Elevated sleep arousal thresholds in enuretic boys: clinical implications

Analysis of sleep pattern in patients with nocturnal enuresis: A prospective, observational, pilot study

PURPOSE

This study aimed to analyze the sleep patterns of patients with nocturnal enuresis (NE) using a wearable brain-wave-sensing device.

MATERIALS AND METHODS

We prospectively analyzed 10 of the 14 patients who visited the hospital for NE between August 2023 and July 2024 and agreed to participate in the study. Four patients were excluded owing to pairing errors and loss to follow-up. Participants were instructed to maintain a frequency volume chart for 1 week and sleep while wearing MUSE-S™, a wearable brain-wave detection device. We monitored the arousal threshold state based on sleep patterns when NE occurred in all patients.

RESULTS

The median age of the patients was 8.7 years (interquartile range, 7.0-10.6), and 4 patients (40.0%) were male. In all participants, non-rapid eye movement (NREM) deep sleep was the dominant stage in the early part of sleep, whereas NREM light sleep was dominant in the middle part. The arousal threshold was high in the early part of sleep and decreased toward the end. A poor response to enuretic alarms was observed when NE occurred during the NREM deep-dominant period. In contrast, a good response was observed when NE occurred during the NREM light-dominant period.

CONCLUSIONS

Differences in sleep stages influence the arousal threshold more than individual characteristics. To effectively manage the NE, focusing on the timing of urination is important in the latter part of the sleep period.

The Parasomnias

Parasomnias usually present in childhood and resolve spontaneously. The diagnosis of non-rapid eye movement-related parasomnias is mainly based on clinical descriptors and can be challenging. Rapid eye movement-related parasomnias may index an underlying psychiatric disorder. Even if benign, parasomnias can affect quality of life. Pediatricians and child psychiatrists should be familiarized with these sleep disorders and suggest adequate sleep hygiene, avoidance of sleep deprivation, and regular bedtimes even on weekends as the first step in management of these disorders. Clinicians should pursue the opportunity for tailoring treatments and consider referral to a sleep expert when indicated.

Sleep features of nocturnal enuresis: relationship between rapid eye movement sleep latency prolongation and nocturnal enuresis

Nocturnal enuresis, or bed wetting, is the involuntary urination during sleep. One of its causes is difficulty awakening during sleep, suggesting a relationship between Nocturnal enuresis (NE) and sleep. However, no studies have yet clarified the relationship between NE and sleep, and the effects of sleep structure in NE children are not yet known. Assuming that changes in sleep structure are related to NE, there would be a difference in sleep structure between days with and without NE. We measured the sleep electroencephalograms of 27 at home patients aged 6-16 years, evaluated the differences between days with and without NE, and examined the NE-associated sleep characteristics associated. The evaluation items were total sleep time, sleep efficiency, the ratio of rapid eye movement (REM) to non-REM sleep, REM sleep latency, and non-REM sleep latency. Factors influencing NE were examined by logistic regression analysis, with NE presence/absence as the dependent variable and each evaluation item as the independent variable. Given that 2-6 measurements were made for each patient, Generalized Estimating Equations was used in the analysis. NE positively correlated with prolonged REM sleep latency, but no significant differences were found in other sleep structures. A positive correlation exists between NE and prolonged REM sleep latency. Changes in sleep structure in the early stages of sleep may lead to increased nocturnal urine volume and increased NE frequency.

The effect of screen time on the presentation and treatment of primary monosymptomatic nocturnal enuresis

BACKGROUND

We aimed to investigate if there was any relationship between screen time (ST) and the severity of primary monosymptomatic nocturnal enuresis (PMNE) and treatment success.

METHODS

This study was conducted in urology and child and adolescent phsychiatry clinic in Afyonkarahisar Health Sciences University Hospital. After diagnosis patients were seperated by the ST for exploring causation. Group 1 > 120, Group 2 < 120 (min/day). For the the treatment response, patients were grouped again. Group 3 patients were administered 120 mcg Desmopressin Melt (DeM) and were requested < 60 min ST. Patients in Group 4 were given 120 mcg DeM solely.

RESULTS

The first stage of the study included 71 patients. The ages of the patients ranged from 6 to 13. Group 1 comprised 47 patients, 26 males and 21 females. Group 2 comprised 24 patients,11 males and 13 famales. Median age was 7 years in both groups. The groups were similar in respect of age and gender (p = 0.670, p = 0.449, respectively). A significant relationship was determined between ST and PMNE severity. Severe symptoms were seen at the rate of 42.6% in the Group 1, and at 16.7% in the Group 2 (p = 0.033). 44 patients completed the second stage of the study. Group 3 comprised 21 patients, 11 males and 10 females. Group 4 comprised 23 patients,11 males and 12 famales. Median age was 7 years in both groups. The groups were similar in respect of age and gender (p = 0.708, p = 0.765, respectively). Response to treatment was determined as full response in 70% (14/20) in Group 3 and in 31% (5/16) in Group 4 (p = 0.021). Failure was determined in 5% (1/21) in Group 3 and in 30% (7/23) in Group 4 (p = 0.048). Recurrence was determined at a lower rate in Group 3 where ST was restricted (7% vs. 60%, p = 0.037).

CONCLUSION

High screen exposure may be a factor for PMNE aetiology. And also reducing ST to a normal range can be an easy and beneficial method for treatment of PMNE. Trial Registration ISRCTN15760867( www.isrctn.com ). Date of registration: 23/05/2022. This trial was registered retrospectively.

A prospective and randomized study comparing the use of alarms, desmopressin and imipramine in the treatment of monosymptomatic nocturnal enuresis

BACKGROUND

Monosymptomatic enuresis (MNE) results from a pathogenic triad that may include lack of vasopressin secretion during sleep, reduced functional bladder capacity and inability to wake up during sleep. The treatment of MNE can be performed through behavioral therapy, use of alarms or medications such as desmopressin and imipramine.

OBJECTIVE

To compare the effectiveness of different treatments of MNE.

STUDY DESIGN

Prospective and randomized study comparing different intervention and a control group (receiving only behavior therapy) for MNE.

INCLUSION CRITERIA

age between 5 and 16 years old, with MNE, evaluated at the pediatric urology outpatient clinic of Hospital Infantil Menino Jesus. At first visit children were submitted to behavior therapy (urotherapy) for 3 months, children were subsequently characterized according to the ICCS as non-responders, partial responders, or full responders. Those partial responders or non-responders received a patient ID and were randomized to four groups: Alarm Group (G1), Desmopressin Group - DDAVP (G2), Imipramine Group (G3) and Control (G4). All groups were monitored monthly, for a period of 6 months. After 6 months, the children were reevaluated for MNE.

RESULTS

93 patients were enrolled. Mean age was 10.96 years with a standard deviation of 2.28 years, 59,1% were male. All groups had improvement in the number of dry nights (Table). Taking in account success the population full responders and partial responders: Alarm Group (G1) achieve success in 100% of cases, Desmopressin Group - DDAVP (G2) in 63.6% of cases, Imipramine Group (G3) in 73.7% of cases (Table 3). No drugs side effects were observed in both groups (G2 and G3), there was no dropout in patients who used alarms.

