Diagnosis and management of nocturnal enuresis

Glucocorticoids coordinate the bladder peripheral clock and diurnal micturition pattern in mice

Peripheral clocks function to regulate each organ and are synchronized though various molecular and behavioral signals. However, signals that entrain the bladder clock remain elusive. Here, we show that glucocorticoids are a key cue for the bladder clock in vitro and in vivo. A pBmal1-dLuc human urothelial cell-line showed significant shifts in gene expression after cortisol treatment. In vivo, rhythmic bladder clock gene expression was unchanged by bilateral adrenalectomy but shifted 4 h forward by corticosterone administration at the inactive phase. Moreover, the bladder clock shifted 8-12 h in mice that underwent both bilateral adrenalectomy and corticosterone administration at the inactive phase. These mice showed decreases in the diurnal rhythm of volume voided per micturition, while maintaining diurnal activity rhythms. These results indicate that the diurnal rhythm of glucocorticoid signaling is a zeitgeber that overcomes other bladder clock entrainment factors and coordinates the diurnal rhythm of volume voided per micturition.

Evaluation of the influence of a history of childhood nocturnal enuresis on nighttime urinary frequency and the causes of nocturia in adults

OBJECTIVES

To examine whether a history of nocturnal enuresis affects nighttime urinary frequency and to evaluate nocturia etiologies in adults.

METHODS

A total of 143 participants with at least one episode of nocturia per night were included in this study. The self-reported questionnaire collected data on demographic characteristics, medical history, history of nocturnal enuresis in elementary school, lower urinary tract symptoms, and frequency-volume charts.

RESULTS

A history of nocturnal enuresis was observed in 52.4% of participants. However, night-time urinary frequency was significantly lower in participants with a history of nocturnal enuresis in elementary school than in those without such history. On multivariate analysis, a history of nocturnal enuresis was also negatively associated with nighttime urinary frequency (p<0.01). There was a collinearity effect between age and nighttime urinary frequency. A history of nocturnal enuresis did not affect the presence of nocturnal polyuria or overactive bladder in participants. However, sleep disturbances were fewer in participants with a history of nocturnal enuresis (odds ratio 0.404).

CONCLUSIONS

A history of nocturnal enuresis might be negatively associated with nighttime urinary frequency due to fewer sleep disturbances. Further, progression of nocturia may depend on conditions, such as age and acquired diseases.

Transition from Childhood Nocturnal Enuresis to Adult Nocturia: A Systematic Review and Meta-Analysis

Purpose

Current literature has suggested a relationship between nocturnal enuresis (NE) in childhood and the development of nocturia later in life as both disorders have similar underlying etiologies, comorbidities, and treatments. The objective was to synthesize the available evidence on the association between childhood NE and later presentation of nocturia.

Methods

PubMed, CINAHL, Scopus, and Google Scholar were searched for peer-reviewed studies published between January 1980 and April 2021. Case–control and cohort studies that reported on childhood NE and current nocturia were included. The PRISMA protocol was followed (PROSPERO ID: CRD42021256255). A random-effects model was applied to calculate the pooled odds ratio (OR) and 95% confidence interval (CI). Risk of bias was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria and with a funnel plot.

Results

Of the 278 articles identified, 8 studies met inclusion criteria. The 6 case–control and 2 prospective cohort studies resulted in a total sample size of 26,070 participants. In a random-effect pooled analysis, childhood NE was significantly associated with the development of nocturia (OR: 1.75, 95% CI: 1.11–2.40). Significant heterogeneity (I² = 92.7%, p < 0.01) was identified among the included studies, which was reflected in an asymmetrical funnel plot. NE and nocturia have similar underlying etiologies of hormonal abnormalities, sleep disorders, physiological disorders, and psychological disorders.

Conclusion

The history of childhood NE is significantly associated with nocturia later in life. The data in this meta-analysis support this transition and identify potential similarities between the two disorders. The sparse number of articles relevant to this topic is a strong indicator of the need for more work on this transition from childhood to maturity. More studies are warranted to further explore the association between NE and nocturia.

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.

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.

