping during sleep. On the contrary, in children without nocturnal polyuria, it is mostly associated with bladder overactivity due to parasympathetic overstimulation as demonstrated by the NREM-related enuretic episodes and the lower aldosterone and dopamine levels.

Maternal Anxiety Associated with Nocturnal Childhood Enuresis

Introduction: Nocturnal enuresis is a common problem affecting 20% of 5-year-old children; its prevalence decreases with age. Nocturnal bedwetting in children younger than 5 is generally accepted by parents and society, but the expectation of parents is that children will achieve a higher degree of responsibility and increased control with age. Some studies have identified maternal distress as a factor associated with childhood urinary incontinence; specifically, maternal stress, maternal depression, and maternal anxiety. The aim of this study was to compare the degree of anxiety (trait and state) among mothers of children with nocturnal enuresis and mothers of healthy children. Methods: This was a prospective, cross-sectional, comparative study including two groups: a control group of 25 mothers of healthy children from open population, and an enuresis group of 25 mothers of children with nocturnal enuresis of the pediatric urology clinic of a third-level Mexican Hospital. STAI-T and STAI-S tests were performed and assessed blindly. Quantitative variables were compared using the Mann−Whitney U test, and qualitative determinations using a chi-square test or Fischer’s exact test. Results: The STAI-S and STAI-T tests results identified 14 (56%) mothers of enuretic children with moderate-to-severe trait anxiety versus 4 (16%) mothers from the control group and moderate-to-severe state anxiety in 23 (92%) of the mothers of enuretic children compared to 7 (28%) control-group mothers. The anxiety scores were significantly higher for the enuresis group for both tests: STAI-T: 53.00 ± 8.39 versus 41.52 ± 9.61 (p < 0.001) and STAI-S: 56.48 ± 6.83 versus 43.84 ± 10.57 (p < 0.001). Conclusion: Mothers of children with nocturnal enuresis present state anxiety ranging from moderate to severe. In clinical practice, our results indicate that the transitory emotion experienced by mothers of enuretic children cannot be neglected in an enuresis treatment program, state anxiety needs to be evaluated, and psychological interventions need to be implemented.

Current perspectives on the correlation of nocturnal enuresis with obstructive sleep apnea in children

BACKGROUND

Obstructive sleep apnea (OSA) and nocturnal enuresis (NE) are common clinical problems in children. OSA and NE are thought to be interrelated, but the exact pathophysiological mechanisms are not yet clear. This review aims to explain the possible pathogenesis of NE in children with OSA.

DATE SOURCES

We have retrieved all relevant original articles from Database that have been published so far, including the prevalence studies of NE and OSA in children, sleep characteristic studies that use polysomnography (PSG) to focus on children with NE, and studies on the relationship between OSA and NE.

RESULTS

Clinical studies have revealed that the risk of NE in children with OSA was increased compared with that of their healthy peers. This increased risk may be associated with sleep disorders, bladder instability, detrusor overactivity, nocturnal polyuria, endocrine and metabolic disorders, and inflammation.

CONCLUSIONS

Cardiopulmonary and renal reflex-induced neuroendocrine disorder may play an important role in the mechanism of NE in children with OSA, but this remains to be confirmed by animal studies. Other causes such as oxidative stress and inflammatory responses need to be further researched.

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.

Recent advances in managing and understanding enuresis

Enuresis, particularly in children during sleep, can be a debilitating condition, affecting the quality of life of the child and his or her family. The pathophysiology of nocturnal enuresis, though not clear, revolves around the inter-related mechanisms of overactive bladder, excessive nocturnal urine production, and sleep fragmentation. The first mechanism is more related to isolated nocturnal voiding, whereas the latter two are more related to nocturnal enuresis, in which circadian variations in arginine vasopressin hormone play a key role. A successful treatment would depend upon appropriately addressing the key factors precipitating nocturnal enuresis, necessitating an accurate diagnosis. Thus, advancements in diagnostic tools and treatment options play a key role in achieving overall success. This review summarizes recent advances in understanding the pathophysiology of nocturnal enuresis, diagnostic tools, and treatment options which can be explored in the future.