DISCUSSION

Our data suggests that the use of alarms is the most effective treatment of ENM with superior results when compared to imipramine and DDAVP. The small number of participants is a weakness of the study, as well as the lack of a voiding diary at the end of the study.

CONCLUSION

All therapeutics options utilized in the treatment of MNE are safe, effective and has a low rate of abandonment.

Incontinence and sleep disturbances in young children: A population-based study

Aims

Nocturnal enuresis (NE), daytime urinary incontinence (DUI), fecal incontinence (FI), as well as sleep and behavioral problems are common in young children. The aim of this study was to analyze the association of sleep and psychological parameters for all types of incontinence in a representative sample of young children.

Methods

Six hundred thirty eight (of 1161) children with a mean age of 5.9 years (50.9% boys) were assessed during their mandatory school entry examination. The participation rate was 55%. Instruments included the Strengths and Difficulties Questionnaire, the Children's Sleep Habits Questionnaire and other clinical questions. Incontinence was diagnosed according to ICCS standards. Constipation was assessed by two questions.

Results

17.1% of children had at least one type of incontinence, 14.8% had NE, 5.0% DUI, 2.1% FI, and 4.8% were constipated. 6.7% of children had clinically relevant psychological problems. 22.7% of children had sleep problems regularly (5−7 times/week). A wide variety of sleep problems were reported. Children with incontinence were not affected by a higher rate of sleep problems. Children with NE had fewer night wakings and those with constipation fewer parasomnias. Sleep and psychological problems were significantly associated, especially in children with DUI and FI.

Conclusions

Sleep and behavioral problems are common in young children. Psychological problems have a clear impact on sleep. Young children with incontinence do not have more sleep problems than continent children. Therefore, both sleep and psychological problems should be addressed in young children with incontinence.

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.

The Importance of Understanding Parental Perception When Treating Primary Nocturnal Enuresis: A Topic Review and an Institutional Experience

Primary nocturnal enuresis (PNE) is a common childhood disorder that adversely affects a child’s mental well-being and social life. Our clinical experience showed parents and their child often have significantly different perspective of enuresis, and these differences can affect family dynamics, treatment approaches, and treatment success. Parents’ perception of PNE also influences the likelihood of seeking medical treatment, and we found parents of children with enuresis have markedly different beliefs regarding bedwetting than those of physicians. Because achieving remission for PNE requires parents and their child to actively participate in treatment, assessing their expectancy of success and their beliefs will allow clinicians to adjust treatment goals as necessary. When treating PNE, guidelines consistently recommend incorporating bed alarms as part of the therapy. However, through interviewing parents and treating their children, we found parents preferred medications or other behavioral strategies, such as limiting water intake, because of their convenience. Many parents would complain bed alarms woke them up instead of their child, and they would soon give up on bed alarms. Part of assessing their beliefs includes assessing their confidence in their child being able to wake up to alarms and to persist with treatment. Understanding how they manage and approach setbacks will also determine the treatment modality suited for their child. In this review paper, we detailed our experiences interviewing parents and treating their child with NE with urodynamics and medications at the Changhua Christian Hospital in Taiwan.

Desmopressin response in nocturnal enuresis without nocturnal polyuria in Japanese children

OBJECTIVES

To evaluate whether the efficacy of desmopressin differs between patients with and without nocturnal polyuria.

METHODS

A total of 65 treatment-naïve children with monosymptomatic nocturnal enuresis were enrolled (45 boys; median age 8.9 years). Patients received desmopressin as their first-line treatment. Four different standards were used (Akashi and Hoashi >0.9 mL/kg/sleeping hour; Hamano >[age + 2] × 25 × 130% mL; the International Children's Continence Society >[age + 1] × 30 × 130% mL; and Rittig >[age + 9] × 20 mL) to assess nocturnal polyuria. The effectiveness of desmopressin was compared between patients with and without nocturnal polyuria according to each standard. A response was defined as a reduction in wet nights of >50%.

RESULTS

The desmopressin treatment efficacy rate was 54% for polyuria and 67% for non-polyuria patients (P = 0.20), 45% for polyuria and 68% for non-polyuria patients (P = 0.08), 54% for polyuria and 59% for non-polyuria patients (P = 0.80), and 52% for polyuria and 61% for non-polyuria patients (P = 0.61), for the Akashi and Hoashi's, Hamano's, International Children's Continence Society and Rittig's standards, respectively.

CONCLUSIONS

No difference was observed in the short-term clinical efficacy of desmopressin regardless of the presence of nocturnal polyuria. Thus, this might be a feasible treatment option for patients with nocturnal enuresis without nocturnal polyuria.

Suvorexant improves intractable nocturnal enuresis by altering sleep architecture

Little is known about sleep-based approaches to the treatment of nocturnal enuresis (NE). This report is the first to describe the successful use of suvorexant, an orexin receptor antagonist, in a 12-year-old boy with intractable NE. With suvorexant, the frequency of NE gradually decreased from 14 of 14 days (100%) to 5 of 14 days (35.7%). Sleep polysomnography indicated that rapid eye movement (REM) sleep increased from 101.5 min (19.9%) before suvorexant to 122.1 min (24.9%) with suvorexant. Furthermore, N2 increased from 233 min (45.6%) to 287.5 min (58.7%) during non-REM sleep. In contrast, N3 decreased from 160 min (31.3%) to 65 min (13.3%) during non-REM sleep. Suvorexant appeared to lighten the depth of sleep and alter sleep architecture. Although the application of an insomnia medication for treating NE seems paradoxical, suvorexant reduced the frequency of NE in patients with severe intractable NE. Thus, this treatment strategy warrants further examination.

The Parasomnias

Parasomnias usually present in childhood and resolve spontaneously. The diagnosis of non-rapid eye movement-related parasomnias is mainly based on clinical descriptors and can be challenging. Rapid eye movement-related parasomnias may index an underlying psychiatric disorder. Even if benign, parasomnias can affect quality of life. Pediatricians and child psychiatrists should be familiarized with these sleep disorders and suggest adequate sleep hygiene, avoidance of sleep deprivation, and regular bedtimes even on weekends as the first step in management of these disorders. Clinicians should pursue the opportunity for tailoring treatments and consider referral to a sleep expert when indicated.

