Atomoxetine ameliorates nocturnal enuresis with subclinical attention-deficit/hyperactivity disorder

Management of the refractory nocturnal enuresis patient to desmopressin in a pediatric population: Desmopressin + oxybutynin vs. desmopressin + imipramine

INTRODUCTION AND OBJECTIVE

Desmopressin is well accepted as first-line medical therapy for enuresis. If ineffective, combination therapy of desmopressin + oxybutynin or desmopressin + imipramine has been used. This study assessed the efficacy of adjunct therapy with either imipramine or oxybutynin in the management of enuresis patients who failed desmopressin treatment.

STUDY DESIGN

A retrospective chart review of our database for patients with enuresis was performed. Patients who were prescribed desmopressin, oxybutynin, and imipramine over 14 years for enuresis were included. Two cohorts of patients were examined; group OXY was treated with desmopressin and oxybutynin, and group IMP received desmopressin and imipramine. Pretreatment measurement of Vancouver Symptom Scores (VSS) were used to compare groups using the VSS question "I wet my bed at night" where 4: every night, 3: 4-5 nights per week, 2: 1-2 nights per week, 1: 3-4 nights per month, and 0: never. International Children's Continence Society (ICCS) criteria for continence success was utilized to determine outcomes.

RESULTS

2521 patients prescribed one of the 3 medications were identified. Among them, 81 patients (mean age: 10.5 ± 2.8 years) received combination therapy. Of which, 55 were male and 26 female. Specifically, 58 were prescribed both desmopressin and imipramine (group IMP), 23 desmopressin and oxybutynin (group OXY), and 4 transitioned from OXY to IMP. Mean pretreatment VSS showed no difference between groups. Both groups experienced minimal drops in wet nights with desmopressin alone. A comparison revealed that group IMP reduced wet nights significantly more than group OXY (VSS wet night score 0.7 ± 1.2 vs. 2.3 ± 1.1 respectively, p < 0.0001). Non-intent-to-treat complete response rate was 68% vs 5% (OR = 42.5, p < 0.001) (IMP vs. OXY respectively). Intent-to-treat response rates were 58%.

DISCUSSION

Although first-line desmopressin treatment for enuresis is effective, it does not work for all patients, and many parents and children desire nighttime dryness. Clinicians have combined desmopressin with oxybutynin or imipramine for improved results, but research comparing these modalities is scarce. Our study suggests that the desmopressin and imipramine combination is superior at reducing nights wet compared to desmopressin and oxybutynin, attributed to imipramine's probable central mechanism rather than its secondary anticholinergic properties. Limitations include a modest sample size, retrospective design, and subjective responses to the Vancouver questionnaire.

CONCLUSION

A combination of desmopressin and imipramine was more effective in reducing wet nights and had a complete response rate that was 42.5 times greater than desmopressin and oxybutynin.

Optimising the management of children with concomitant bladder dysfunction and behavioural disorders

Bladder dysfunction and behavioural disorders in children are commonly concomitant; hence, it is difficult to treat each in isolation. Pharmacotherapy is common treatment for behavioural disorders, and these medications may have intended or unintended positive or negative bladder sequelae. This review identifies the literature regarding the effects of behavioural pharmacotherapy on bladder functioning and possible bladder management strategies in children with concomitant behaviour and bladder disorders to enable clinicians to better manage both conditions. A PROSPERO registered PRISMA-guided review of three major databases was performed. After an initial scoping study revealed significant heterogeneity, a narrative approach was undertaken to discuss the results of all relevant cases relating to children being treated with pharmacotherapy for behaviour disorders and outcomes related to bladder function. Studies were screened to identify those that described effects of commonly prescribed medications in children with behavioural disorders such as stimulants, alpha 2 agonists, tricyclic antidepressants (TCA), serotonin and noradrenergic reuptake inhibitors (SNRI), selective serotonin reuptake inhibitors (SSRI) and antipsychotics, and the findings and implications were summarised. The review identified 46 studies relevant to behavioural pharmacotherapy and bladder function (stimulants (n = 9), alpha 2 agonists (n = 2), TCAs (n = 7), SNRIs (n = 8), SSRIs (n = 8) and antipsychotics (n = 6). Six studies focused specifically on bladder management in children with behavioural disorders with concurrent behavioural pharmacotherapy. This review identifies useful factors that may assist clinicians with predicting unintended bladder effects following initiation of behavioural pharmacotherapy to facilitate the best approach to the treatment of bladder dysfunction in children with behavioural disorders. With this evidence, we have provided a useful decision-making algorithm to aide clinicians in the management of these dual pathologies.

[Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment]

Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment Abstract: Objective: Enuresis and daytime urinary incontinence are common disorders in children and adolescents and are associated with incapacitation and a high rate of comorbid psychological disorders. This interdisciplinary guideline summarizes the current state of knowledge regarding somatic and psychiatric assessment and treatment. We formulate consensus-based, practical recommendations. Methods: The members of this guideline commission consisted of 18 professional associations. The guideline results from current literature searches, several online surveys, and consensus conferences based on standard procedures. Results: According to the International Children's Continence Society (ICCS), there are four different subtypes of nocturnal enuresis and nine subtypes of daytime urinary incontinence. Organic factors first have to be excluded. Clinical and noninvasive assessment is sufficient in most cases. Standard urotherapy is the mainstay of treatment. If indicated, one can add specific urotherapy and pharmacotherapy. Medication can be useful, especially in enuresis and urge incontinence. Psychological and somatic comorbid disorders must also be addressed. Conclusions: The recommendations of this guideline were passed with a high consensus. Interdisciplinary cooperation is especially important, as somatic factors and comorbid psychological disorders and symptoms need to be considered. More research is required especially regarding functional (nonorganic) daytime urinary incontinence.

Impaired selective attention in patients with severe primary monosymptomatic nocturnal enuresis: An event-related potential study

Objectives

Primary monosymptomatic nocturnal enuresis (PMNE) is a very common problem in school age children. It is thought that PMNE represents a maturational lag in the central nervous system of those children. We did this case control study to assess the selective attention and resource allocation in those children using the P300 wave of the Event-Related Potentials (ERPs) and its relation to disease severity.

Methods

Forty four patients with PMNE and twenty three healthy controls were included in this study. Patients were diagnosed according to the criteria of international children's continence society and were classified into two groups; patients with frequent wetting (≥4 episodes/week), and patients with infrequent wetting (<4 episodes/week). ERPs were recorded at Fz, Cz, and Pz locations using odd-ball paradigm. N200 and P300 peak latencies (ms), and N200/P300 peak to peak amplitudes (µV) were measured.

Results

We found significant increase of P300 and N200/P300 interpeak latencies, and significant decrease of P300 amplitudes in frequent wetting group "severe" PMNE compared to healthy controls and infrequent wetting group.

Conclusion

Abnormal selective attention and resource allocation were found in patients with severe PMNE. Measures to improve selective attention might be helpful in treatment of patients with severe PMNE.

Significance

Impaired selective attention might play a role in pathogenesis of severe PMNE and the need for the various measures to improve selective attention may be further studied as a therapeutic tool for patients with severe PMNE.

Neurodevelopmental disorders and incontinence in children and adolescents: Attention-deficit/hyperactivity disorder, autism spectrum disorder, and intellectual disability-A consensus document of the International Children's Continence Society

AIMS

Neurodevelopmental disorders (NDs) are incapacitating disorders, which begin early in life, are mainly caused by genetic and neurobiological factors, and show a tendency to persist. They are associated with higher rates of incontinence in children and adolescents, including nocturnal enuresis, daytime urinary incontinence, fecal incontinence, and constipation. Without diagnosis and treatment, they will interfere with incontinence treatment leading to less favorable outcomes. The aim of this International Children's Continence Society (ICCS) document is to provide an overview of the three most important NDs, that is, attention-deficit/hyperactivity disorder, autism spectrum disorder (ASD), and intellectual disability (ID).

METHODS

This consensus paper was commissioned by the ICCS. A selective, nonsystematic review was performed. Guidelines, reviews, and selected studies were included. The recommendations are consensus-based.

RESULTS

ADHD is the most common ND with special relevance in clinical practice. ASD and ID are less common, but more severe disorders than ADHD. Basic principles of the assessment and treatment of NDs are provided. Incontinence is common among patients with NDs. Specific modifications and practical approaches in the treatment of incontinence in children with NDs are outlined.

CONCLUSIONS

Incontinence in children and adolescents with NDs is common. Effective treatment of incontinence should be adapted and modified to the specific needs of patients with NDs. A multiprofessional approach is recommended.

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.

Parental Stress and Parental Ratings of Behavioral Problems of Enuretic Children

Background: Primary monosymptomatic nocturnal enuresis (PMNE) may have a stressful impact on the everyday life of children and parents, and it may represent a cumulative stress factor increasing feelings of “learned helplessness.”

Methods: The current study investigated parental stress in a group of parents (n = 330) of children affected by PMNE, compared to a group of parents (n = 330) of typical developing children (TDC). In addition, the study evaluated whether parents of PMNE children experience more emotional, social, and behavioral problems in their children, compared to parents of TDC. Finally, the study correlated frequency of enuresis with stress values and Child Behavior Checklist (CBCL) subscales and total stress with CBCL. Both groups were given The Parental Stress Inventory-Short Form (PSI-SF) and the Child Behavior Checklist (CBCL).