Desmopressin plus anticholinergic agent in the treatment of nocturnal enuresis: A meta-analysis

The present study aimed to evaluate the clinical efficacy and safety of combination therapy comprising desmopressin plus anticholinergic agent compared with desmopressin alone for children with nocturnal enuresis (NE). A meta-analysis of 8 eligible studies was performed to analyze the effects of desmopressin plus anticholinergic agent combination therapy and desmopressin monotherapy in the treatment of NE in children. The overall odds ratio (OR) or standardized mean difference (SMD) and 95% confidence interval were calculated for full responders (FR), partial responders (PR), non-responders (NR), the change in the mean number of wet nights and adverse events. Following 1 month of treatment, efficacy analysis yielded an OR of 3.736, which suggested that the proportion of FR for patients treated with the combination therapy was higher than that for patients treated with monotherapy. Analysis of the change in the mean number of wet nights yielded an SMD of 0.719, which indicated that the change in the mean number of wet nights in the patients treated with combination therapy was greater than that in the patients treated with monotherapy. Following 3 months of treatment, the OR calculated for FR plus PR compared with NR was 2.857, indicating that the proportion of FR and PR was elevated by the combination therapy compared with desmopressin alone. The OR for adverse events was 4.074, which suggested that the combination therapy did not lead to more adverse events in the treatment of NE. Therefore, the present meta-analysis suggests that, compared with desmopressin monotherapy, a combination therapy comprising desmopressin and anticholinergic agent is more effective with equivalent safety for children with NE.

Immediate 1-month efficacy of desmopressin and anticholinergic combination therapy versus desmopressin monotherapy in the treatment of pediatric enuresis: A meta-analysis

BACKGROUND

Several studies have proposed the combination of desmopressin and anticholinergic as a treatment regimen to address the pathophysiology of polyuria and bladder dysfunction in pediatric enuresis. However, the available literature is inconsistent with regards to the immediate 1-month efficiency of the combination therapy in the treatment for pediatric enuresis.

OBJECTIVE

The aim was to assess the immediate 1-month efficacy and safety of desmopressin and anticholinergic agent combination therapy versus desmopressin monotherapy in the treatment of pediatric enuresis using meta-analysis of randomized controlled trials (RCTs).

STUDY DESIGN

Systematic literature acquisition was carried out on electronic medical databases up to April 2015. RCTs relevant to the topic were critically appraised. Dichotomous data of the 1-month post-treatment response rate (defined as ≥90% reduction of wet nights) were extracted for calculation of the risk ratio (RR) and 95% confidence interval (CI). The Mantel-Haenszel method with the random effects model was used to pool effect estimates. Inter-study heterogeneity and publication bias were assessed. Subgroup analysis was done for the desmopressin treatment-naive versus treatment-resistant groups: PROSPERO (CRD42015017922).

RESULTS

Four RCTs of good methodological quality without heterogeneity were included for meta-analysis. The pooled effect estimates showed that combination therapy was associated with a significantly better immediate 1-month response rate than desmopressin monotherapy. Subgroup analysis showed a greater immediate 1-month response rate among desmopressin-resistant patients than treatment-naive patients. No severe adverse events were noted among combination therapy treated groups.

DISCUSSION

The limitation of the current meta-analyses is the small sample size, albeit with high-quality studies pooled for effect estimation. Despite the limitation, the study results were able to consistently illustrate a large treatment effect of combination therapy among desmopressin treatment-resistant patients. It was consistent with the literature review of retrospective and non-comparative studies by Alloussi et al. (2011), who summarized a similar impressive treatment outcome. However, due to the low level of evidence available at the time of their study, only a grade B-C recommendation was given to combination therapy as an approach for second-line treatment. This study also summarized that combination therapy was well tolerated and similar to desmopressin monotherapy.