Nocturnal enuresis in children: The role of arginine-vasopressin

Nocturnal enuresis is the involuntary pass of urine during sleep beyond the age of 5 years. It is a common condition in childhood and has an impact on the child's well-being. Research into the pathophysiology of the condition in the last decades has led to a paradigm shift, and enuresis is no longer considered a psychiatric disorder but rather a maturation defect with a somatic background. An excess urine production during sleep is a common finding in children with enuresis and disturbances in the circadian rhythm of arginine-vasopressin (AVP) is found in the majority of children with nocturnal polyuria. Children with enuresis and nocturnal polyuria lack the physiologic increase in AVP levels during sleep and treatment with the AVP analogue desmopressin can restore this rhythm and lead to dry nights. The reasons for this aberrant circadian AVP rhythm are not established. Furthermore, not all children with enuresis and nocturnal polyuria can be successfully treated with desmopressin suggesting that factors beyond renal water handling can be implicated such as natriuresis, hypercalciuria, and sleep-disordered breathing. The advances in the research of the genetic background of the condition may shed further light on the enuresis pathophysiology.

Sleep Monitoring of Children With Nocturnal Enuresis: A Narrative Review

The purpose of this article is to provide a succinct summary of the sleep monitoring efforts that have been used in nocturnal enuresis (NE) and an overview of the knowledge that has accrued. This is not intended to be a comprehensive review, but rather is intended to highlight how polysomnography (PSG), a common sleep detection tool, has contributed to our understanding of NE, as arousal disorder is considered to be one of the important mechanisms. The authors have organized this report by analysis and display of different ingredients of PSG, starting with comparing the electroencephalogram (EEG) of controls and the enuretic children and then moving to evaluation of respiratory patterns of NE and comorbid disease obstructive sleep apnea (OSA). In addition, the authors' goal is to better understand the mechanism of NE by integrating various levels of sleep monitoring; those sleep-related clinical scale scores for NE are presented to date. Finally, we propose further research of NE to explore the microstructure alterations via PSG combined with EEG-fMRI or to use novel technology like portable device internet and deep learning strategy.

Boxer Underwear Incorporating Textile Moisture Sensor to Prevent Nocturnal Enuresis

Around 15% of children still wet their bed after five years old. Although bedwetting alarms have proven to be effective to achieve nighttime dryness, they are cumbersome so children could be reluctant to use them. Therefore, the moisture sensor and wire were made unobtrusive by seamlessly integrated them into fully textile underwear by using conductive yarns. Consequently, the alarm acceptability should be enhanced by improving children’s comfort. Three conductive textile metallic yarns, made of silver or stainless steel, were considered to fabricate the urine leakage sensor. Silver-plated-nylon yarn, which showed the highest electrical conductivity, outperformed the stainless-steel yarns regarding its ability to detect urine leakage as well as its detection speed. Furthermore, it was proven to withstand multiple urine soakings and the following machine-washings, even at high temperature (60 °C). However, the electrical current, necessary to detect the leakage, tends to corrode the silver. Therefore, the detection circuit was adapted. Eventually, the designed leakage sensor was seamlessly integrated into a child’s trunk underwear, into which a miniaturized alarm can be plugged. The resulting textile underwear aims at replacing the rigid alarm system currently available, hence improving the quality of life of enuretic children and help them achieving nighttime dryness.

The prognostic value of voiding chart data in therapy-resistant enuresis

INTRODUCTION

The case history is the primary tool when investigating the enuretic child. To further determine whether nocturnal polyuria or detrusor overactivity is present, a full voiding chart, is the method of choice. However, there is no robust evidence that daytime voiding chart data actually do predict nocturnal detrusor function.

AIM

The aim of this study was to assess the predictive value of anamnestic data and the voiding chart in the treatment of children with therapy-resistant enuresis.

PATIENTS AND METHODS

The patients all suffered from enuresis resistant to first-line therapy. None of the children had daytime incontinence. In accordance with international recommendations, the children were first treated with anticholinergics. If the therapeutic effect was not satisfactory dosage was adjusted and desmopressin was added. If sufficient treatment effect was not achieved, antidepressant therapy was tried next, combined with desmopressin if needed. Since this was an evaluation of clinical practice, not a randomized trial, treatment success was graded according to family satisfaction, not the actual frequency of wet nights. Thus, only children who reported that they were completely dry were regarded as full responders and those who stated that there was a substantial and useful reduction of wet nights were labeled intermediate responders.

RESULTS

In total, 154 patients were included. Few and inconsistent differences were found between the groups responding or not responding to the various treatment regimens, and this was true both for anamnestic and voiding chart data (see Table). The only statistically significant findings were that responders to antidepressant therapy were older (p = 0.013) than non-responders, and patients who benefited from addition of desmopressin had a higher micturition frequency than those who did not (p = 0.027). The children who needed desmopressin as part of combination treatment to become dry did not have significantly higher nocturnal urine production than those who had no such benefit (p = 0.619). Neither the presence of urgency nor a history of previous daytime incontinence was significantly more common in children responding to anticholinergics (p = 0.375 and 0.072, respectively).

DISCUSSION

No clear and consistent differences in either anamnestic factors or voiding chart data were found between the patients responding or not responding to the various treatment regimens. Not even urgency could predict anticholinergic efficacy. Somewhat surprisingly, no association between nocturnal polyuria and desmopressin benefit was found.

CONCLUSION

In this study no prognostic value was found in anamnestic or voiding chart data in children with therapy resistant enuresis.

Management and treatment of nocturnal enuresis-an updated standardization document from the International Children's Continence Society

BACKGROUND

Enuresis is an extremely common condition, which, although somatically benign, poses long-term psychosocial risks if untreated. There are still many misconceptions regarding the proper management of these children.

AIM

A cross-professional team of experts affiliated with the International Children's Continence Society (ICCS) undertook to update the previous guidelines for the evaluation and treatment of children with enuresis.

METHODS

The document used the globally accepted ICCS terminology. Evidence-based literature served as the basis, but in areas lacking in primary evidence, expert consensus was used. Before submission, a full draft was made available to all ICCS members for additional comments.

RESULTS

The enuretic child does, in the absence of certain warning signs (i.e., voiding difficulties, excessive thirst), not need blood tests, radiology or urodynamic assessment. Active therapy is recommended from the age of 6 years. The most important comorbid conditions to take into account are psychiatric disorders, constipation, urinary tract infections and snoring or sleep apneas. Constipation and daytime incontinence, if present, should be treated. In nonmonosymptomatic enuresis, it is recommended that basic advice regarding voiding and drinking habits be provided. In monosymptomatic enuresis, or if the above strategy did not make the child dry, the first-line treatment modalities are desmopressin or the enuresis alarm. If both these therapies fail alone or in combination, anticholinergic treatment is a possible next step. If the child is unresponsive to initial therapy, antidepressant treatment may be considered by the expert. Children with concomitant sleep disordered breathing may become dry if the airway obstruction is removed.

Practical recommendations of the EAU-ESPU guidelines committee for monosymptomatic enuresis-Bedwetting

BACKGROUND AND AIMS

The objective of this update of the EAU-ESPU guidelines recommendations for nocturnal enuresis was to review the recent published literature of studies, reviews, guidelines regarding the etiology, diagnosis and treatment options of nocturnal enuresis and transform the information into a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist and urologist.

