Epidemiology of enuresis: a large number of children at risk of low regard

Beyond bedwetting: How successful treatment is observed in sleep macrostructure

INTRODUCTION

Sleep enuresis (SE), commonly known as bedwetting, refers to involuntary urination during sleep. It is a prevalent condition affecting approximately 15 % of children at age 5, 10 % by age 7, and 5 % by age 10. This condition can significantly impact both children and their families. The pathophysiology of SE is complex and not yet fully understood. There are several established treatment methods, but limited information on their sleep dynamics.

OBJECTIVE

This study aimed to evaluate differences in sleep structure before and after treatment in patients with monosymptomatic SE (MSE), focusing on alarm therapy, desmopressin, and a combination of both. The analysis compared pre- and post-treatment differences within each treatment arm. The analysis was conducted for both successful and unsuccessful treatment outcomes.

METHODS/RESULTS

This was a prospective study with MSE patients, aged 6-16 years, diagnosed by multidisciplinary assessment. Of the 140 initial applicants 75 were initially included in the study and randomized for therapeutic intervention in three treatment arms, namely: alarm, desmopressin and alarm + desmopressin. Therapeutic response was evaluated 12 months after treatment discontinuation. Polysomnographic evaluation pre and post treatment was carried out. 51/75 completed the entire protocol. 42/51 were successfully treated and had a median age of 10 [8-12] and the non-success, 8 [7-10]. Among the successful patients, the percentage of N2 sleep decreased from a median of 55.7 %-48.5 % (p = 0.0004) in the alarm arm, from 58.8 % to 50 % (p = 0.002) in the desmopressin arm, and from 54.7 % to 50.9 % (p = 0.044) in the combined arm. The percentage of N3 sleep increased from 25.7 % to 30.1 % (p = 0.004) in the alarm arm, from 21.6 % to 26 % (p = 0.032) in the desmopressin arm, and from 23.7 % to 28.3 % (p = 0.014) in the combined arm. The arousal index significantly increased from pre-to post-treatment in all arms: in the alarm arm, from 1.25 to 2.8 (p = 0.002); in the desmopressin arm, from 1.3 to 2.7 (p = 0.019); and in the combined treatment arm, from 1 to 4 (p = 0.003). No significant differences were observed in the non-successful arm or among those who experienced complete resolution of the enuresis without treatment.

CONCLUSION

The observed increase in N3 sleep and arousal and decrease in N2 sleep following successful treatment, regardless of the specific interventions, underscores the role of sleep in the pathophysiology of enuresis. Conversely, the lack of sleep differences in the non-successful arm further highlights the importance of sleep, beyond developmental factors, in influencing the clinical outcomes of enuresis, especially since all children were assessed 12 months after the start of treatment.

The Relationship between video game addiction and bladder/bowel dysfunction in children

INTRODUCTION

Video games have a strong influence on children and adolescents. Video game addiction has negative effects on children's health.

OBJECTIVE

To determine the relationship between video game addiction and bladder/bowel dysfunction in children.

MATERIALS AND METHODS

Three hundred sixty-three children and their mothers who met the inclusion criteria constituted the sample of this correlational study. The data were collected using a descriptive information form, the Video Game Addiction Scale for Children, and the Childhood Bladder and Bowel Dysfunction Questionnaire.

RESULTS

We found that 72.5% of the children were nine years old and 27.5% were ten years old; 50.4% were males and 49.6% were female. While 4.7% of the children who participated in the study were underweight, 19.6% were overweight, and 17.9% were obese. The mean Video Game Addiction Scale for Children score was 50.77 ± 16.17, whereas the mean Childhood Bladder and Bowel Dysfunction Questionnaire score was 29.98 ± 8.90. The ratio of children with a mean Video Game Addiction Scale for Children scores equal to or greater than 90 was 0.8% (n = 3). We found that 3.6% (n = 13) of the children had urinary/fecal incontinence while playing video games. There was a weak positive relationship between the dimensions of the Video Game Addiction Scale for Children scores, the Childhood Bladder and Bowel Dysfunction Questionnaire scores, and children's bladder and bowel function (r = 0.220; p ˂ 0.05).

CONCLUSIONS

There is a correlation between children's video game addiction level and their bladder and bowel dysfunction grade. Higher video game addiction levels correspond to higher bladder and bowel dysfunction.