Results: Parents of PMNE children showed significantly higher stress level than parents of TDC. Nocturnal enuresis, as a demanding clinical condition difficult to control, represents a relevant stress factor. Mothers appeared as more vulnerable to stress than fathers. Parents of PMNE children reported higher behavioral and emotional problems, compared to reports of parents of TDC. PMNE children appeared to their parents as having lower competency in social activities, school performance, and social relationships than TDC. Moreover, they were rated as more withdrawn, anxious-depressed, more aggressive, inattentive, and with more somatic complaints than healthy children. It was always the mother who rated a significantly higher number of emotional, social, and behavioral problems compared to fathers. Correlational analysis showed that the higher the frequency of enuresis, the greater the parental stress level, the lower the social activities, school performance and relational competencies and the higher the emotional, social and behavioral problems in children, according to the parents' evaluations. The greater the parental stress level, the lower the competencies rated and the higher the behavioral problems detected by parents.

Conclusion: The physicians who deal with PMNE children have taken into account the stressful role and emotional dimensions of this clinical condition, both for children and mothers, in order to improve clinical management. Psychological support is needed for parents, and mothers especially, for a more functional stress management related to the PMNE.

Children with nocturnal enuresis and attention deficit hyperactivity disorder: A separate entity?

INTRODUCTION

There is ongoing debate about whether nocturnal enuresis (NE) is affected by the presence of attention deficit hyperactivity disorder (ADHD) in children. Clarifying this relationship could categorize them as a separate entity, potentially requiring a different management from enuretic children without ADHD.

AIMS

To study whether (1) children with ADHD exhibited greater severity of enuresis and associated voiding symptoms compared with children without ADHD, (2) whether there was a difference in enuretic response to treatment between children with/without ADHD, (3) whether previously prescribed medication for ADHD affected severity of enuresis or voiding symptoms, and response to treatment.

METHODS

Data on all consecutive children seen with primary NE and ADHD and age- and gender-matched children with NE without ADHD over the course of 2 years were extracted from our database. Controls were identified using a random number generator to choose patients within each age/gender group. Changes in Dysfunctional Voiding Scoring System (DVSS) and Bristol scores were assessed before and after treatment for NE using repeated measures ANOVAs. Number of weekly wet nights was compared between the groups before and after the treatment of enuresis. Children with more than a 50% decrease in number of wet nights per week were categorized as responding to treatment.

RESULTS

Compared with controls, ADHD children (N = 95) had significantly more severe voiding symptoms, NE and constipation (Table). No significant differences were found between children on ADHD medication (63.2%) and those who were not on ADHD medication (36.8%) on any of the demographic and pre-treatment clinical parameters. Similar enuretic response rates to behavioral modification alone were seen in both study (13.5%) and control (12.8%) groups (p = 0.73). Response to pharmacological treatment was seen in nine patients with ADHD (42.9%) and in six (20.7%) controls, with pharmacological intervention being significantly more effective than behavioral modification for patients with ADHD (p = 0.012). Additionally, no difference was found between ADHD patients on and off ADHD medication in terms of response to enuresis treatment.

CONCLUSION

In children with primary NE, the presence of ADHD was associated with more severe NE, voiding symptoms and constipation. The severity of voiding symptoms and/or NE was unrelated to the use of stimulant medication. The response to behavioral modification was comparable in both groups. However, patients with ADHD were significantly more responsive to medication for NE compared with behavioral modification, indicating a possible benefit for earlier pharmacological treatment for enuresis in this population subgroup.

Clonidine may have a beneficial effect on refractory nocturnal enuresis

BACKGROUND

Although the evidence-based treatment for nocturnal enuresis is established, nearly one-third of patients are still enuretic with desmopressin, anti-cholinergic treatment and alarm. The fourth option, imipramine, is limited because of the risk of cardiotoxicity on overdose. Clonidine, an α₂ -adrenoceptor agonist that also has noradrenergic effects like imipramine, is a new option for refractory enuresis.

METHODS

A total of 148 patients (6-14 years of age; mean, 9.1 years) with refractory enuresis under desmopressin, anti-cholinergic treatment and alarm were enrolled. The patients consisted of 100 boys and 48 girls, of whom 23 had monosymptomatic nocturnal enuresis and 125 had non-monosymptomatic nocturnal enuresis. Clonidine 4 μg/kg/day (maximum, 75 μg/day) orally 30 min before bedtime was added and its effects were evaluated after 4 weeks of treatment.

RESULTS

A total of 83 patients (56.1%) achieved partial or complete response with the additional clonidine. No significant adverse reactions were noted.

CONCLUSIONS

Clonidine could be an aid for refractory enuresis, although further randomized controlled trials are needed.