MATERIAL AND METHODS

Since 2012 a monthly literature search using Scopus® was performed and the relevant literature was reviewed and prospectively registered on the European Urology bedwetting enuresis resource center (http://bedwetting.europeanurology.com/). In addition, guideline papers and statements of the European Society for Paediatric Urology (ESPU), the European Association of Urology (EAU), the National Institute for Health and Care Excellence (NICE) and the International Children Continence Society (ICCS) were used to update the knowledge and evidence resulting in this practical recommendation strategy. Recommendations have been discussed and agreed within the working group of the EAU-ESPU guidelines committee members.

RESULTS

The recommendations focus to place the child and his family in a control position. Pragmatic analysis is made of the bedwetting problem by collecting voiding and drinking habits during the day, measuring nighttime urine production and identification of possible risk factors such as high-volume evening drinking, nighttime overactive bladder, behavioral or psychological problems or sleep disordered breathing. A questionnaire will help to identify those risk factors.

CONCLUSION

Motivation of the child is important for success. Continuous involvement of the child and the family in the treatment will improve treatment compliance, success and patient satisfaction.

Enuretic children have a higher variability in REM sleep when comparing their sleep parameters with nonenuretic control children using a wearable sleep tracker at home

PURPOSE

That children with nocturnal enuresis ("bedwetting") are deep sleepers is a fact that their parents often state when asking for advice. However, until today no clear difference in sleep has been observed between children who do and do not wet the bed. This study investigates the difference in sleep parameters and heart rate variability (HRV) between enuretic and control children in their home setting by using a wearable sleep tracker during a long observation period.

METHODS

Twenty-one enuretic and 18 control children, aged 6 to 12 years old, slept with a wearable sleep tracker device, a Fitbit Charge 2, for 14 consecutive days. In addition, nocturnal urine production (voided volumes and/or weight of the diaper) were measured. The HRV was calculated using the standard time and frequency domain parameters. The Kruskal-Wallis test was applied to evaluate the differences in the sleep and HRV parameters between both groups.

RESULTS

Compared with healthy controls, enuretic children showed a higher standard deviation (P = .0209) of minutes spent in rapid eye movement (REM) sleep among the different nights. In addition, they showed the tendencies to fewer awakenings (P = .1161), although this was not significant. Analyzing the wet nights of the enuretic children, they showed higher autonomic activity, lower sleep efficiency and a higher restlessness compared with their dry nights and to the control group.

CONCLUSION

This 2-weeks sleep-study, using a wrist-worn sleep tracker device Fitbit Charge 2, in the normal home environment has shown that enuretic children have a larger variation in their REM sleep and sleepless efficiently during a wet night when compared with non-bedwetting children.

The efficacy of electrical stimulation in treating children with nocturnal enuresis: A systematic review and meta-analysis

AIM

We performed a systematic review and meta-analysis to evaluate the efficacy of electrical stimulation (ES) in treating children with nocturnal enuresis (NE).

METHODS

Randomized controlled trials (RCTs) of the use of ES for the treatment of NE in children were searched using EMBASE, MEDLINE, and the Cochrane Controlled Trials Register. The references of related articles were also searched. The systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-analyses.

RESULTS

Four RCTs involving 171 patients were studied. We found that there was statistically significant difference in the wet nights per week (mean difference [MD], -0.70; 95% confidence interval [CI], -0.89 to -0.51; P < .00001), the number of patients with clinical response (MD, 26.88; 95% CI, 11.16 to 64.74; P < .00001), and bladder capacity (MD, -0.70; 95% CI -0.89 to -0.51; P < .00001) in the ES group compared with the placebo group with the exception of maximum voided volume (MVV) (MD, 19.48; 95% CI, -9.18 to 48.14; P = .18).

CONCLUSIONS

The study provides a significant improvement in statistics in the wet nights per week, the number of patients with clinical response and bladder capacity for children with NE compared with the placebo group with the exception of MVV.

Night-time diuresis pattern in children with and without primary monosymptomatic nocturnal enuresis

INTRODUCTION

Night-time polyuria as the dominating pathophysiological mechanism for primary monosymptomatic nocturnal enuresis (PMNE) has been put in question with nocturnal detrusor overactivity and high arousal thresholds as alternatives. An earlier finding of night-time polyuria in 12% of healthy non-enuretic schoolchildren underscores that excessive night-time diuresis per se is unlikely the major cause of PMNE.

OBJECTIVE

The objective of this study was to compare the night-time diuresis pattern in children with and without PMNE and to evaluate the role of night-time polyuria in provoking enuretic episodes in children with PMNE.

STUDY DESIGN

Night-time diuresis pattern was recorded in 27 children with PMNE, aged 6-15 years, and 29 non-enuretic children, aged 6-13 years. Using a portable ultrasound recorder, the bladder volume was estimated at 15-min intervals for at least three nights with the child sleeping in its own bed at home. The volume of enuretic episodes was controlled using preweighed diapers. All voids were registered by time and volume. Diuresis during night time was estimated from the slope of regression lines fitted to ultrasound recording points. Mean night-time diuresis was calculated from total urine production during the night and time interval from the last void before bedtime to the first morning void.

RESULTS

Night-time bladder filling pattern was recorded from 189 nights, giving 149 interpretable patterns for analysis (77 children with PMNE and 72 dry children). The night-time diuresis pattern was similar for children with or without PMNE, showing large variability between different nights of the same child. Most nights displayed a smooth bladder filling at constant low rate, whereas other nights showed an early phase with high diuresis followed by a longer period of low diuresis with no difference between the two groups.

DISCUSSION

Night-time diuresis has been non-invasively monitored in children while asleep in their own beds at home. The pattern of night-time diuresis varies considerably between different nights of the same child, with no obvious differences in any diuresis parameters between children with or without PMNE.

CONCLUSION

Non-enuretic children have similar diuresis pattern and maximal night-time diuresis values as children with PMNE, making it unlikely that PMNE is caused by night-time polyuria per se (Summary figure). Delayed maturation of sleep mechanisms such as decreased arousability or sleep inhibition of the micturition reflex is more likely to be the main etiology for enuresis.

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.

Evaluation of the effect of 3-month bladder basic advice in children with monosymptomatic nocturnal enuresis

INTRODUCTION

Advice (BBA) into the standards of patients' care in both monosymptomatic and non-monosymptomatic nocturnal enuresis. Although the idea of this recommendation was clear and reflects clinical experience, duration and efficacy have not been definitely established. Recent data have demonstrated the lack of efficacy of BBA and a fierce discussion has ensued. The present study was aimed to assess the efficacy of BBA in a group of previously untreated children with primary monosymptomatic nocturnal enuresis (MNE).

STUDY DESIGN

The study was a prospective interventional multicenter trial in a cohort of previously untreated MNE patients. Forty-nine children (36 males, 13 females, mean age 7.2 years) were included in the analysis. The treatment efficacy was assessed at the 30th, 60th, and 90th days of BBA.

