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PubMed2002

The role of pelvic traction in the management of primary monosymptomatic nocturnal enuresis.

OBJECTIVE: To determine whether pelvic traction is beneficial in children with primary nocturnal enuresis. PATIENTS AND METHODS: There can be disproportionate growth between the spinal column and neural tube in prepubertal children. The normal elongation of the vertebral column in children during sleep could stretch the filum terminale and nerve roots, representing a minor degree of tethering that affects neural function and contributes to nocturnal enuresis. Pelvic traction induces a similar or more intense stretch while a patient is fully awake (and able to control their bladder). Releasing the potential tethering in this way, combined with conditioning therapy, could be beneficial. Fifty patients (aged 7-17 years) with monosymptomatic primary nocturnal enuresis were evaluated in a prospective study. All had 10 sessions of pelvic traction applied over 4 weeks and were followed up for 3 months afterward; no other medications were given. RESULTS: All patients had fewer wet nights, with variable degrees of success (20-80%) during and 3 months after traction. CONCLUSION: Pelvic traction is a safe, simple, economic and effective treatment for primary monosymptomatic nocturnal enuresis.

Adolescent↗
PubMed1998

The effectiveness of desmopressin in the treatment of childhood nocturnal enuresis: predicting response using pretreatment variables.

OBJECTIVE: To determine the factors that predict the effectiveness of desmopressin in the treatment of childhood nocturnal enuresis. PATIENTS AND METHOD: Sixty-six children with monosymptomatic nocturnal enuresis were treated with intranasal or oral desmopressin for a 4-week period. starting with a standard dose of 20 microg (0.2 mg oral) and increasing after 2 weeks where no progress was apparent to 40 microg (0.4 mg oral). Before treatment a range of variables (demographic, situational, enuretic history, physiological, parental attitude and child) were recorded. Three parameters of success acted as dependent variables, with stepwise linear regression models used to determine pretreatment predictors of success with desmopressin. RESULT: Each outcome variable produced a very similar model of predictors. Success, as assessed by the most dry nights over a 14-night period, was associated with less severe enuresis before treatment, a parental belief that the child's enuresis was unstable and higher birthweight. CONCLUSION: From the analysis, a model of arginine vasopressin release is proposed and the clinical implications of the findings addressed.

Administration, Intranasal↗
PubMed1998

Using multimedia for patient information--a program about nocturnal enuresis.

OBJECTIVES: To identify the information needs of children with nocturnal enuresis, and to design, produce and evaluate an interactive computer program to provide this information. SUBJECTS AND METHODS: The program was developed over an 18-month period using information provided by children, parents and professionals, and was evaluated in a hospital-based enuresis clinic in 65 children. Usability and knowledge gained were also evaluated in 43 healthy children aged 8-10 years attending a local inner-city primary school. RESULTS: An interactive program about nocturnal enuresis was developed, which runs on a personal computer and uses sound, voice, cartoon drawings and animation in a modular design. Knowledge scores increased in clinic attendees and in schoolchildren after using the program (Wilcoxon matched pairs test, P < 0.001). This improvement was maintained when the program was re-tested 6-10 months later. CONCLUSION: This interactive computer program holds children's attention and increases their understanding of enuresis. Interactive multimedia may be useful to complement the information provided by health professionals. This method of communication may be particularly useful for children with a low level of literacy.

CD-ROM↗
PubMed2001

An epidemiological study of nocturnal enuresis in Taiwanese children.

OBJECTIVE: To estimate the prevalence of primary nocturnal enuresis (PNE) in Taiwanese children, and to examine factors associated with PNE and its severity. SUBJECTS AND METHODS: In all, 1683 questionnaires were sent to parents of schoolchildren aged 6-11 years randomly selected from three primary schools in Taipei City, Taiwan. The questionnaire was designed to collect information about the prevalence of and factors associated with PNE. RESULTS: Of the questionnaires distributed, 1176 (70%) were completed. PNE was reported in 92 (8%) of the children; nine (10%) of these children were wet > 3 nights per week. Factors associated with PNE included male gender, deep sleep, divorced parents or separated family and a positive family history of enuresis. Of these factors, only those children with deep sleep were more likely to have > 3 wet nights per week. CONCLUSION: The prevalence of and factors associated with PNE in Taiwan are similar to those reported in Western countries, but the percentage of children with severe enuresis is lower than in Sweden, France and Turkey. Deep sleepers are more likely to have severe enuresis.

