Central nervous system processing of emotions in children with nocturnal enuresis and attention-deficit/hyperactivity disorder

Functional neuroimaging related to lower urinary tract sensations: Future directions for study designs and selection of patient groups: ICI-RS 2023

OBJECTIVES

Neuroimaging studies have advanced our understanding of the intricate central nervous system control network governing lower urinary tract (LUT) function, shedding light on mechanisms for urine storage and voiding. However, a lack of consensus in methodological approaches hinders the comparability of results among research groups and limits the translation of this knowledge to clinical applications, emphasizing the need for standardized methodologies and clinical utilization guidelines.

METHODS

This paper reports the discussions of a workshop at the 2023 meeting of the International Consultation on Incontinence Research Society, which reviewed uncertainties and research priorities to progress the field of neuroimaging in LUT control and dysfunction.

RESULTS

Neuroimaging holds great potential for improving our understanding of LUT control and pathophysiological conditions. To date, functional neuroimaging techniques have not yet achieved sufficient strength to make a direct clinical impact. Potential approaches that can improve the clinical utilization of neuroimaging were discussed and research questions proposed.

CONCLUSIONS

Neuroimaging offers a valuable tool for investigating LUT control, but it's essential to acknowledge the potential for oversimplification when interpreting brain activity due to the complex neural processing and filtering of sensory information. Moreover, technical limitations pose challenges in assessing key brain stem and spinal cord centers, particularly in cases of neurological dysfunction, highlighting the need for more reliable imaging of these centers to advance our understanding of LUT function and dysfunction.

Bladder-bowel interactions: Do we understand pelvic organ cross-sensitization? International Consultation on Incontinence Research Society (ICI-RS) 2018

AIMS

Mounting evidence from experimental animal and human studies suggests that cross-sensitization exists between different organs. Lower urinary tract (LUT) and bowel dysfunction commonly overlap, and the role of cross-sensitization between pelvic visceral organs is uncertain.

METHODS

At the International Consultation on Incontinence Research Society (ICI-RS) meeting in 2018, a panel of clinicians participated in a discussion on bladder and bowel interactions in the context of pelvic organ cross-sensitization.

RESULTS

Bladder and bowel problems commonly co-occur in adults and children across different disorders, and the mechanism responsible for overlapping dysfunction is uncertain in most instances. At a neuronal level, cross-sensitization occurs as a result of afferent signaling from the LUT and lower bowel through different central and peripheral mechanisms. Studies in animals and humans have demonstrated evidence for cross-organ sensitization following experimental inflammation or distension of the lower bowel, affecting the LUT. Nerve stimulation is an effective treatment for different functional LUT and bowel disorders, and whether this treatment may influence cross-organ sensitization remains uncertain. The role of physiologically dormant C-fibers, the bladder-gut-brain axis, and gut microbiome in cross-sensitization are speculative.

CONCLUSION

Recommendations for research were made to explore the role of cross-organ sensitization in the pathogenesis of co-occurring LUT and bowel dysfunction in humans.

Abnormal neural responses to emotional stimuli in children with primary monosymptomatic nocturnal enuresis

Nocturnal enuresis (NE) is a common disorder in school-aged children that has been reported to affect nearly 10% of 7-year-old children and affects both the children and their families. Previous studies have shown that the risk of psychosocial difficulties in children with enuresis is elevated. Thus, children with NE may experience negative effects on psychosocial health or emotion processing. Therefore, the aim of this study was to investigate the potential disturbance in emotional processing in children with NE using functional magnetic resonance imaging (fMRI). In this work, we used fMRI and an affective picture task to evaluate brain response changes in children with NE. Two groups, one consisting of 22 children with primary monosymptomatic NE and one with 23 healthy controls, were scanned using fMRI. Compared to the healthy subjects, children with NE mainly showed increased activation when viewing negative vs. neutral pictures in the bilateral medial superior frontal gyrus that extended to the anterior cingulate cortex. Our results demonstrated that children with primary monosymptomatic NE showed abnormal neural responses to emotional stimuli and overactivation in the medial prefrontal and anterior cingulate cortices suggested that children with primary monosymptomatic NE may be hypersensitive in their sensory perception of negative pictures.