RESULTS

We discovered that the mean number of wet nights decreased significantly (p < 0.001) only after 3 months of BBA from 8.9 to 5.9 episodes every 2 weeks. BBA was fully successful in 2% o the children after 30 day, 12% after 60 days, and 18% after 90 days (Figure). Partial response (by ICCS) was assessed for 8%, 20%, and 34% of the patients. We noted a relatively high rate of non-responders that decreased from 90% to 47% after 90 days. We detected no differences in BBA efficacy between children with night-time polyuria or decreased maximal voided volume. A lower number of wet nights initially predicted the response to the BBA.

DISCUSSION

Our study confirmed rather limited efficacy of BBA, similarly to previous observations, but provided more information on isolated MNE, because of a more specific study group and longer period of observation. The limitation of the study was lack of randomization.

CONCLUSION

Our study revealed that in treatment-naïve children with monosymptomatic enuresis basic bladder training had a low (18%) and late effect, mostly pronounced after the third month of therapy. It seems that only if the patient presents with a favorable profile of bedwetting, occasionally and with a high maximum voided volume, it is worth maintaining BBA for a longer period of up to 3 months before initiating second-line therapy. In an unfavorable initial profile desmopressin or an alarm may be introduced much earlier.

Sleep disordered breathing in enuretic children and controls

INTRODUCTION

Nocturnal enuresis and sleep disordered breathing are common childhood problems that are reported to be associated with each other. Sleep disordered breathing is often found in children with upper airway obstruction and, according to some studies, its presence is associated with an increased risk of nocturnal enuresis. Respiration during sleep in children with therapy-resistant enuresis, but no history of snoring or sleep apneas, has previously been investigated, and subclinical signs of disordered respiration were found in this group. However, sleep disordered breathing in enuretic children without a history of snoring or sleep apneas has not been thoroughly studied before.

AIM

To evaluate sleep disordered breathing in enuretic children and compare them with healthy control children.

SUBJECTS AND METHODS

Children aged 8-13 years with nocturnal enuresis were included. Exclusion criteria were: daytime incontinence, on-going anti-enuretic treatment, and concomitant urological, endocrinological, nephrological or psychiatric disorders. Twenty children (19 boys and 1 girl) suffering from therapy-resistant nocturnal enuresis, and 21 healthy controls (18 boys and 3 girls) underwent one night of polygraphic sleep registration focused on respiratory variables. The registration included electroencephalography as well as assessment of respiratory movements, nasal airflow and oxygen saturation; it was performed with a portable sleep device at the subjects' homes. In addition to this, OSA 18, a health-related quality of life instrument, was used to evaluate subjective issues related to sleep and breathing.

RESULTS

The mean apnea hypopnea index values were 0.96 ± 0.8 for the patient group and 0.46 ± 0.4 for the control group. The oxygen desaturation index was slightly higher for the children with nocturnal enuresis compared with the healthy controls (P = 0.05). No other differences were found in the respiratory variables. Both groups of children showed low levels of arousals (Summary Table). The enuretic children reported significantly more subjective sleep disturbances and a lower quality of life than their healthy peers.

DISCUSSION

This was the first controlled study of sleep disordered breathing in children with nocturnal enuresis. One limitation of the study was that some variables were known to be underestimated when scoring polygraphic data. The apnea hypopnea index was such a variable and was indeed lower than in a previous study.

CONCLUSION

No major differences in respiration during sleep were found between enuretic children and controls.

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.

Non-REM Sleep Instability in Children With Primary Monosymptomatic Sleep Enuresis

STUDY OBJECTIVES

Sleep enuresis is one of the most common sleep disturbances in childhood. Parental perception of deeper sleep in children with sleep enuresis is not confirmed by objective studies. However, evidence of disturbed sleep has been demonstrated by questionnaire, actigraphy, and polysomnographic studies, but no neurophysiological correlation with low arousability has been found. The goal of this study was to analyze the sleep microstructure of children with sleep enuresis using cyclic alternating pattern (CAP) analysis.

METHODS

Forty-nine children were recruited, 27 with enuresis (19 males and 8 females, mean age 9.78 years, 2.52 standard deviation) and 22 normal control patients (11 males and 11 females, mean age 10.7 years, 3.43 standard deviation); all subjects underwent clinical evaluation followed by a full-night polysomnographic recording. Psychiatric, neurological, respiratory, and renal diseases were excluded.

RESULTS

No differences in sex, age, and apnea-hypopnea index were noted in the patients with enuresis and the control patients. Sleep stage architecture in children with sleep enuresis showed a decrease in percentage of stage N3 sleep. CAP analysis showed an increase in CAP rate in stage N3 sleep and in phase A1 index during stage N3 sleep in the sleep enuresis group, but also a significant reduction of A2% and A3% and of phases A2 and A3 indexes, supporting the concept of decreased arousability in patients with sleep enuresis. The decrease of phase A2 and A3 indexes in our patients might reflect the impaired arousal threshold of children with sleep enuresis. Sleep fragmentation might result in a compensatory increase of slow wave activity (indicated by the increase of CAP rate in stage N3 sleep) and may explain the higher arousal threshold (indicated by a decrease of phase A2 and A3 indexes) linked to an increased sleep pressure.

CONCLUSIONS

The findings of this study indicate the presence of a significant disruption of sleep microstructure (CAP) in children with sleep enuresis, supporting the hypothesis of a higher arousal threshold.

Psychological and Physical Environmental Factors in the Development of Incontinence in Adults and Children: A Comprehensive Review

The aim of this review was to identify etiological environmental factors related to incontinence in children and adults. A variety of etiological environmental factors for the development of incontinence were identified. In children, these encompass stressful life events and trauma, family dysfunction, parental psychopathology, school-related stressors, toilet or "potty" training, fluid consumption habits, housing conditions, and the availability of toilets. In adults, physical exercise, obesity, working conditions, fluid intake, and the availability of toilets play a role. Intervening variables such as hormonal variations due to work shifts have also been identified as influencing the likelihood of incontinence. Current research suggests that environmental factors influence the development of incontinence in children and adults. The interactions between biological factors, the immediate environment, and intervening variables need to be explored in greater detail. Practical solutions to reduce barriers to adequate fluid intake and healthy toileting habits should be implemented in school and work settings.

Factors associated with remission of primary nocturnal enuresis and changes of parental perception towards management strategies: A follow-up study

OBJECTIVE

To understand the remission rates, shifts in treatment methods used by parents, and parents' attitudes towards their children with primary nocturnal enuresis (NE).

STUDY DESIGN

A total of 408 children aged 6-12 years and diagnosed with primary nocturnal enuresis from a 2004 epidemiological study in Taiwan were enrolled. After a 5.5-year follow-up period, the remission rates of the children of each age group were evaluated, and the corresponding treatment methods were employed daily. Furthermore, the major risk factors that influenced the remission rates in these children were investigated.