Analysis of Variance↗
PubMed2002

Increased urinary nitrite excretion in primary enuresis: effects of indomethacin treatment on urinary and serum osmolality and electrolytes, urinary volumes and nitrite excretion.

OBJECTIVE: To assess urinary nitrite excretion, a stable end product of nitric oxide (NO), in patients with enuresis and in normal controls, and to evaluate the effects of indomethacin (a potent prostaglandin synthesis inhibitor) on urinary nitrite excretion, other urinary variables and bladder capacity. PATIENTS AND METHODS: The study comprised 10 patients with primary enuresis and 10 normal comparable controls (age range 6-14 years). Nitrite was assayed in 'spot' morning urine samples in both the enuretics and normal controls. Enuretics were then given 50 mg indomethacin suppositories each night; urine volume, urinary osmolality and electrolytes, serum osmolality and electrolytes and urinary nitrite were assayed before indomethacin treatment and after 15 days of treatment. RESULTS: The mean (sd) urinary nitrite excretion was 24.4 (19.6) micromol/L in normal children and 275.9 (111.2) micromol/L in enuretics (P<0.05). With indomethacin, the urinary nitrite concentration was significantly decreased to 141 (45.1) micromol/L (P<0.05) and associated with a significant reduction in bed-wetting episodes and voiding frequency. The functional bladder capacity was <70% of the predicted value for age in six of the patients; they had significant improvements on indomethacin, to values similar to those in patients with a nearly normal functional bladder capacity. Indomethacin decreased the 24-h urinary volume by 41%, the night volume by 40%, clearance of free water by 46% and increased the day : night urinary volume ratio by 55%. The absolute amounts of urinary calcium, magnesium, phosphorus, urea, creatinine, and glucose were lower on indomethacin, although not statistically significantly so. Indomethacin decreased the 24-h urinary and 'spot' morning osmolality and osmotic clearance. There were no significant changes in serum osmolality and electrolyte concentrations. Indomethacin also decreased the absolute amount of urinary sodium, chloride and potassium, fractional sodium and potassium excretion, and filtered sodium. Creatinine clearance was decreased by 20% (P>0.05) and normal 24-h urinary protein was significantly lower, by 47%, after indomethacin treatment (P<0.05). CONCLUSION: Urinary nitrite excretion increased significantly in patients with primary nocturnal enuresis; indomethacin markedly reduced bed-wetting episodes and decreased the frequency of voiding in enuretics with small or normal functional bladder capacity, which was associated with a significant decrease in urinary nitrite excretion. Indomethacin reduced bed-wetting by decreasing the urine volume, clearance of free water and urinary electrolytes, and through possible effects on bladder and urethral contraction, by inhibiting NO and prostaglandin synthesis. NO and prostaglandins might be important in the pathogenesis of primary enuresis.

Adolescent↗
PubMed2006

[Therapy of monosymptomatic nocturnal enuresis in childhood and adolescence: what is the evidence?].

Nocturnal enuresis (bedwetting) is one of the most frequent urological symptoms in children, affecting about 20% of five year olds. It is a heterogeneous disorder with a whole variety of etiologic factors (genetic, endocrinological, neurobiological), particularly a dysfunction of the lower urinary tract. Despite the prevalence of enuresis many questions regarding the complex pathophysiological mechanisms remain unanswered. While nocturnal enuresis per se is clearly not a disease, psychosocial problems have been reported in up to 40% of affected children. Management strategies comprise behavioural and pharmacological approaches, either in isolation or combined. Although expectations were high, especially with pharmacological interventions, the results are usually disappointing with high recurrence rates. Extensive analyses of the available literature on the efficacy of enuresis treatment modalities reveal a poor quality of many trials with a whole range of methodological flaws. Therefore, further comparative studies of adequate methodological quality are needed.

Adolescent↗
PubMed2002

Demographics of enuresis patients attending a referral centre.

OBJECTIVE: To study and compare the demography of enuretic children 7-16 years old attending a tertiary referral centre for childhood urinary incontinence, with that of normal children and what is generally known about enuretics from population-based studies. METHODS AND MATERIALS: This was a retrospective analysis of data compiled from 298 enuretic patients referred to The Centre of Child Incontinence, Aarhus University Hospital, Skejby, Denmark, and 53 healthy controls. Data was obtained by conducting standardised questionnaire interviews. Patients were stratified according to accompanying symptoms and severity of enuresis. Statistical analysis of the results was then performed. RESULTS: Two hundred and ninety-three patients had sufficient data registered to allow reliable analysis. Male-female ratio was 2.2:1. Primary and secondary enuresis was found in 87.4% and 11.6% of the patients respectively. Enuresis was associated with a reported history of bronchial asthma (p < 0.05), verified allergy (p < 0.05) and a positive family history of the same disorder (p < 0.01). No association with psycho-developmental factors was evident. Approximately 98% of the patients had undergone some form of therapy at presentation. 74.1% of the patients had pure monosymptomatic enuresis, 16.4% had day and night time incontinence, while the remaining 9.6% had nocturnal incontinence combined with other lower urinary tract symptoms other than daytime wetting. CONCLUSIONS: The demography of our patient population was, with a few exceptions, within the confines of what has previously been reported. Our results also reaffirmed the heterogeneity of enuretic patients.