Nocturnal enuresis in obese children: a nation-wide epidemiological study from China

Childhood obesity increases the risk of obstructive sleep apnea syndrome, type 2 diabetes mellitus, cardiovascular abnormalities, and psychological and behavioral disorders. But it is unclear whether obesity is associated with childhood nocturnal enuresis (NE). This study aimed to assess the relationship between childhood obesity and NE in a nationally representative large sample in China. Subjects were enrolled from Urumqi, Chengdu, Xi'an, Hohhot, Wuhan, Canton, Shanghai, and Harbin cities in China in November and December 2005. The survey included 20,987 children aged 5-12 years and they and their caregivers completed questionnaires. Height and weight were measured by school teachers trained in healthcare. According to the WHO child growth standards, obesity was defined as a body mass index >95th percentile of peers with the same age and gender. NE was defined as bed wetting for more than twice a week for 3 consecutive months. Demographic variables were compared among different groups. The prevalence of obesity, asthma, attention-deficit/hyperactivity disorder (ADHD), depressive moods, and snoring were different between the NE and without-NE groups (P < 0.05). The raw odds ratio (OR) for NE and obesity was 1.36 (95%CI = 1.07-1.74; P = 0.013) and the adjusted OR was 1.42 (95%CI = 1.11-1.82; P = 0.005) in the multivariable analysis. When adjusting for co-occurring conditions, the results showed that asthma did not affect the risk of NE (OR = 1.42, 95%CI = 1.11-1.82; P = 0.005), but ADHD (OR = 1.41; 95%CI = 1.10-1.81; P = 0.006) and depressive moods (OR = 1.34; 95%CI = 1.07-1.76; P = 0.012) slightly weakens the association between NE in children and obesity, while snoring weakens the association between obesity and NE and the risk became non-significant (OR = 1.21; 95%CI = 0.94-1.56; P = 0.138). In conclusion, obese children were at a higher risk of incurring NE compared to non-obese children. This association was weaker in children who either snored, had ADHD, or had depressive mood.

Retrospective evaluation of early risk factors in children with different types of micturition disorders

AIM

The aetiology of micturition disorders in children is multifactorial and still unclear. The perinatal factors may play a role in the development of children's urinary incontinence. We compared each type of micturition disorders in terms of length of gestation, birthweight, family history of bedwetting and delivery type.

METHODS

Data were from 488 patients of the Department of Pediatrics and Nephrology, Children's Clinical Hospital of the Medical University of Bialystok, and included: age, sex, clinical diagnosis, perinatal history, constipation, history of vesicoureteral reflux, family history of nocturnal enuresis, urodynamic diagnosis, bladder capacity. We performed statistical analysis using Mann-Whitney and Spearman tests.

RESULTS

Combined daytime-nocturnal incontinence made a higher percentage and nocturnal enuresis made a lower percentage of clinical diagnoses in children with low birthweight compared with group of normal birthweight. In children with micturition disorders, lower birthweight was associated with smaller bladder capacity than normal for age.

CONCLUSION

Low birthweight might predispose to combined daytime-nocturnal incontinence. We are the first to show that patients suffering from micturition disorders with low birthweight present lower estimated bladder capacity than age-matched children. Thus, we assume that low birthweight may have strong clinical relevance in children's micturition disorders.

Central Nervous System Processing of Emotions in Children with Fecal Incontinence and Constipation

OBJECTIVE

Fecal incontinence and constipation are common disorders in childhood. The enteric nervous system and the central nervous system are highly interactive along the brain-gut axis. The interaction is mainly afferent. These afferent pathways include centers that are involved in the central nervous processing of emotions as the mid/posterior insula and the anterior cingulate cortex. A previous study revealed altered processing of emotions in children with fecal incontinence. The present study replicates these results.

