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

From Clinical Scenarios to the Management of Lower Urinary Tract Symptoms in Children: A Focus for the General Pediatrician

Lower urinary tract symptoms (LUTS) are a relevant problem in the pediatric population, having a very high prevalence. Diurnal incontinence and nocturnal enuresis are surely the most frequent symptoms, presenting, respectively, in up to 30% of school-age children and up to 10% of children between 6 and 7 years. Stypsis is the most common comorbidity, and it must be considered in the management of LUTS; indeed, the treatment of constipation is curative in most cases for both incontinence and enuresis. The presence or absence of diurnal symptoms in nocturnal enuresis and urgency in diurnal incontinence helps in the differential diagnosis. Urotherapy is always the first-line treatment, while oxybutynin and desmopressin (where appropriate) may help if the first-line treatment is unsuccessful. It is essential to identify conditions that are potentially dangerous for kidney and urinary tract well-being, for which LUTS can be the first manifestation. Starting from a series of clinical scenarios, we will underline the diagnostic clues behind LUTS in children and we will summarize clinical and surgical approaches for the proper management of these conditions.

Practical consensus guidelines for the management of enuresis

Despite the high prevalence of enuresis, the professional training of doctors in the evaluation and management of this condition is often minimal and/or inconsistent. Therefore, patient care is neither optimal nor efficient, which can have a profound impact on affected children and their families. Once comprehensive history taking and evaluation has eliminated daytime symptoms or comorbidities, monosymptomatic enuresis can be managed efficaciously in the majority of patients. Non-monosymptomatic enuresis is often a more complex condition; these patients may benefit from referral to specialty care centers. We outline two alternative strategies to determine the most appropriate course of care. The first is a basic assessment covering only the essential components of diagnostic investigation which can be carried out in one office visit. The second strategy includes several additional evaluations including completion of a voiding diary, which requires extra time during the initial consultation and two office visits before treatment or specialty referral is provided. This should yield greater success than first-line treatment.

CONCLUSION

This guideline, endorsed by major international pediatric urology and nephrology societies, aims to equip a general pediatric practice in both primary and secondary care with simple yet comprehensive guidelines and practical tools (i.e., checklists, diary templates, and quick-reference flowcharts) for complete evaluation and successful treatment of enuresis.

Evaluation of different modes of combined therapy in children with monosymptomatic nocturnal enuresis

OBJECTIVE

To evaluate the efficacy of different modes of combined therapy in children with monosymptomatic nocturnal enuresis (MNE).

PATIENTS AND METHODS

A randomized prospective study was performed to compare the order of two types of combined therapy in children with MNE. Group A was treated with primary desmopressin treatment that was combined with alarm treatment after 3 months, while group B was treated with primary alarm treatment that was combined with desmopressin after 3 months.

RESULTS

Within a period of 18 months, 43 previously untreated children fulfilled the inclusion criteria. Thirteen children achieved dryness after initial monotherapy or discontinued the study. Group A consisted of 16 children and group B of 14 children. After the standardized treatment course of 6 months, 11/16 children in group A and 11/14 children in group B became dry (<3 wet nights/month). Altogether, 22/30 (73%) children were dry after combined treatment, consisting of 12/18 boys and 10/12 girls. Of the children with a normal maximum voided volume, 79% (19/24) achieved dryness, whereas only three of six children with small maximum voided volumes became dry. In all, 13/19 (68%) children with nocturnal polyuria and nine of 11 without nocturnal polyuria became dry. Only one child relapsed (group A).

CONCLUSIONS

Combined therapy proved effective in children with MNE after 6 months, with no statistically significant differences between the two different orders of treatment.

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.

Refractory enuresis related to alarm therapy

OBJECTIVE

To clarify refractory enuresis related to alarm therapy, we evaluated the possibility of the prediction of refractory cases, the effectiveness of alarm therapy for cases refractory to pharmacotherapy and the prognosis of non-responders to alarm therapy.

METHODS

First, the effectiveness of alarm therapy in 55 monosymptomatic patients and 29 with daytime symptoms was evaluated. Next, another 37 patients with monosymptomatic nocturnal enuresis were treated by enuresis alarm. Possible predictive factors of therapeutic effect were compared between the 'effective' patients and the 'no-change' patients. The effectiveness of alarm monotherapy for non-responders to pharmacotherapy was evaluated. The prognosis of non-responders to alarm therapy at 6 months was also studied.

RESULTS

In the 55 monosymptomatic patients, the total effective rate at 3 months was 59%, while that in the 29 patients with daytime symptoms was only 38%. In the 37 patients with monosymptomatic nocturnal enuresis, there were no significant differences between the effective patients and the no-change patients in possible predictive factors. Even in patients who had previously had pharmacotherapy, the effective rate of alarm therapy was 64%, while it was 57% in patients without previous therapy. The effective rates of DDAVP and imipramine for non-responders to alarm monotherapy were only 25% and 33%, respectively.

CONCLUSION

Daytime symptoms were the only predictive factor of alarm therapy. Alarm therapy was effective for cases refractory to pharmacotherapy. Non-responders to alarm therapy were also refractory to pharmacotherapy.