Adolescent↗
PubMed2004

The impact of monosymptomatic nocturnal enuresis on attachment parameters.

OBJECTIVE: This study assesses the impact of monosymptomatic nocturnal enuresis (MSNE) on the child's perception of quality of attachment to a caregiver and the caregiver's perception of dissociative behavior. MATERIAL AND METHODS: The study group comprised 47 boys and 63 girls (mean age 11.7 years; range 9-18 years). Subjects were classified into two groups as follows: Group I (normal children without nocturnal enuresis); or Group II (children with MSNE). MSNE was defined as more than three wet episodes per week without day-time enuresis, urge incontinence, frequency or dysuria. The Adolescent Attachment Questionnaire (AAQ) was administered to the children and the Child Dissociative Checklist (CDC) to the caregiver. Comparison groups were divided by gender, feeding method and type of caregiver. The AAQ and CDC scores in each subgroup were compared between the enuretic and non-enuretic groups. RESULTS: Mean scores for attachment pathology were significantly higher in the enuretic (n = 50) than the non-enuretic group (n = 60) (p < 0.05). The most significant attachment pathology was evident for the AAQ Angry Distress dimension in the nocturnally enuretic group. Caregivers' CDC scores did not differ significantly between the two groups. Highest mean dissociation scores were evident for those children whose caregiver was not a biologic parent or grandparent. CONCLUSIONS: MSNE may negatively impact the child's perception of the quality of attachment. Caregivers reported no significant dissociative behavior in nocturnally enuretic children. With prolonged nocturnal enuresis, physicians should be aware of the possibility of anger and distress within the child-caregiver relationship. In such cases, the modified treatment protocol should include psychologic counseling and support.

Adolescent↗
PubMed2003

Children presenting at UK community enuresis clinics--comparison with hospital-based samples.

OBJECTIVE: This study compares the clinical and psychosocial characteristics and the treatment outcomes of bedwetting UK children presenting at a community enuresis service with those from studies conducted in hospital-based settings. MATERIAL AND METHODS: Cluster stratification by clinic was applied to ensure that the population attending the 15 enuresis clinics selected was representative. Parents completed the maternal tolerance scale and children completed the impact of bedwetting and Coopersmith self-esteem scales. The electronic databases MEDLINE and CINAHL were searched for the years 1966-2002 for UK-based empirical studies conducted in children aged 5-16 years with nocturnal enuresis. RESULTS: Children in the community sample were younger and had more day-time wetting than the hospital-based population but did not have significantly lower self-esteem. The impact of bedwetting had the strongest relationship with the Coopersmith self-esteem score, followed by ethnicity and the maternal tolerance score (beta = -0.49, p < 0.001; beta = 2.83, p < 0.001; and beta = 0.45, p = 0.015; respectively). CONCLUSION: Primary referrals to community enuresis services are younger and have more day-time wetting than those attending hospital-based clinics but the majority do not have low self-esteem. Ethnicity appears to be an important factor in evaluating the impact of wetting on the child.

Adolescent↗
PubMed2006

Reboxetine in therapy-resistant enuresis: results and pathogenetic implications.

OBJECTIVE: To investigate whether the norepinephrine reuptake inhibitor reboxetine is effective as a non-cardiotoxic alternative to imipramine in the treatment of therapy-resistant enuresis. MATERIAL AND METHODS: Twenty-two children with severely socially handicapping enuresis resistant to urotherapy, the enuresis alarm, desmopressin and anticholinergics (all children had tried all these treatments) were given reboxetine, 4-8 mg at bed-time, for compassionate reasons. RESULTS: Thirteen of the children (59%) achieved complete dryness with reboxetine, either as monotherapy or combined with desmopressin. Side-effects were minor and did not lead to discontinuation of treatment. CONCLUSIONS: Although the results of this study need to be confirmed in randomized, placebo-controlled trials, reboxetine may prove to be a useful treatment for therapy-resistant nocturnal enuresis.