Prevalence of Sleep-Disordered Breathing in Children Referring for First Dental Examination. A Multicenter Cross-Sectional Study Using Pediatric Sleep Questionnaire

Background: Sleep-related breathing disorders (SRDB) are a group of pathological conditions characterized by a dysfunction of the upper airways. The value of SRDB's prevalence, in the pediatric population, ranges from 2 to 11% depending on the different methodologies used in measure and the difficulties in the diagnosis. The aim of this study was to assess the prevalence of SRDB using the Pediatric Sleep Questionnaire (PSQ). Methods: 668 patients were enrolled from the Department of Oral and Maxillo-Facial Sciences, Sapienza University of Rome, Italy and from the Unit of Integrated Pediatric Dentistry, University of Murcia, Spain. The questionnaires were administered to patients with no previous orthodontic and surgical treatment who attended on the first visit at the two units of pediatric dentistry. Data regarding general health status were extracted from the standard anamnestic module for first visit. Prevalence and logistic regression models were computed. Results: The ages ranged from 2 to 16 years old (average 7 years old). The prevalence of SRDB was 9.7% for the entire sample. The models showed a positive correlation between three variables (snoring, bad habits, and anxiety) and SRDB. Conclusions: The prevalence obtained demonstrates the relevance of sleep disorders in the pediatric population and highlights the central role of pediatric dentists in the earlier diagnosis of these disorders.

Circadian coordination of ATP release in the urothelium via connexin43 hemichannels

Day-night changes in the storage capacity of the urinary bladder are indispensable for sound sleep. Connexin 43 (Cx43), a major gap junction protein, forms hemichannels as a pathway of ATP in other cell types, and the urinary bladder utilizes ATP as a mechanotransduction signals to modulate its capacity. Here, we demonstrate that the circadian clock of the urothelium regulates diurnal ATP release through Cx43 hemichannels. Cx43 was expressed in human and mouse urothelium, and clock genes oscillated in the mouse urothelium accompanied by daily cycles in the expression of Cx43 and extracellular ATP release into the bladder lumen. Equivalent chronological changes in Cx43 and ATP were observed in immortalized human urothelial cells, but these diurnal changes were lost in both arrhythmic Bmal1-knockout mice and in BMAL1-knockdown urothelial cells. ATP release was increased by Cx43 overexpression and was decreased in Cx43 knockdown or in the presence of a selective Cx43 hemichannel blocker, which indicated that Cx43 hemichannels are considered part of the components regulating ATP release in the urothelium. Thus, a functional circadian rhythm exists in the urothelium, and coordinates Cx43 expression and function as hemichannels that provide a direct pathway of ATP release for mechanotransduction and signalling in the urothelium.

Enuresis and sleep disordered breathing: An old and new link

The causes of nocturnal enuresis (NE) are likely multifactorial. It has been related to several (urological-nephrological-hormonal) reasons but clear and univocal pathogenesis remains mostly undetermined. Sleep disordered breathing (SDB) is a syndrome of upper airway dysfunction that occurs during sleep and is characterized by snoring and/or increased respiratory effort secondary to increased upper airway resistance and pharyngeal collapsibility. Adenotonsillar hypertrophy is the main cause of SDB in children. To date, several studies have associated childhood NE with coexistent SDB. Adenotonsillectomy was successful for both SDB and NE in about half of patients. Unfortunately, practical consensus guidelines for the management of primary NE do not mention, or marginally concern, SDB in these children, particularly in those who have treatment resistance and comorbidities. The concerns regard the concomitant presence of two relatively frequent sleep disorders, raising the question whether they are really coincidental problems of childhood.

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.

Abnormal Neural Responses to Emotional Stimuli but Not Go/NoGo and Stroop Tasks in Adults with a History of Childhood Nocturnal Enuresis

Background

Nocturnal enuresis (NE) is a common disorder in school-aged children. Previous studies have reported that children with NE exhibit structural, functional and neurochemical abnormalities in the brain, suggesting that children with NE may have cognitive problems. Additionally, children with NE have been shown to process emotions differently from control children. In fact, most cases of NE resolve with age. However, adults who had experienced NE during childhood may still have potential cognitive or emotion problems, and this possibility has not been thoroughly investigated.

Methodology/Principal Findings

In this work, we used functional magnetic resonance imaging (fMRI) to evaluate brain functional changes in adults with a history of NE. Two groups, consisting of 21 adults with NE and 21 healthy controls, were scanned using fMRI. We did not observe a significant abnormality in activation during the Go/NoGo and Stroop tasks in adults with a history of NE compared with the control group. However, compared to healthy subjects, young adults with a history of NE mainly showed increased activation in the bilateral temporoparietal junctions, bilateral dorsolateral prefrontal cortex, and bilateral anterior cingulate cortex while looking at negative vs. neutral pictures.

Conclusions/Significance

Our results demonstrate that adults with a history of childhood NE have no obvious deficit in response inhibition or cognitive control but showed abnormal neural responses to emotional stimuli.