METHODS

In order to analyze the processing of emotions, we compared the event-related potentials of 25 children with fecal incontinence and constipation to those of 15 control children during the presentation of positive, negative, and neutral pictures.

RESULTS

Children with fecal incontinence and constipation showed altered processing of emotions, especially in the parietal and central cortical regions.

CONCLUSIONS

The main study results of the previous study were replicated, increasing the certainty and validity of the findings.

EEG Measurement of Emotion Processing in Children with Daytime Urinary Incontinence

OBJECTIVE

Daytime urinary incontinence (DUI) is common in childhood. The aim of the study was to neurophysiologically analyse the central emotion processing in children with DUI.

METHOD

In 20 children with DUI (mean age 8.1 years, 55 % male) and 20 controls (mean age 9.1 years, 75 % male) visual event-related potentials (ERPs) were recorded after presenting emotionally valent (80 neutral, 40 positive, and 40 negative) pictures from the International Affective Picture System (IAPS) as an oddball-paradigm. All children received a full organic and psychiatric assessment.

RESULTS

Children with DUI did not differ significantly from controls regarding responses to emotional pictures in the frontal, central, and parietal regions and in the time intervals 250-450 ms, 450-650 ms, and 650-850 ms after stimulus onset. The patient group had more psychological symptoms and psychiatric comorbidities than the control group.

CONCLUSIONS

EEG responses to emotional stimuli are not altered in children with DUI. Central emotion processing does not play a major role in DUI. Further research, including a larger sample size, a more homogeneous patient group (regarding subtype of DUI) or brain imaging techniques, could reveal more about the central processing in DUI.

Predictors and Outcomes of Childhood Primary Enuresis

OBJECTIVE

Although enuresis is relatively common in early childhood, research exploring its antecedents and implications is surprisingly limited, perhaps because the condition typically remits in middle childhood.

METHOD

We examined the prevalence, predictors, prognostic factors, and outcomes of primary enuresis in a large (N = 559) multi-method, multi-informant prospective study with a community-based sample of children followed from age 3 years to age 9 years.

RESULTS

We found that 12.7% of our sample met criteria for lifetime enuresis, suggesting that it is a commonly occurring childhood disorder. Males were more than twice as likely as females to have a lifetime diagnosis. Significant age 3 predictors of developing primary enuresis by age 9 included child anxiety and low positive affectivity, maternal history of anxiety, and low authoritative parenting. In addition, poorer global functioning and more depressive and anxiety symptoms at age 3 years predicted a greater likelihood of persistence through age 9. By age 9 years, 77% of children who had received a diagnosis of primary enuresis were in remission and continent. However, children who had remitted exhibited a higher rate of attention-deficit/hyperactivity disorder (ADHD) and greater ADHD and depressive symptoms at age 9 compared to children with no lifetime history of enuresis.

CONCLUSION

Results of the present study underscore the clinical significance of primary enuresis and demonstrate that it shows both strong antecedent and prospective associations with psychopathology. The findings also highlight the possible role of parenting in the development of enuresis.

Importance of neuropsychiatric evaluation in children with primary monosymptomatic enuresis

BACKGROUND

Nocturnal enuresis (NE) is an involuntary voiding during sleep. It is a very common disorder in school-age children. Comorbid psychopathologies are common in patients affected by enuresis. According to the ICCS, the rate of behavioral and emotional disorders in children with enuresis is doubled compared with healthy control (HC) children.

OBJECTIVE

The aim of the present study was to investigate the prevalence of neuropsychiatric comorbidities in children affected by NE.

STUDY DESIGN

Two hundred children with a diagnosis of enuresis were recruited from the Neuropsychiatric Unit of Catania University and 200 age-matched neurologically intact HC children were recruited from local schools. The inclusion criteria were a normal IQ and the absence of other pathological clinical conditions such as diabetes or kidney malformation. The exclusion criteria were failure to complete the initial evaluation or clinical/diagnostic procedures, inability (because of young age) to complete study questionnaires, and severe neurological or physical impairment.

