Terodiline in the treatment of diurnal enuresis in children

Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics)

BACKGROUND

Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 20% of five-year olds and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis.

OBJECTIVES

To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi-randomised trials. The reference lists of relevant articles were also searched.

SELECTION CRITERIA

All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author.

MAIN RESULTS

A total of 40 randomised or quasi-randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials.For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights.Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects.

AUTHORS' CONCLUSIONS

There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials.

Treatment of daytime urinary incontinence in children: a systematic review of randomized controlled trials

PURPOSE

We sought to determine the benefits and harms of interventions for children with daytime urinary incontinence.

MATERIALS AND METHODS

Trials of any interventions for children with primary daytime incontinence (the urge syndrome and/or dysfunctional voiding) were identified from the Cochrane Controlled Trials Register, MEDLINE, EMBASE, reference lists of articles, abstracts from conference proceedings and contact with known experts in the field. Once identified, trial quality was assessed, data were extracted and results were expressed in terms of relative risks (RR) with 95% confidence intervals (CI) for individual trials, and summary estimates were obtained using a random effects model. All steps were done by 2 independent reviewers.

RESULTS

Randomized trials of terodiline (2 studies), daytime alarms (1), imipramine (1) and biofeedback/oxybutynin (1) involving 383 children were reviewed. No intervention was demonstrated to be effective. In the latter trial, which was the only one to evaluate a currently used intervention, after 9 months of treatment there was no difference in the proportions of children with unimproved daytime wetting with oxybutynin (RR 0.74, CI 0.26 to 2.13) and biofeedback (0.92, 0.59 to 1.43) compared with placebo.

CONCLUSIONS

No intervention tested in a trial to date has been proved to be of benefit to children with daytime urinary incontinence.

Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics)

BACKGROUND

Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great.

OBJECTIVES

To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children, and to compare them with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register. Date of the most recent search: December 2002. The reference list of a previous version of this review was also searched.

SELECTION CRITERIA

All randomised trials of drugs (excluding desmopressin or tricyclics) for nocturnal enuresis in children were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or other conservative interventions for nocturnal bedwetting. Trials focused solely on daytime wetting were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials and extracted data.

MAIN RESULTS

In 32 randomised controlled trials (25 new in this update), a total of 1225 out of 1613 children received an active drug other than desmopressin or a tricyclic. In all, 28 different drugs or classes of drugs were tested, but the trials were generally small or of poor methodological quality (five were quasi-randomised and the remainder failed to give adequate details about the randomisation process). Although indomethacin and diclofenac were better than placebo during treatment, desmopressin was better than both of them, with less chance of adverse effects. There were no data regarding what happened after treatment stopped. Limited data suggested that an alarm was better than drugs during treatment.

REVIEWER'S CONCLUSIONS

There was not enough evidence to judge whether the included drugs reduced bedwetting. There was limited evidence to suggest that desmopressin, imipramine and alarms were better than the drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective.

Urethral obstruction in patients with nighttime wetting: urodynamic evaluation and outcome of surgical incision

The aim of this study was to investigate urodynamic findings and the outcome of surgical incision in patients with nighttime wetting due to urethral obstruction. A total of 239 patients with nighttime wetting (157 males and 82 females; mean age, 8.7; range, 4-18 years) was studied. One hundred and ten patients had monosymptomatic enuresis alone and 129 both nighttime wetting and daytime symptoms, that is, the majority was not simple bedwetters, but had signs of bladder overactivity. All patients were first treated with bladder training and fluid intake after dinner was restricted. The non-responders were then treated with tricyclic antidepressants, anticholinergics, or intra-nasal desmopressin and conditioning therapy. Ninety-seven patients who did not respond to these conventional treatments were investigated by voiding cystourethrography, bougie à boule, and urodynamic study. Urethral obstruction was noted in 34 patients (14.2%); posterior urethral valves in three males, ring stricture of the bulbar urethra in 26 males and distal urethral stenosis in five females. Detrusor instability was noted in 30 (94%) of 32 patients. Three patients had <15 mL/s of maximum flow rate and none had post-void residual urine. Pressure at maximum flow (PQ(max)) was 106.5 +/- 26.3 cm H(2)O in pressure/flow study. After surgery, nighttime wetting was cured in 25 patients (73.5%), improved in four (11.8%). Detrusor instability disappeared in six of 16 patients studied (37.5%) and improved in 8 (50%), and PQ(max) decreased significantly after operation (P = 0. 0034). In conclusion, most of the patients with urethral obstruction have detrusor instability and high pressure voiding, and these conditions improved after operation.

Terodiline in the treatment of nocturnal enuresis in children

The effect of terodiline was investigated in 17 children with nocturnal enuresis. Twelve of them were evaluated urodynamically before treatment and 6 of these were proved to have detrusor instability with or without provocation. Terodiline in a daily dose of 12.5 mg was administered for 4 weeks. After treatment the number of wet nights per week has significantly decreased. Urodynamically, maximum cystometric capacity has statistically increased and in 2 patients involuntary contraction has disappeared. During these periods no serious side effects were encountered. Terodiline could improve urodynamic parameters in nocturnal enuresis. These changes appear to be favourable in clinical improvement.

Terodiline: a dose titrated, multicenter study of the treatment of idiopathic detrusor instability in women

Idiopathic detrusor instability is a common cause of lower urinary tract symptoms at all ages and in both sexes. Treatment initially is conservative and often includes drug therapy. Terodiline has the theoretical advantage of being a drug with anticholinergic and calcium channel blocking effects. Theoretically, by using a drug with dual action the beneficial effect of reduced detrusor overactivity might occur at a dosage below that likely to lead to the troublesome side effects experienced by patients who take pure anticholinergic agents. A total of 70 female patients completed a study characterized by extremely strict inclusion criteria and a tight protocol. Other novel elements to the study were the extensive use of urinary diaries for symptom evaluation, standardized urodynamic studies agreed upon by the participating centers and the dose titration design of the trial. Terodiline has been demonstrated to be a safe, well tolerated and effective drug in the treatment of idiopathic detrusor instability. Drug treatment led to significant decreases in urinary frequency and incontinence episodes. Pre-micturition symptoms, such as urgency, were markedly reduced and the voided volume was significantly increased. Although there were consistent trends towards greater improvement in the urodynamic measurements, when the terodiline and placebo groups were compared these did not reach statistical significance, partly due to a large improvement in the placebo group. Nevertheless, terodiline has been shown to be a useful drug for conservative management of patients with detrusor instability.

Sleep cystometries in children with nocturnal enuresis

A combined analysis was done of sleep and bladder filling during sleep. Cystometry did not specifically affect sleep, since most of the cystometry studies in cases of enuresis did not lead to sleep stage changes on electroencephalography. Bladder instability was not accompanied by lighter sleep. Increasing patient age did not appear to have any influence on sleep or bladder behavior. We conclude that it is possible to provoke enuresis at any sleep stage and that sleep is unaffected by bladder filling in enuretic patients.