Task positive and default mode networks during a working memory in children with primary monosymptomatic nocturnal enuresis and healthy controls

BACKGROUND

Nocturnal enuresis is a common developmental disorder in children, and primary monosymptomatic nocturnal enuresis (PMNE) is the dominant subtype.

METHODS

This study investigated brain functional abnormalities that are specifically related to working memory in children with PMNE using function magnetic resonance imaging (fMRI) in combination with an n-back task. Twenty children with PMNE and 20 healthy children, group-matched for age and sex, participated in this experiment.

RESULTS

Several brain regions exhibited reduced activation during the n-back task in children with PMNE, including the right precentral gyrus and the right inferior parietal lobule extending to the postcentral gyrus. Children with PMNE exhibited decreased cerebral activation in the task-positive network, increased task-related cerebral deactivation during a working memory task, and longer response times.

CONCLUSION

Patients exhibited different brain response patterns to different levels of working memory and tended to compensate by greater default mode network deactivation to sustain normal working memory function. Our results suggest that children with PMNE have potential working memory dysfunction.

Connectome-Scale Assessments of Functional Connectivity in Children with Primary Monosymptomatic Nocturnal Enuresis

Primary monosymptomatic nocturnal enuresis (PMNE) is a common developmental disorder in children. Previous literature has suggested that PMNE not only is a micturition disorder but also is characterized by cerebral structure abnormalities and dysfunction. However, the biological mechanisms underlying the disease are not thoroughly understood. Graph theoretical analysis has provided a unique tool to reveal the intrinsic attributes of the connectivity patterns of a complex network from a global perspective. Resting-state fMRI was performed in 20 children with PMNE and 20 healthy controls. Brain networks were constructed by computing Pearson's correlations for blood oxygenation level-dependent temporal fluctuations among the 2 groups, followed by graph-based network analyses. The functional brain networks in the PMNE patients were characterized by a significantly lower clustering coefficient, global and local efficiency, and higher characteristic path length compared with controls. PMNE patients also showed a reduced nodal efficiency in the bilateral calcarine sulcus, bilateral cuneus, bilateral lingual gyri, and right superior temporal gyrus. Our findings suggest that PMNE includes brain network alterations that may affect global communication and integration.

Overactive bladder in adults with sickle cell disease

AIMS

To characterize the prevalence and impact of nocturnal enuresis and overactive bladder (OAB) symptomatology in the adult sickle-cell disease (SCD) population.

METHODS

We performed a single-center, cross-sectional study of adult SCD patients from October 2012 to February 2014, using the validated Pfizer OAB short form questionnaire and brief voiding history surveys. Patient responses and scores were compared to that of controls having normal or sickle cell trait hemoglobin genotypes.

RESULTS

A group of 239 SCD patients (116 males, 123 females) were compared with 104 normal and 57 sickle cell trait patients. Seven of 239 (2.9%) SCD patients compared to none of the 161 patients without SCD (P = 0.04) reported current nocturnal enuresis. The median age of nocturnal enuresis cessation was higher in SCD patients (12.0, IQR 9.0-15.0 years) compared to that of both normal (7.5, IQR 6.0-9.8 years) and sickle cell trait (7.5, IQR 6.0-8.8 years) groups (P < 0.0001). Ninety-three of 239 (38.9%) SCD patients compared to 17 of 104 (16.3%) normal and 11 of 57 (19.3%) sickle cell trait had scores indicating OAB symptomatology (P < 0.0001). Patients with SCD had higher OAB symptom severity and lower health-related quality of life (HRQL) scores compared to the normal and sickle cell trait groups (P < 0.0001 and P < 0.0001, respectively).

CONCLUSIONS

We demonstrate an elevated rate of nocturnal enuresis and OAB symptoms in the adult SCD population. An OAB phenotype may be an under-recognized complication of SCD irrespective of age. Neurourol. Urodynam. 35:642-646, 2016. © 2015 Wiley Periodicals, Inc.

Nocturnal enuresis and nocturia, differences and similarities - lessons to learn?