Logistic regression analysis of risk factors influencing childhood enuresis: a comprehensive survey study

OBJECTIVE

To identify risk factors associated with childhood enuresis.

METHODS

We conducted a retrospective analysis of 146 children aged 6 to 13 years diagnosed with enuresis at Anhui Province Children's Hospital between June 2020 and June 2023. Children were categorized based on bedwetting frequency: those with less frequent episodes (once a week to twice a month) were placed in the mild group (60 cases), and those with frequent episodes (two or more times per week) were placed in the severe group (86 cases). We compared demographic data, family histories, and personal characteristics between the groups and performed logistic regression to determine significant risk factors.

RESULTS

The analysis revealed that a stubborn personality, nocturnal polyuria, sleep-wake disorders, and bladder dysfunction significantly increased the risk of enuresis (P < 0.05). These findings underscore the importance of a holistic approach in evaluating psychological aspects, nocturnal urination patterns, sleep quality, and bladder health in managing enuresis.

CONCLUSION

The study identifies stubborn personality, nocturnal polyuria, sleep-wake disorders, and bladder dysfunction as independent risk factors for childhood enuresis. Understanding these factors is crucial for developing targeted interventions that can enhance the management and outcomes of enuresis. Future research should explore the interrelationships among these factors to refine preventive and therapeutic strategies for early childhood enuresis.

A systematic review and meta-analysis assessing the efficacy of Tuina for nocturnal enuresis in children

Background: Desmopressin acetate (DDAVP) and behavioral interventions (BI) are cornerstone treatments for nocturnal enuresis (NE), a common pediatric urinary disorder. Despite the growing body of clinical studies on massage therapy for NE, comprehensive evaluations comparing the effectiveness of Tuina with DDAVP or BI are scarce. This study aims to explore the efficacy of Tuina in the management of NE. Methods: A systematic search of international databases was conducted using keywords pertinent to Tuina and NE. The inclusion criteria were limited to randomized controlled trials (RCTs) that evaluated NE treatments utilizing Tuina against DDAVP or BI. This meta-analysis included nine RCTs, comprising a total of 685 children, to assess both complete and partial response rates. Results: Tuina, used as a combination therapy, showed enhanced clinical efficacy and improved long-term outcomes relative to the control group. The therapeutic efficacy of Tuina was not directly associated with the number of acupoints used. Instead, employing between 11 and 20 acupoints appeared to have the most significant effect. Conclusion: The findings of this meta-analysis support the potential of Tuina as an adjunct therapy to enhance the sustained clinical efficacy of traditional treatments for NE. However, Tuina cannot completely replace DDAVP or BI in the management of NE. While this study illuminates some aspects of the effective acupoint combinations, further research is crucial to fully understand how Tuina acupoints contribute to the treatment of NE in children. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=442644, identifier CRD42023442644.

Not only enuresis: do not disregard organic disorders

Nocturnal enuresis (NE) is a common condition in the pediatric age. NE is defined as an intermittent bedwetting with any frequency while sleeping in children. NE is classified into primary form (patient never had achieved nocturnal urinary control) or secondary form (children with a period of 6 consecutive months of night-time urinary control before incontinence, which is generally associated with organic or psychological causes). Moreover, NE could be monosymptomatic (MNE) or non-monosymptomatic (NMNE), depending on the presence of daytime incontinence or any other lower urinary tract symptoms (LUTS). We report a 7-year- old female with a history of recent onset of sphincter troubles and recurrent low urinary tract infections. She presented urinary urgency associated to daytime incontinence, bedwetting almost every night in the previous 3 months and sometimes encopresis. The physical and neurological examination was silent, no psychological or social problem intercurred. As first approach, she was treated with deamino-delta-D-arginine vasopressin (dDAVP) 120 mcg associated with oxybutynin 5 mg and educational therapy, for 3 months without benefits. So, she underwent a magnetic resonance imaging (MRI) of the spinal cord, that highlighted the presence of hydrosyringomyelia from D6 to D10, lipoma of the terminal filum and the presence of synovial cyst between L5-S1. This case remarks that in secondary NMNE, any possible organic cause must be investigated.

[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.