RESULTS

The overall remission rate was 93.1% among all age groups, and the median age of remission was 9.9 years (95% CI 9.5-10.2 years). Comparing the previous and after results of this study, the treatment methods utilized by the parents in response to enuresis were significantly different. More parents chose combination therapy and sought medical attention as the children grew older, particularly the parents of children with severe NE. Few parents still continued to use punishment method. A Cox proportional hazards regression model revealed that girls, young children, those with low enuresis frequency, and light sleepers had higher remission rates than did their counterparts.

CONCLUSION

Parents' attitudes towards enuresis influence their choice of therapy for their children. In most cases, parents chose a combination of therapies, particularly combining limited fluid intake and regular voiding. Only 37 (9.1%) children received medicine. The older the enuretic child, the more likely the parents were to seek medical treatment for their children. Enuresis might disappear spontaneously but not always. A small proportion of children will continue to wet till adulthood. The treatment of NE at this age would be challenging. Children who were deep sleepers or affected by severe enuresis had a low probability of achieving dryness. However, girls and young children had a higher probability of achieving remission than did their counterparts.

Evaluation of the Effectiveness of a Short-term Treatment and Repeat Treatment of Nocturnal Enuresis Using an Enuresis Alarm

OBJECTIVE

To evaluate the effectiveness of a 3-month enuresis alarm (EA) treatment and repeat EA treatment among pediatric patients with nocturnal enuresis, and to compare patient characteristics among "responders" and "nonresponders" to treatment.

MATERIALS AND METHODS

Clinical outcomes were retrospectively evaluated for 137 children (94 boys and 43 girls, mean age, 10.1 years). Effectiveness was evaluated after an initial 3-month treatment, using the International Children's Continence Society criteria. Among children in the no-response group at 3 months, those who continued the EA treatment for ≥4 months were subclassified into group 1, whereas children who repeated the EA treatment at an interval ≥6 months were subclassified into group 2.

RESULTS

Among our 137 cases, 19 achieved complete response and 47 achieved partial response at 3 months, for an overall treatment effectiveness rate of 48%. Among the no-response group, treatment was extended in 17 cases (group 1), with 3 (18%) achieving a successful outcome. Treatment was repeated in 18 cases (group 2). In group 2, 8 (44%) achieved successful outcome at 3-month time point. Daytime urinary incontinence did not modify treatment effectiveness.

CONCLUSION

EA treatment should be given for a short period of time and should not be continued without a definite purpose or clear response. Suspending and then repeating this treatment after an appropriate interval is effective for patients who do not respond to the initial course of treatment.

Desmopressin (melt) therapy in children with monosymptomatic nocturnal enuresis and nocturnal polyuria results in improved neuropsychological functioning and sleep

BACKGROUND

There is a high comorbidity between nocturnal enuresis, sleep disorders and psychological problems. The aim of this study was to investigate whether a decrease in nocturnal diuresis volume not only improves enuresis but also ameliorates disrupted sleep and (neuro)psychological dysfunction, the major comorbidities of this disorder.

METHODS

In this open-label, prospective phase IV study, 30 children with monosymptomatic nocturnal enuresis (MNE) underwent standardized video-polysomnographic testing and multi-informant (neuro)psychological testing at baseline and 6 months after the start of desmopressin treatment in the University Hospital Ghent, Belgium. Primary endpoints were the effect on sleep and (neuro)psychological functioning. The secondary endpoint was the change in the first undisturbed sleep period or the time to the first void.

RESULTS

Thirty children aged between 6 and 16 (mean 10.43, standard deviation 3.08) years completed the study. The results demonstrated a significant decrease in periodic limb movements during sleep (PLMS) and a prolonged first undisturbed sleep period. Additionally, (neuro)psychological functioning was improved on several domains.

CONCLUSIONS

The study demonstrates that the degree of comorbidity symptoms is at least aggravated by enuresis (and/or high nocturnal diuresis rate) since sleep and (neuro)psychological functioning were significantly ameliorated by treatment of enuresis. These results indicate that enuresis is not such a benign condition as has previously been assumed.

Impact of a multidisciplinary evaluation in pediatric patients with nocturnal monosymptomatic enuresis

BACKGROUND

Enuresis (NE) is a clinical condition of multifactorial etiology that leads to difficulties in child/adolescent social interaction.

METHODS

This was a prospective study on the impact of multidisciplinary assessment of 6- to 17-year-old patients with monosymptomatic nocturnal enuresis (MNE), including a structured history, clinical/neurological examination, bladder and bowel diaries, sleep diary and questionnaires, psychological evaluation [Child Behavior Checklist (CBCL) and PedsQL 4.0 questionnaires], urinary sonography, blood and urine laboratory tests, polysonography (PSG), and balance evaluation.

RESULTS

A total of 140 enuretic participants were evaluated, of whom 27 were diagnosed with NE complicated by urinary disorder, four with hypercalciuria, three with nephropathy and one with attention-deficit hyperactivity disorder. Among the 87 participants who underwent PSG, six were diagnosed with severe apnea. Of the 82 MNE patients who underwent full assessment, 62 were male (75.6 %), and the mean age was 9.5 (±2.6) years. A family history of NE was diagnosed in 91.1 % of first- and second-degree relatives, constipation in 89.3 % and mild/moderate apnea in 40.7 %. Balance control alteration was identified by physical therapy evaluation of MNE patients. Participants' quality of life evaluation scores were significantly lower than those of their parents.

CONCLUSION

Enuresis is a multifactorial disorder that requires a structured diagnostic approach.

Management of nocturnal enuresis - myths and facts

Nocturnal enuresis often causes considerable distress or functional impairment to patient and their parents necessitating a multidisciplinary approach from paediatrician, paediatric nephrologist, urologists and psychiatrist. Mechanisms of monosymptomatic nocturnal enuresis are mainly nocturnal polyuria, bladder overactivity and failure to awaken from sleep in response to bladder sensations. Goal oriented and etiology wise treatment includes simple behavioral intervention, conditioning alarm regimen and pharmacotherapy with desmopressin, imipramine and anticholinergic drugs. Symptoms often recurs requiring change over or combination of different modes of

treatment.

Stressful Events in Early Childhood and Developmental Trajectories of Bedwetting at School Age

Objective To examine whether early stressful events are associated with developmental trajectories of bedwetting. Methods This is a prospective cohort study comprising 8,761 participants from the Avon Longitudinal Study of Parents and Children. Stressful events were measured using a maternal questionnaire completed at 3 time points before their child was 4 years old. The association between stressful events and trajectories of bedwetting from 4 to 9 years was examined using multinomial regression. Results The association with stressful events was strongest for the frequent persistent bedwetting trajectory (wetting at least twice a week up to age 9). A 1 standard deviation increase in the stressful events score was associated with a 29% (13–47%) increase in the odds of experiencing frequent persistent bedwetting compared with normal attainment of nighttime bladder control. Conclusions Clinicians and parents should be aware that continence is a developmental outcome that is associated with high levels of stress in the family.