This review highlights the current views on and differences and similarities between nocturnal enuresis (NE) in children and nocturia in adults, which might be a guidance to elucidate the missing links in our knowledge. In both conditions, a genetic factor is suspected. Reduced bladder capacity and nocturnal polyuria are the main underlying lower urinary tract-related conditions. There is a link with sleep disorders, although it is not clear whether this is a cause or consequence. Physical and mental health are comprised in both conditions, however, in different ways. In NE, constipation and attention deficit disorder are the most important comorbidities and the effect on mental health and quality of life is mainly through the negative impact on self-esteem. In nocturia, cardiovascular disease and fall injuries are important comorbidities, mainly affecting the older nocturia population; personal distress and depression are consequences of the related poor sleep quality. For both conditions, treatment is often inadequate and a more individualized approach seems to be necessary. The main difference between NE and nocturia seems to be the difference in arousal to bladder stimuli, suggesting that sleep characteristics might be a key factor in these conditions.

Do rotational shifts affect micturition patterns in real practice? A pilot study in healthy, young female nurses

Purpose

Healthy, young individuals are known to exhibit circadian variation in urinary functions. However, the effects of chronic circadian disturbance on voiding functions are largely unknown. The present work compared the effects of rotational shifts on the micturition patterns of female nurses to that in female nurses with routine daytime shifts.

Methods

A total of 19 nurses without lower urinary tract symptoms who worked rotational shifts for an average duration of 2 years were recruited. A voiding diary was kept for 9 consecutive days, and the overactive bladder symptom score (OABSS) questionnaire was completed three times, starting 3 days before their night duties until 3 days after completion of their night duties. For comparison, seven nurses with regular shifts completed a 3-day voiding diary and the OABSS questionnaire.

Results

Female nurses working rotational shifts had lower overall urine production and had decreased urination frequency and nocturia than female nurses working regular shifts, even when the nurses who worked rotational shifts had a regular night's sleep for at least 7 days. Upon reinitiation of night duty, overall urine production increased significantly, with no significant changes in urgency and frequency. When these nurses returned to daytime duty, the volume of urine decreased but nocturnal urine production remained high, and the incidence of nocturia also increased significantly. However, the effects on OABSS score were not significant under the study design used.

Conclusions

Long-term rotational shifts resulted in adaptive changes such as decreased urine production and frequency in healthy, young female nurses. In addition, their micturition patterns were significantly affected by abrupt changes in their work schedules. Although working in shifts did not increase urgency or frequency of urination in healthy, young female nurses working rotational shifts for an average 2 years, large-scale studies are needed to systematically analyze the influence of shift work timings on micturition in humans.

Nocturnal enuresis: A topic review and institution experience

The objective is to provide a review of nocturnal enuresis (NE), including its epidemiology, etiology, pathophysiology, evaluation, and current management. We also set to provide further insight on the treatment of this condition from the experience derived from patients cared for at our tertiary-care institution. NE affects approximately 15% of all children at 5-year-old, affecting boys more frequently than girls. At our large university tertiary pediatric urology center, NE and incontinence, in general, is one the most common chief complaints prompting urologic care. In this review, we examine the condition in detail, highlighting specific goals of the initial evaluation and treatment. We contrast the commonly implemented treatment recommendations, available from the literature with strategies we have found valuable from our extensive experience in treating patients with this disorder. Using current urologic reference textbooks, book chapters, Medline, journal articles and reviews describing the many aspects of NE were reviewed in order to describe NE and the current practices at our institution. Although, this is not a systematic literature review, it includes relevant available research, institutional experience and urological expert opinion and current practices at a tertiary state health facility. The treatment of NE remains a challenge for many pediatricians and pediatric urologists. This likely stems from the multiple possible etiologies of the disorder. We have established a treatment algorithm at our institution, which we have found successful in the majority of our patients. This consists of starting patients on urotherapy, then offering both the enuresis alarm device and medication therapy as first line treatments, and finally adding anticholingerics for combination therapy. Our hope is with further research the treatment of NE will continue to improve.

Brain metabolite alterations in children with primary nocturnal enuresis using proton magnetic resonance spectroscopy

Nocturnal enuresis is a common developmental disorder in children; primary monosymptomatic nocturnal enuresis (PMNE) is the dominant subtype. Previous literature has suggested that the prefrontal cortex and the pons are both involved in micturition control. This study aimed to investigate the metabolic levels of the left prefrontal cortex and the pons in children with PMNE by proton magnetic resonance spectroscopy (1H-MRS). Twenty-five children with PMNE and 25 healthy children took part in our experiments. Magnetic resonance examinations were performed on a Siemens 3T Trio Tim scanner. For each subject, localized 1H-MRS was acquired from the left prefrontal cortex (mainly in brodmann area 9) and the pons with a point-resolved spectroscopy sequence with repetition time 2,000 ms, echo time 30 ms and 64 averages. The LCModel software package was used to analyze the MRS raw data, and two-sample t tests were used to determine significant differences between the two groups. The results revealed a significant reduction in metabolite to total creatine ratios of N-acetylaspartate (NAA/tCr) in the left prefrontal cortex and the pons for children with PMNE compared to healthy children. Our study suggests that metabolism is disturbed in the prefrontal cortex and the pons in children with PMNE, which may be associated with the symptoms of enuresis.