CONCLUSION

This study was able to summarize the immediate 1-month efficacy of combination therapy compared with desmopressin monotherapy in the treatment of pediatric enuresis. For both treatment-naive and desmopressin-resistant pediatric enuresis, combination therapy of desmopressin with an anticholinergic agent is well tolerated and resulted in a significantly better immediate 1-month response rate than desmopressin monotherapy.

Prevalence and risk factors of monosymptomatic nocturnal enuresis in Turkish children

Objectives

To determine the prevalence of primary monosymptomatic nocturnal enuresis (PMNE) and assess risk factors that can cause this disease.

Methods

After the determination of 15 primary schools in the provincial center of Ankara, questionnaires were given to 15,150 students to be answered by their parents. Detailed urologic history was obtained and physical examination applied to the students whose parents answered the questionnaire. After excluding children with polysymptomatic NE, 14060 questionnaires of MNE patients were evaluated. Demographic features with social and medical history of students and their parents, general approach of family to the children, school success of the students and general behavioral attitudes, method of toilet training and the presence of nocturnal enuresis were questioned.

Results

MNE was determined in 9.0% (n: 1266) of the students and nocturnal enuresis frequency was higher in boys than girls (P<0.05). Univariate analysis revealed gender, method of toilet training, sleep problems, school success, and general approach of the family to children and general behavioral attitudes of the children as significant factors. In logistic regression analysis; age, male gender, toilette training with threatening method, deep sleeper, sleep walking, being introverted and shy, significantly increases the risk of nocturnal enuresis.

Conclusions

The current study suggests that the methods of toilet training are extremely important to prevent bedwetting and behavioral disorders due to enuresis. Parents should be well-informed about the appropriate toilet training method.

Desmopressin treatment regimens in monosymptomatic and nonmonosymptomatic enuresis: A review from a clinical perspective

OBJECTIVE

To evaluate outcomes of desmopressin treatment in monosymptomatic enuresis (ME) and nonmonosymptomatic enuresis (NME).

MATERIALS AND METHODS

PubMed was searched for all studies investigating enuresis, up to July 2009, in which desmopressin was administered alone or combined with other treatments. Each study was graded according to its respective level of evidence.

RESULTS

Altogether, 99 studies enrolling 7422 patients were identified as fulfilling the inclusion criteria. In 76 studies, desmopressin was administered as monotherapy; in 29 it was combined with other treatments such as antimuscarinics and enuresis alarm.

CONCLUSION

Studies incorporating a minor invasive versus a non-invasive diagnostic approach seem to achieve superior long-term success rates. Primary efficacy outcomes following desmopressin treatment are more favourable in ME than NME. Desmopressin administered with adjunct measures achieves superior outcomes compared to monotherapy, especially in NME. Compared to sudden withdrawal, the structured withdrawal programs show better long-term success and lower relapse rates. So far, no superiority has been shown for either time- or dose-dependent structured withdrawal programs. Most studies incorporated only small case series; only 25 studies with level of evidence 1 or 2 have been conducted. The broad range of mono- and adjunct treatments were evaluated according to the evidence based criteria recommended by the European Association of Urology.

Risk factors for nocturnal enuresis in school-age children

PURPOSE

Although nocturnal enuresis is common in children, its etiology is multifactorial and not fully understood. We evaluated potential risk factors for presence and severity of nocturnal enuresis.

MATERIALS AND METHODS

A validated, reproducible questionnaire was distributed to 8,230 school children in Sydney, Australia. Nocturnal enuresis was defined as any wetting in the previous month and categorized as mild (1 to 6 nights), moderate (7 or more nights but less than nightly) or severe (nightly).

RESULTS

Parents of 2,856 children (mean +/- SD age 7.3 +/- 1.3 years) completed the questionnaire (response rate 35%). Overall prevalence of nocturnal enuresis was 18.2%, with 12.3% of patients having mild, 2.5% moderate and 3.6% severe enuresis. Multivariate analysis showed that daytime incontinence (OR 4.8, 95% CI 2.9 to 7.9), encopresis (OR 2.7, 95% CI 1.6 to 4.4), bladder dysfunction (OR 3.6, 95% CI 2.4 to 5.3) and male gender (OR 2.0, 95% CI 1.3 to 3.1) were associated with severe nocturnal enuresis after adjustment for age. Emotional stressors (OR 2.3, 95% CI 1.2 to 4.2) and social concerns (OR 2.4, 95% CI 1.2 to 4.5) were associated with moderate nocturnal enuresis only.