The Prevalence of Nocturnal Enuresis in Bangkok, Thailand: A Descriptive and Questionnaire Survey of 5 to 15 Year-Old School Students

Objectives. Nocturnal enuresis (NE) is a common problem among school-aged children. Nonetheless, further information on NE prevalence in Thailand is needed. The prevalence of NE and factors associated with it were investigated. Methods. A descriptive study was conducted in schools in Bangkok, Thailand, among children aged 5 to 15 years, using a questionnaire survey between November 2018 and July 2019. Results. The prevalence of primary monosymptomatic, primary nonmonosymptomatic, and secondary NEs was 9.7%, 11.6%, and 8.2%, respectively. Primary NE was associated with a family history of NE (OR = 4.05, P < .001), drinking within 2 hours before bedtime (OR = 1.77, P = .01), and deep sleep (OR = 1.62, P = .001). Conclusion. Primary NE was prevalent in this setting, and the most related factor was a family history of NE. Parents should be aware of NE in their children, especially if a child has a linked factor.

Sleep-Disordered Breathing and Its Association with Nocturnal Enuresis at the Primary Schools in Saudi Arabia: A Cross-Sectional Study

The correlation between nocturnal enuresis (NE) and sleep-disordered breathing (SDB) was reported. We aim to determine whether there is an association between NE and SDB in children and to assess the prevalence of SDB and NE in primary school children aged 6-12 years in Saudi Arabia. A cross-sectional observational study was conducted among the caregivers of children aged 6-12 years in all Saudi Arabia regions. The data were gathered through a self-administered online questionnaire. It included demographic information, weight and height, and associated comorbidities, in addition to the weekly frequencies of snoring symptoms and of enuresis, as well as of unrefreshing sleep using Likert-type response scales. Counts and percentages, the mean ± standard deviation, chi-square test, independent samples t-test, and regression analysis were used in the statistical analysis using R v 3.6.3. The questionnaire was completed by 686 respondents. Most respondents did not report any comorbidities in their children (77.1%). Asthma and adenotonsillar hypertrophy were reported in 16.2% and 15.6% of children, respectively. Unrefreshing sleep, mouth breathing at night, snoring, chronic nasal obstruction, and difficulty breathing while asleep were reported once or twice per week in 38%, 34%, 28%, 18%, and 18% of children, respectively. The prevalence of NE was 22.3%, with about 36.6% of children having NE two or more times per week. Significantly, NE was reported in 26.6% of children who slept before 10 PM compared to 19% of children who slept after 10 PM; in 28.6% of children who snored or loudly snored (57.1%) three times or more per week; and in 51.2% and 27.5% of children with difficulty breathing while asleep and who breathed through their mouth at night for one or two nights per week, respectively. A multivariable regression analysis showed that male gender (OR = 1.52, p = 0.010), obesity (OR = 1.24, p = 0.028), early sleeping time (OR = 1.40, p = 0.048), loud snoring for three or more nights per week (OR = 1.54, p = 0.001), difficulty breathing for one or two nights per week (OR = 1.85, p = 0.010), and mouth breathing at night for one or two nights per week (OR = 1.55, p = 0.049) were associated with higher odds of NE. Our study revealed that 22.3% of primary school children reported suffering from NE. SDB is a common problem among children with NE. The exact mechanism that links SDB to the increase in the risk of NE is unknown. Male gender, obesity, early sleeping time, loud snoring, difficulty breathing, and mouth breathing at night are potential independent risk factors of NE in school-age children.

Limited caffeine consumption as first-line treatment in managing primary monosymptomatic enuresis in children: how effective is it? A randomised clinical trial

OBJECTIVE

Evidence about the negative caffeine effect on enuresis in children remains understudied or poorly understood. The study aimed to investigate the effect of caffeine restriction on the improvement and severity of primary monosymptomatic nocturnal enuresis (PMNE).

DESIGN

Randomised clinical trial.

SETTING

Two referral hospitals in Tehran, Iran, from 2021 to 2023.

PATIENTS

Five hundred and thirty-four PMNE children aged 6-15 years (each group 267).

INTERVENTIONS

Amount of caffeine consumption was recorded by the feed frequency questionnaire and was estimated by Nutrition 4 software. Caffeine consumption per day in the intervention group was <30 mg, and in the control group, 80-110 mg. All children were asked to return 1 month later to check the recorded data. The ordinal logistic regression analysis was used to assay the effects of caffeine restriction on PMNE by relative risk (RR) at a 95% CI.

MAIN OUTCOME MEASURES

The effect of limited caffeine consumption on the improvement and severity of PMNE.