Adolescent↗
PubMed1999

Nocturnal enuresis can be caused by absorptive hypercalciuria.

OBJECTIVE: The aim of this study was to determine whether nocturnal enuresis (NE) can be caused by absorptive hypercalciuria. MATERIALS AND METHODS: From 1981 to 1995, 406 patients with primary monosymptomatic nocturnal enuresis were studied. Up to 1989 (Group 1), urinary electrolytes and urinary creatinine were not evaluated, but since 1990 (Group 2) these tests have been performed routinely. In doing so, we noticed that in 8 patients in Group 2 and in 13 patients in Group 1 with persistent NE the urinary calcium and the urinary calcium/creatinine ratios were significantly high (p < 0.001). These patients were submitted to Pak's test and parathyroid hormone (PTH) and antidiuretic hormone (ADH) measurements. RESULTS: In all 21 patients, PTH and ADH levels were normal, while the Pak's test showed absorptive hypercalciuria. They were given an appropriate diet. After 3 months, NE had ceased completely in 4 patients (19%); bedwetting episodes diminished and calciuria levels were found to be borderline in the remaining 17. A new urodynamic evaluation showed normal patterns in 12 and detrusor instability (DI) in 5. Patients with DI received oxybutinine: enuresis disappeared in all. The remaining 12 children with persistent NE and normal urodynamic findings and the child with DI and persistent NE empirically received DDAVP; enuresis ceased in all of them within 1 month and calciuria stabilized at normal levels. CONCLUSIONS: This study revealed that absorptive hypercalciuria can be responsible for NE and can be treated with the combination of diet and DDAVP.

Calcium↗
PubMed2003

The role of sleep and arousal in nocturnal enuresis.

AIM: To review what is known about the role of sleep and arousal mechanisms in the pathogenesis of nocturnal enuresis. METHODS: A review of the literature was carried out. RESULTS: The sleep of enuretic children, although polysomnographically quite normal, is exceedingly "deep"; that is enuretic children have high arousal thresholds. Apart from some overlap between enuresis and the (other) classic parasomnias, the sleep of enuretic children is no more problematic than that of the general population. Recently, the exciting possibility has arisen that the low arousability of enuretic children may be linked to the autonomous nervous system and to disturbances in the upper pons. CONCLUSIONS: Enuresis is not just a nocturnal problem but a disorder of sleep. The high arousal threshold is one of three major pathogenetic factors in enuresis-nocturnal polyuria and detrusor hyperactivity being the other two.

Autonomic Nervous System↗
PubMed2004

Atomoxetine for the treatment of pediatric nocturnal enuresis.

Current treatments for pediatric nocturnal enuresis rely upon the use of behavioral interventions, such as enuresis alarms, and pharmacological interventions, such as antidiuretic hormone analogs, tricyclic antidepressants, and anticholinergics. However, a considerable number of patients do not respond fully to any of these interventions, in spite of optimal behavioral management and medication dosing. This report describes 4 children with attention deficit hyperactivity disorder (ADHD) comorbid with nocturnal enuresis. Each child was treated with atomoxetine for ADHD and experienced serendipitous resolution of enuresis.

Adolescent↗
PubMed1994

Plasma levels and efficacy of imipramine treatment for enuresis.

OBJECTIVE: To determine the relationship between serum drug level and treatment efficacy in enuretic children treated with imipramine (IMI). METHOD: Eighteen children with primary nocturnal enuresis recruited from an ambulatory enuresis clinic population were the subjects of the study. After a baseline period of 2 weeks, children received placebo for 1 week followed by treatment with IMI in increasing dosages (1.0 mg/kg, 1.5 mg/kg, 2.0 mg/kg, and 2.5 mg/kg), each dosage being given for 2 weeks. Steady state IMI and desipramine levels were determined in each child for each dosage. Medication response ([drug % dryness-placebo % dryness] divided by [100%-placebo % dryness]) was determined for each dosing interval. RESULTS: Average dryness increased from 27.8% on placebo to 73% with 2.5 mg/kg of IMI. The overall correlation between medication response and combined serum level was .26 (p < .05). Side effects were monitored throughout the study and were found to be rare. CONCLUSIONS: The efficacy of IMI over placebo in reducing the frequency of nocturnal enuresis in children was confirmed. Efficacy was moderately but significantly related to increasing mg/kg dose. A higher serum level tended to be associated with a better response, but there was at least 700% variation in serum level between subjects at every dosage. Monitoring serum levels of imipramine in children with idiopathic functional nocturnal enuresis treated with that medication has a limited but real usefulness in clinical management.