CONCLUSIONS

Encopresis and daytime incontinence are significant modifiable risk factors for nocturnal enuresis. Expressed as population attributable risk, 23% of nocturnal enuresis is associated with encopresis and daytime incontinence. Psychosocial factors appear to contribute to moderate but not severe nocturnal enuresis.

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.

Primary monosymptomatic nocturnal enuresis in children and adolescents

Nocturnal enuresis (NE) is one of the most frequent paediatric pathologies. The prevalence of primary nocturnal enuresis (PNE) is around 9% in children between 5 and 10 years of age and about 40% of them have one or more episodes per week. Still for too long, PNE has not been recognised as a pathological condition, particularly by the medical community; as a consequence, there was no specific education at medical school, and a poor involvement by the practitioners. Enuretic children have a sense of social difference and isolation; some of them do express a low self-esteem. Also, self-esteem is improved by the management NE even if this management fails to cure the condition. Primary monosymptomatic nocturnal enuresis (PMNE) is an heterogeneous condition for which various causative factors have been identified such as: nocturnal polyuria, sleep disturbances, reduced bladder capacity or bladder dysfunction, upper airway obstruction. The positive diagnosis of PMNE is based on a complete questionnaire and a careful physical examination. A drinking and voiding chart is an essential non-invasive tool: first, to collect information about the initial drinking and voiding habits of the child, then to reassess the accuracy of the diagnosis. Only motivated patients should receive a specific treatment for their NE and the treatment should be proposed based on the type of PMNE. PMNE associated with nocturnal polyuria should be treated with desmopressin, which reduces nighttime urine production. For PMNE with a reduced bladder capacity alarms should be the first-line treatment. Oxybutinin, a drug with anticholinergic properties, is not theoretically indicated for the treatment of PMNE except for a very small subgroup of patients who have an overactive bladder only during sleep. In cases refractory to monotherapy, NE is probably the result of an association of different physiopathological factors (e.g. both a nocturnal polyuria together with a small bladder capacity) some of them are still unknown. In these patients, a combination of treatments may be more effective than monotherapy. Various combination therapies can be proposed to improve the cure rates.

Nocturnal enuresis at 7.5 years old: prevalence and analysis of clinical signs

OBJECTIVE

To determine the prevalence of nocturnal enuresis (NE) in a large cohort of children at 7.5 years old, and to examine the frequency of variables such as gender, severity, associated elimination problems, and clinical signs within the identified group.

SUBJECTS AND METHODS

Of an original cohort of 13 971 infants alive at 12 months, 11 251 who were still active in the Avon Longitudinal Study of Parents and Children (ALSPAC) survey, were followed at 91 months. The mother or main carer was given a questionnaire which asked, amongst other items, about the presence and frequency of bedwetting, other elimination problems, and signs related to the wetting behaviour; 8269 (73.5%) questionnaires were returned and 8151 contained information on the frequency of bedwetting.

RESULTS

In all, 1260 children (15.5%) at 7.5 years wet the bed, but most wet once or less a week, and only 215 (2.6%) met the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria of NE (wetting at least twice a week). A higher prevalence was reported in boys than girls and 266 children (3.3%) had both daytime wetting and bedwetting, with 189 (2.3%) having both daytime soiling and bedwetting. Daytime urgency increased with severity of bedwetting and occurred in 28.9% of children with NE.

CONCLUSION

At 7.5 years old the incidence of bedwetting is high, but only 2.6% of this large population-based sample wet at a frequency meeting the definition of NE. Although a small percentage of children had both daytime wetting and bedwetting, the evidence suggests that these are discrete problems. Amongst children with NE, indicators of bladder overactivity were present, supporting the view of heterogeneity and the importance of individual assessment in deciding on appropriate treatment.

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.