RESULTS

The mean age of the intervention and control groups was 10.9±2.3 and 10.5±2.5 years, respectively. The mean number of bed-wetting before caffeine restriction in the intervention and control group was 3.5 (SD 1.7) times/week and 3.4 (SD 1.9) times/week (p=0.91) and 1 month after intervention were 2.3 (SD 1.8) times/week and 3.2 (SD 1.9) times/week, respectively (p=0.001). Caffeine restriction significantly reduced the severity of enuresis in the intervention group. Fifty-four children (20.2%) improved (dry at night) in caffeine restriction and 18 children (6.7%) in the control group with RR 0.615 at 95% CI 0.521 to 0.726, p=0.001. The caffeine restriction significantly reduced the enuresis in children with a number-needed-to-treat benefit 7.417. It means you must treat 7.417 PMNE children with caffeine limitation to improve one child with enuresis (become dry).

CONCLUSION

Caffeine restriction can be helpful in reducing PMNE or its severity. Constructive limitation of caffeine is suggested as one of the first-line treatments in the management of PMNE.

TRIAL REGISTRATION NUMBER

IRCT20180401039167N3.

Do Sleep Disorders Influence the Prognosis and the Response to the Therapy in Enuretic Children?

OBJECTIVE

The current study describes the prevalence of sleep disorders in enuretic children, playing as influencing factors in the response to treatment and risk of relapse.

MATERIALS AND METHODS

Data were collected from September 2020 to February 2021 in 114 children aged between 5 and 14 years, with a diagnosis of nocturnal enuresis and concomitant sleep disorders, referred to the Pediatric Unit, Campus BioMedico University, Rome. Enuretic children were subjected to an anamnestic and clinical assessment. Sleep disorders investigated were sleep apnea, sleep talking, snoring, bruxism, restless sleep, and somnambulism. Each patient was subjected both to pharmacological and to non-pharmacological treatments and monitored for 3 months to identify the presence of relapse. Patients were divided into 2 groups according to therapy response, and statistical analysis was performed to evaluate possible variables involved in enuresis relapse.

RESULTS

A high prevalence of sleep disorders was documented: 8/114 children (7%) had sleep apnea, 47/114 (41.2%) had bruxism, 66/114 (57.8%) had snoring, 54/114 (47.3%) had sleep talking, 18/114 (15.7%) had restless sleep. Forty-three of 114 children (37.7%) had relapses: 21/43 (49%) relapses occurred in children with only 1 sleep disorder, while 22/43 (51%) relapses occurred in children with 2 or more sleep disorders. Lower risk of relapses was reported in children subjected to dual therapy.

CONCLUSION

Sleep disorders were widely associated with nocturnal enuresis, acting as comorbidities in the clinical course of nocturnal enuresis. Combined therapy seems to be associated with a lower rate of relapse of enuresis in a 3-month follow-up. A multidisciplinary approach is required to improve patients' management.

Attention deficit and hyperactivity disorder and nocturnal enuresis co-occurrence in the pediatric population: a systematic review and meta-analysis

BACKGROUND

Attention deficit and hyperactivity/impulsivity disorder (ADHD) and enuresis are common behavioral disorders in childhood, impacting adolescence and adult life. Enuresis (NE) is an incontinence disorder frequently observed in children with ADHD. The relationship between ADHD and NE has been a matter of debate.

OBJECTIVES

We aimed to verify the relationship between ADHD and enuresis and how these conditions can modify each other during development. Using PRISMA guidelines, under the PROSPERO registration number CRD42020208299, we systematically searched the literature and conducted a meta-analysis to answer the following question: how frequent is ADHD and enuresis comorbidity? Twenty-five studies were fully read, and data from seven less heterogeneous case-control studies were pooled to estimate enuresis prevalence comparing ADHD and control samples, whereas six studies were combined to evaluate ADHD frequencies in children with and without enuresis.

RESULTS

We found the ADHD rates in children with enuresis are similar to the enuresis rates in the group of children with ADHD. The presence of ADHD and enuresis comorbidity does not seem to play a role in gender distribution and the presence of other comorbidities in comparison to controls. However, enuresis seems to persist for more time in children with ADHD.

LIMITATIONS

The selected papers differed in study type, research question, samples, and controls utilized.

CONCLUSIONS

Our systematic review with meta-analysis supports the reciprocal association between enuresis and ADHD. Further studies are necessary to build more robust evidence.