Long-term followup of children with nocturnal enuresis: increased frequency of nocturia in adulthood

PURPOSE

We investigated the long-term prognosis of a cohort of children with nocturnal enuresis, and identified the prevalence of nocturia and persistent comorbid symptoms.

MATERIALS AND METHODS

A questionnaire was sent to 1,265 patients treated for nocturnal enuresis during childhood at our university hospital. We used a validated tool, the International Consultation on Incontinence Modular Questionnaire on overactive bladder and urinary incontinence, to evaluate the presence of current urological symptoms. Participants were also asked about treatment received for nocturnal enuresis, and their medical files were analyzed.

RESULTS

A total of 516 patients (41%) returned the questionnaire. Mean age was 17 years, and 64% of patients were male. Current urgency, daytime frequency and urinary incontinence were reported by 17%, 8% and 25% of patients, respectively. During the period of nocturnal enuresis up to 60% of patients had concomitant daytime symptoms. Nocturia was reported by 182 participants (35%). Males comprised 56% of patients (101) with nocturia and 69% of patients (230) without nocturia. Prevalence of current daytime symptoms and incontinence was higher in patients with nocturia (p<0.001). Those with nocturia were older at resolution of nocturnal enuresis (p<0.001) and suffered more nonmonosymptomatic nocturnal enuresis (p<0.014).

CONCLUSIONS

About a third of patients experience nocturia, a fourth still report some kind of urinary incontinence, a fifth have regular urgency and a tenth have daytime frequency. Thus, resolution of nocturnal enuresis does not necessarily mean resolution of the underlying pathological condition. Some patients with nocturia who continue to suffer with bothersome symptoms might benefit from continuous treatment for the underlying condition.

Treatment response of an outpatient training for children with enuresis in a tertiary health care setting

PURPOSE

To evaluate treatment effectiveness for children with enuresis, according to the definitions of the International Children's Continence Society (ICCS, 2006).

MATERIAL AND METHODS

Children ≥6 years of age followed a 4-month outpatient treatment consisted of a visit during which history regarding enuresis was taken, causes were explained and therapeutic tips & tricks were discussed. All children received a booklet about enuresis and were trained with an alarm and/or pharmacological therapy. At baseline, 4, 10 and 16 months, the number of wet nights during the previous 28 days and the use of medication were assessed. Success of treatment was determined using ICCS definitions of treatment outcome.

RESULTS

66 children with enuresis were included (48 boys/18 girls) in this retrospective study. Mean age: 11(± 2.6) years. 91%(n = 60) of the children had non-monosymptomatic enuresis. Results at 4 months: 46% full, 15% good, 21% partial response (n = 66). At 10 months: 55% full, 4% good, 29% partial response (n = 49). At 16 months: 53% full, 6% good, 25% partial response (n = 34). Overall, use of pharmacological therapy showed a decline in time.

CONCLUSION

According to the ICCS definitions, outpatient treatment for enuresis shows a good overall treatment response, and these results can be used to compare with other studies in the future.

Acompanhamento presencial e à distância para o tratamento da enurese noturna com alarme

A enurese é definida como a micção normal que ocorre durante o sono. Para o seu diagnóstico, são necessárias a idade mínima de cinco anos e frequência de pelo menos um episódio por mês. As causas mais consensuais são a poliúria noturna, dificuldades em despertar e a hiperatividade detrusora. O objetivo deste trabalho foi comparar crianças e adolescentes enuréticos que se submeteram ao tratamento com alarme, divididas entre dois protocolos de tratamento: presencial e à distância. Participaram do trabalho 61 crianças e adolescentes com idades entre seis e 17 anos e suas famílias. Todos participaram de duas sessões presenciais nas quais foram fornecidas informações sobre a enurese e o tratamento baseado no programa de espectro total. Os participantes foram alocados randomicamente entre protocolos de acompanhamento presencial (n=27) e à distância (n=34). Verificou-se que as crianças e adolescentes acompanhados à distância apresentam resultado comparável ao relatado na literatura, sendo uma alternativa viável ao acompanhamento presencial.