RESULTS

Age and gender proportions were not significantly different between the groups. In the NE group, 138 subjects (69%) had a familial history of NE, compared with 24 subjects (12%) in the HC group (p < 0.01). The NE group demonstrated significantly higher scores in the Child Behavior Check List, Conners' Multidimensional Anxiety Scale for Children, and the Child Depression Inventory compared than the HC group as well as the Yale Global Tic Severity Score and Child-Yale-Brown Obsessive Compulsive Scale scores (p < 0.01). Quality of life scores were significantly lower in the NE group than in the HCs group; specifically, between-group differences were significant in the relationship and self domains (p > 0.01 for both comparisons) (Figure).

DISCUSSION

The present case-control study evaluates the prevalence of different neuropsychiatric comorbidities in children with NE as diagnosed according to the new ICCS criteria. An important finding was that neuropsychiatric conditions were more prevalent in NE patients than in age-matched HC subjects. To the best of our knowledge, this is the first study to report associations between enuresis and obsessive compulsive disorder as well as tic disorder, and is the first to describe the comparative psychopathological profiles of 200 children with enuresis and 200 matched HC children.

CONCLUSION

The results suggest that clinicians should not underestimate the effects of enuresis on psychosocial development. Childhood NE should be managed carefully and comprehensively in order to prevent the development of more serious behavioral problems in the future.

Voiding postponement in children-a systematic review

Voiding postponement (VP) has been defined as a habitual postponement of micturition using holding maneuvers. VP can represent both a symptom, as well as a condition. As divergent definitions are used internationally, the aim was to review the current state of knowledge on VP and provide recommendations for assessment, diagnosis and treatment. A Scopus and a Pubmed search was conducted, entering the terms 'voiding postponement' without any restrictions or specifications. Other publications relevant to the topic were added. VP can represent a symptom in healthy children. As a condition, VP in combination with nocturnal enuresis (NE) is a subtype of non-monosymptomatic NE. Most studies have focused on daytime urinary incontinence (DUI) with VP, or more aptly termed voiding postponement incontinence (VPI). It is a behaviorally defined syndrome, i.e., by the habitual deferral of micturition and DUI. VPI is associated with a low micturition frequency, urgency and behavioral problems. The most common comorbid disorder is oppositional defiant disorder (ODD). VP as a symptom and VPI as a condition should be differentiated. VPI is a common disorder with many associated problems and disorders. Urotherapy and timed voiding are the main treatment approaches. Due to the high rate of comorbid ODD, other forms of treatment, especially cognitive behavioral therapy, are often needed.

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.

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.

Comorbidity of ADHD and incontinence in children

ADHD and incontinence are common childhood disorders which co-occur at much higher rates than expected by chance. The aim of this review was to provide an overview both of the comorbidity of nocturnal enuresis (NE), daytime urinary incontinence (DUI) and faecal incontinence (FI) in children with ADHD; and, vice versa, of the co-occurrence of ADHD in children with NE, DUI and FI. Most clinical studies have focussed on the association of ADHD and NE. Population-based studies have shown that children with DUI have an even greater risk for ADHD than those with NE. While children with FI have the highest overall comorbidity rates of psychological disorders, these are heterogeneous with a wide range of internalising and externalising disorders--not necessarily of ADHD. Genetic studies indicate that ADHD and NE, DUI and FI do not share the same genetic basis. The comorbidity is conferred by non-genetic factors. Possible aetiological and pathogenetic links between ADHD and incontinence are provided by neurophysiological, imaging and pharmacological studies. The co-occurrence has clinical implications: children with ADHD and NE, DUI and FI are more difficult to treat, show lower compliance and have less favourable treatment outcomes for incontinence. Therefore, both groups of disorders have to be assessed and treated specifically.