Sleep disturbances associated with sleep enuresis: A questionnaire study

PURPOSE

Sleep enuresis (SE) is the second most common sleep complaint in childhood. It has been associated with bladder hyperactivity, excessive urine production and deeper sleep. Several sleep disorders have been described in association with SE like parasomnias and sleep apnea. The aim of this study was to analyze the presence of sleep disturbances in children with SE through the use of Sleep Disturbance Scale for Children (SDSC) compared to normal children matched for age and sex.

METHODS

A questionnaire evaluation was performed in 76 enuretic and 112 normal children through the Sleep Disturbance Scale for Children (SDSC) validated for Portuguese language. The Scale is grouped into six subscales: Disorders in Initiating and Maintaining Sleep (DIMS), Sleep Breathing Disorders (SBD), Disorders of Arousal (DA), Sleep-Wake Transition Disorders (SWTD), Disorders Of Excessive Somnolence (DOES), and Nocturnal Hyperhidrosis (SHY). Children with renal and neurological problems were excluded from both groups.

RESULTS

Enuretics scored higher in several of the subscales (SBD, DOA, SWTD) and also in the total scale scores while scored low in the DIMS subscale. No differences were found for the DOES and SHY subscales.

CONCLUSIONS

Enuretic children showed a high comorbidity with other sleep disturbances like sleep disordered breathing and parasomnias. The novel finding of this study is that we found a decreased incidence of DIMS that is consistent with the parental perception of a more deep sleep and a high arousal threshold in SE.

Advances in the management of primary monosymptomatic nocturnal enuresis in children

Intermittent incontinence of urine in a sleeping child who has previously been dry for less than 6 months without any other lower urinary tract symptoms is considered to be primary monosymptomatic nocturnal enuresis (PMNE). Although, most children outgrow PMNE with age, the psychological impact on the child warrants parental education and patient motivation and treatment. Motivational therapy, alarm therapy and drug therapy are the mainstay of treatment. Motivational and alarm therapy have better success rates than drug therapy alone. Desmopressin is the commonly used first-line drug and is best for short-term relief. Other drugs such as anti-cholinergics, imipramine and sertraline are used in resistant cases. This review focuses on the assessment and treatment of PMNE.

Urodynamic function during sleep-like brain states in urethane anesthetized rats

The aim was to investigate urodynamic parameters and functional excitability of the periaqueductal gray matter (PAG) during changes in sleep-like brain states in urethane anesthetized rats. Simultaneous recordings of detrusor pressure, external urethral sphincter (EUS) electromyogram (EMG), cortical electroencephalogram (EEG), and single-unit activity in the PAG were made during repeated voiding induced by continuous infusion of saline into the bladder. The EEG cycled between synchronized, high-amplitude slow wave activity (SWA) and desynchronized low-amplitude fast activity similar to slow wave and 'activated' sleep-like brain states. During (SWA, 0.5-1.5 Hz synchronized oscillation of the EEG waveform) voiding became more irregular than in the 'activated' brain state (2-5 Hz low-amplitude desynchronized EEG waveform) and detrusor void pressure threshold, void volume threshold and the duration of bursting activity in the external urethral sphincter EMG were raised. The spontaneous firing rate of 23/52 neurons recorded within the caudal PAG and adjacent tegmentum was linked to the EEG state, with the majority of responsive cells (92%) firing more slowly during SWA. Almost a quarter of the cells recorded (12/52) showed phasic changes in firing rate that were linked to the occurrence of voids. Inhibition (n=6), excitation (n=4) or excitation/inhibition (n=2) was seen. The spontaneous firing rate of 83% of the micturition-responsive cells was sensitive to changes in EEG state. In nine of the 12 responsive cells (75%) the responses were reduced during SWA. We propose that during different sleep-like brain states changes in urodynamic properties occur which may be linked to changing excitability of the micturition circuitry in the periaqueductal gray.

Periodic limb movements during sleep are associated with a lower quality of life in children with monosymptomatic nocturnal enuresis

The study investigates whether cortical arousals and periodic limb movements during sleep are related to daytime psychological functioning in children with monosymptomatic nocturnal enuresis with associated nocturnal polyuria. Psychological functioning is evaluated on five domains: attention deficit hyperactivity disorder-inattentive problems, quality of life, internalizing problems, externalizing problems, and executive functioning. This multi-informant (parents, teachers, and children) and multi-method study included overnight video-polysomnography, questionnaires, and neuropsychological testing. Thirty children (7 girls) 6 to 16 years (mean 10.43 years, SD 3.08) were selected in a tertiary enuresis center. A high index of periodic limb movements during sleep was associated with a lower quality of life, according to the child. No significant correlations were found with attention deficit hyperactivity disorder-inattentive problems, internalizing problems, externalizing problems, and executive functioning.

CONCLUSION

This study clarifies the relationship between sleep parameters and psychological functioning of the children with monosymptomatic nocturnal enuresis and associated nocturnal polyuria according to the child, the parents, and the teachers. Periodic limb movements during sleep are associated with a lower quality of life of the child.

Sleep fragmentation and periodic limb movements in children with monosymptomatic nocturnal enuresis and polyuria

BACKGROUND

Children with nocturnal enuresis (NE) have been found to have sleep fragmentation and a high incidence of periodic limb movements in sleep (PLMS). This study explored the association of monosymptomatic NE and polyuria in relation to fluid intake, bladder volume, number of wet nights, and number of nights with polyuria to the frequency of PLMS and cortical arousals during sleep.

MATERIALS AND METHODS

Thirty children with monosymptomatic NE and polyuria were enrolled in the study. Enuretic parameters were determined by diaries, forced drinking, uroflow, and ultrasound examination. All subjects participated in one polysomnographic study. The number of cortical arousals and PLMS were compared with those recorded in a former pilot study which included only children with refractory NE.

RESULTS

Of the 30 children who participated in the study, the mean age was 10.43 ± 3.08 (range 6-16) years, and 23 were boys. The PLMS index was positively associated with the arousal index and the awakening index (p < 0.001). No significant association between the sleep and the enuretic parameters was found. Children with refractory NE showed a significantly higher PLMS index (p < 0.001).

CONCLUSIONS

We found that PLMS and cortical arousals in sleep were increased in children with monosymptomatic NE and polyuria, without a significant association with the enuretic parameters. These observations suggest the presence of a comorbid mechanism driven by a common, independent pacemaker. We hypothesize the autonomic system, its sympathetic branch, and the dopaminergic system as candidates for this pacemaker.

Infrequent enuresis, the uninvestigated majority comparisons between children with enuresis of varying severity

OBJECTIVE

The main objective was to compare children with frequent enuresis (FE) and children with infrequent enuresis (IE) using anamnestic data and variables related to bladder and kidney function. A secondary aim was to look at the group of children who wet their beds every single night, a phenomenon we chose to call constant enuresis (CE).

SUBJECTS AND METHODS

The parents recorded the number of wet and dry nights for a period of 14 days, and measured the voided volumes as well as nocturnal urine production for 48 h. History data relevant to bladder and bowel function was also recorded.