Changes in CT cerebral blood flow and volume associated with rapid maxillary expansion in a rabbit model

OBJECTIVE

To evaluate hemodynamic changes of the brain under the high forces of a rapid maxillary expansion (RME) appliance in a rabbit model.

MATERIALS AND METHODS

Twenty-four male New Zealand white rabbits were selected (12 weeks old, mean weight 3.01 ± 0.22 kg). A modified acrylic resin bonded RME appliance was used for expansion. A series of perfusion computed tomography examinations was performed before expansion (T0), on the fifth day of expansion (T1), at the end of the expansion process (T2), and after 10 days of retention (T3). Cerebral blood flow, cerebral blood volume, and mean transit time maps were recorded and parametrics evaluated. Statistical analyses were performed with analysis of variance with post hoc tests.

RESULTS

Mean cerebral blood flow showed an increase from T0 to T2 and then a decrease from T2 to T3, but the change was not statistically significant. Mean cerebral blood volume and mean transit time increased significantly from T0 to T2, and all perfusion parameters increased from T0 to T3.

CONCLUSIONS

RME is a safe orthopedic method despite the high expansion force. Perfusion computed tomography is effective for evaluating the hemodynamic changes of the brain caused by some orthopedic therapies. The increase in both cerebral blood volume and cerebral blood flow may help to explain why RME could alleviate the symptoms of enuretic children.

Involvement of urinary bladder Connexin43 and the circadian clock in coordination of diurnal micturition rhythm

Nocturnal enuresis in children and nocturia in the elderly are two highly prevalent clinical conditions characterized by a mismatch between urine production rate in the kidneys and storage in the urinary bladder during the sleep phase. Here we demonstrate, using a novel method for automated recording of mouse micturition, that connexin43 (Cx43), a bladder gap junction protein, is a negative regulator of functional bladder capacity. Bladder Cx43 levels and functional capacity show circadian oscillations in wild-type mice, but such rhythms are completely lost in Cry-null mice having a dysfunctional biological clock. Bladder muscle cells have an internal clock, and show oscillations of Cx43 and gap junction function. A clock regulator, Rev-erbα, upregulates Cx43 transcription as a co-factor of Sp1 using Sp1 cis-elements of the promoter. Therefore, circadianoscillation of Cx43 is associated with the biological clock and contributes to diurnal changes in bladder capacity, which avoids disturbance of sleep by micturition.

Changes in the brain microstructure of children with primary monosymptomatic nocturnal enuresis: a diffusion tensor imaging study

BACKGROUND

Primary monosymptomatic nocturnal enuresis (PMNE) is a common disorder in school-aged children. Previous studies have suggested that a developmental delay might play a role in the pathology of children with PMNE. However, microstructural abnormalities in the brains of these children have not been thoroughly investigated.

METHODOLOGY/PRINCIPAL FINDINGS

In this work, we evaluated structural changes in the brains of children with PMNE using diffusion tensor imaging (DTI). Two groups consisting of 26 children with PMNE and 26 healthy controls were scanned using magnetic resonance DTI. The diffusion parameters of fractional anisotropy (FA) and mean diffusivity (MD) were subjected to whole-brain, voxel-wise group comparisons using statistical parametric mapping (SPM). When compared to healthy subjects, children with PMNE showed both a decrease in FA and an increase in MD in the thalamus. MD also increased in the frontal lobe, the anterior cingulate cortex and the insula; these areas are all involved in controlling micturition. The significant changes seen in the thalamus could affect both urine storage and arousal from sleep.

CONCLUSIONS/SIGNIFICANCE

The microstructure abnormalities were observed in the thalamus, the medial frontal gyrus, the anterior cingulate cortex and the insula, which are involved in micturition control network. This indicates developmental delay in these areas may be the cause of PMNE.

Behavioral alarm treatment for nocturnal enuresis

PURPOSES

To investigate the efficacy of alarm treatment in a sample of Brazilian children and adolescents with nocturnal enuresis and relate treatment success to age and type of clinical support.

MATERIALS AND METHODS

During 32 weeks, 84 children and adolescents received alarm treatment together with weekly psychological support sessions for individual families or groups of 5 to 10 families.

RESULTS

71% of the participants achieved success, defined as 14 consecutive dry nights. The result was similar for children and adolescents and for individual or group support. The time until success was shorter for participants missing fewer support sessions.

CONCLUSIONS

Alarm treatment was effective for the present sample, regardless of age or type of support. Missing a higher number of support sessions, which may reflect low motivation for treatment, increased the risk of failure.