RESULTS

The children could be grouped as follows: IE, n = 14; FE, n = 18; and CE, n = 22. The children with IE were slightly older than the other groups, IE mean 7.57; FE mean 6.22; CE, mean 6.56 (p = 0.004). When comparing the groups in terms of the measured parameters, only one significant difference was found: the FE group had larger average daytime voided volumes, but only when the first morning void was included. The only significantly differing anamnestic variable was previous daytime incontinence, which was more common among the children in the IE group.

CONCLUSIONS

When comparing children with varying enuresis severity, no major differences regarding bladder function and urine production were found. Furthermore, children with infrequent enuresis tend to be slightly older when they seek medical help.

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.

The management of childhood urinary incontinence

The International Children's Continence Society (ICCS) has undertaken an enormous effort to standardize both the terminology and management of various aspects of incontinence in children, including enuresis, bladder overactivity, dysfunctional voiding and psychological comorbidities. A number of guidelines have been published to aid those involved in the care of children with lower urinary tract symptoms. This review addresses a number of recommended diagnostic and therapeutic strategies, including urotherapy and pharmacological treatment, with emphasis on a focused medical history, information acquired from bladder diaries and uroflow evaluations. The major role of urotherapy is underlined with supportive pharmacotherapy, when indicated. The article provides both a summary of ICCS guidelines and a brief review of recently published papers related to the contemporary management of childhood incontinence, a health issue still underestimated by both the child's caregivers and healthcare providers.

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

AIM

Nocturnal enuresis (NE) and attention-deficit/hyperactivity disorder (ADHD) are common in childhood. We analysed the central processing of emotions in children with NE, ADHD, NE + ADHD and controls.

METHODS

We examined 13 children with NE, 13 with ADHD, 14 with NE + ADHD and 14 controls. Acoustic evoked potentials were recorded using standardised methodology. For the event-related potentials, positive, negative and neutral pictures were presented and time intervals of 250-450, 450-650 and 650-850 msec evaluated. Hypotheses were tested with repeated-measures analyses of variance.

RESULTS

In the frontal region, children with NE showed more intense responses to positive and negative pictures than controls measured with event-related potentials. Viewing positive pictures, children with NE + ADHD differed from children with ADHD in the central and parietal and for all types of stimuli in the parietal region. Children with NE + ADHD elicited the strongest responses. Children with ADHD did not differ from controls. There was an unspecific interaction effect of the acoustic evoked potentials in children with NE compared to the controls.

CONCLUSION

Children with NE processed emotions differently from children with ADHD and controls. Children with NE + ADHD processed emotions the most intense, displaying interaction effects of the central nervous system that cannot be explained by each disorder alone.

Sleep fragmentation and increased periodic limb movements are more common in children with nocturnal enuresis

AIM

To determine sleep fragmentation in children with nocturnal enuresis (NE).

METHODS

Paediatricians assessed NE parameters in children referred to an enuresis clinic. Control subjects, matched by age and gender and without incontinence or (un)treated NE, were recruited from the paediatric sleep clinic regardless of their sleep problem. Sleep was investigated by one overnight video-polysomnography in both groups.

RESULTS

The study group comprised 67 children with proven NE (50 boys and 17 girls between six and 16 years: 11.1 ± 2.8 SD). They were matched with 67 control subjects (47 boys and 20 girls aged between six and 16 years: 11.0 ± 2.9 SD). Children with NE had a higher incidence of periodic limb movements associated with cortical arousals in their sleep. They displayed significant higher periodic limb movement index, arousal index and awakening index than the control group.

CONCLUSION

Children with NE displayed higher sleep fragmentation and periodic limb movements in sleep than the control children with a possible sleep disorder without NE. The findings emphasise the central involvement of the pathophysiology of NE and the multifactorial nature of the condition.

Why does adenotonsillectomy not correct enuresis in all children with sleep disordered breathing?

PURPOSE

We analyzed the outcome of nocturnal enuresis after adenotonsillectomy in children with sleep disordered breathing. We also evaluated differences in demographic, clinical, laboratory and polysomnography parameters between responders and nonresponders after adenotonsillectomy.

MATERIALS AND METHODS

We prospectively evaluated children 5 to 18 years old diagnosed with sleep disordered breathing (snoring or obstructive sleep apnea syndrome) on polysomnography and monosymptomatic primary nocturnal enuresis requiring adenotonsillectomy to release upper airway obstruction. Plasma antidiuretic hormone and brain natriuretic peptide were measured preoperatively and 1 month postoperatively.

RESULTS

Sleep studies were done in 46 children and 32 also underwent blood testing preoperatively and postoperatively. Mean ± SD patient age was 8.79 ± 2.41 years and the mean number of wet nights weekly was 6.39 ± 1.26. Polysomnography revealed obstructive sleep apnea syndrome in 71.7% of patients and snoring in 28.3%. After adenotonsillectomy 43.5% of patients became dry. Preoperative polysomnography findings indicated that responders, who were dry, had significantly more arousals and obstructive apnea episodes but fewer awakenings than nonresponders, who were wet. Significant increases in plasma antidiuretic hormone and significant decreases in plasma brain natriuretic peptide were seen in all children with no difference between responders and nonresponders. No difference between the groups was noted in age, gender, race, body mass index, constipation, preoperative number of wet nights weekly or type of sleep disordered breathing.

CONCLUSIONS

Nocturnal enuresis resolved after adenotonsillectomy in almost half of the children with sleep disordered breathing. Those who became dry had more frequent arousal episodes caused by apnea events than those who remained wet.

Sleep apnea in children with refractory monosymptomatic nocturnal enuresis

BACKGROUND

Children with nocturnal enuresis (NE) are believed to have deep sleep with high arousal threshold. Studies suggest that obstructive sleep apnea-hypopnea syndrome (OSAHS) and NE are common problems during childhood. We sought to assess the prevalence of OSAHS in children with refractory NE and whether its severity is associated with the frequency of bedwetting.

METHODS

The study group comprised 43 children with refractory monosymptomatic NE and a control group of 30 children, both aged 6-12 years. All subjects underwent thorough neurological examination, one night of polysomnography only for the patient group, and a lumbosacral plain X-ray to exclude spina bifida.

RESULTS

The groups were well matched. Two subjects of the control group had mild OSAHS. The mean age of the patients was (9.19±2.4 years), 26 were boys, and 67% showed frequent NE (>3 days bedwetting/week). Patients with NE had significantly higher rates of OSAHS (P<0.0001); three patients had mild, 12 had moderate, and eleven showed severe OSAHS. There was no significant statistical difference among patients having OSAHS in relation to age, sex, or family history of NE. The frequency of bedwetting was statistically significantly higher in patients with severe OSAHS (P=0.003).

CONCLUSION

Patients with refractory NE had a significantly higher prevalence of OSAHS with no sex difference. The frequency of bedwetting was higher in patients with severe OSAHS.