Adolescent↗
PubMed2001

Bladder capacity and renal concentrating ability in enuresis: pathogenic implications.

PURPOSE: We compared bladder volume and renal concentrating capacity in dry children and 2 distinct groups of children with enuresis to hypothesize about the pathogenesis of various types of enuresis. MATERIALS AND METHODS: A total of 55 dry children and 100 with enuresis underwent an overnight thirst provocation test to assess renal concentrating capacity and completed a 2-day voiding chart to assess functional bladder capacity. The enuretic children were subdivided into 27 desmopressin responders and 73 desmopressin nonresponders before study inclusion. RESULTS: The desmopressin responder group had lower average renal concentrating capacity +/-1 standard deviation than dry children and desmopressin responders (856 +/- 158 mOsm./kg. versus 939 +/- 147 and 962 +/- 151, respectively, p <0.05). Analogously average daytime urine production in the desmopressin responder group was greater than in dry children and desmopressin responders (22.2 +/- 10.2 ml./kg. body weight versus 15.4 +/- 7.3 and 15.3 +/- 7.2, respectively, p <0.01). Average functional bladder capacity expected for age was less in desmopressin nonresponders than in dry children and responders (52.2% +/- 19.9% versus 79.2% +/- 30.4% and 69.5% +/- 25.7%, respectively, p <0.001). CONCLUSIONS: Desmopressin responders produced larger amounts of less concentrated urine than the other children, while desmopressin nonresponders had smaller bladder capacity than the other groups. These results support the idea that enuretic children who respond favorably to desmopressin treatment have polyuria, whereas children with therapy resistant enuresis have detrusor hyperactivity.

Child↗
PubMed1994

Diagnosis and management of nocturnal enuresis.

Nocturnal enuresis is a common problem occurring in 15% of children at 5 years of age. Although usually self-limiting, justification for early treatment is founded in the psychological impact on the child. The physician's role in treating enuresis is first to rule out structural causes for enuresis. After this has been done, the physician can tailor an enuresis treatment program for the child and family.

Age Factors↗
PubMed2002

Nocturnal enuresis.

PURPOSE OF REVIEW: The purpose of this review is to highlight and comment upon important areas of enuresis research. RECENT FINDINGS: Current areas of pathophysiological focus are nocturnal urine production, in which alternative mechanisms other than deficient vasopressin secretion has been implicated in some patients. Bladder reservoir function has gained renewed interest, and has proved to be one of the best predictors of treatment response to desmopressin. Various aspects of central nervous system function, including arousability and pontine reflexes, are in focus, and molecular genetics has provided firm evidence of a link between enuresis and different chromosomal markers. The therapeutic focus is directed towards a differential approach based upon the underlying mechanism and towards combination therapies such as alarm devices and desmopressin as well as anticholinergic agents and desmopressin. Furthermore, new exciting treatment concepts such as laser acupuncture have shown promising results in initial studies. SUMMARY: Despite recent advances in our understanding of nocturnal enuresis, we are still far from understanding in detail this socially discomfiting and scientifically intriguing condition, and many controversies remain. However, the substantiation that enuresis is a heterogeneous condition that requires a differential approach has provided the basis for further progress.

Arginine Vasopressin↗
PubMedDate not supplied

Treating nocturnal enuresis in children: review of evidence.

BACKGROUND: Childhood nocturnal enuresis (bedwetting) affects many families. Although it has a high rate of spontaneous remission, bedwetting may bring social and emotional stigma, stress, and inconvenience to both the child with enuresis and his or her family. DESIGN: Summary of systematic reviews of treatment for nocturnal enuresis in children, published in the Cochrane Library, using evidence only from randomized and quasi-randomized trials to compare interventions. Interventions included behavioral, alarm, and pharmacologic treatments. SETTING AND METHODS: Six Cochrane Reviews contributed evidence to this review: simple behavioral interventions, alarms, complex behavioral or educational interventions, desmopressin, tricyclics and related drugs, and other drugs. SUBJECTS: The participants were children (usually up to the age of 16). RESULTS: Much of the available evidence was of poor quality, and there were few direct comparisons between different types of intervention. Simple behavioral Interventions, such as reward systems, are widely used as standard first-line treatment, but they require a high level of parental involvement. There is currently little evidence to show that these interventions work, but they may be worth trying because they have only a few adverse effects. The use of an alarm intervention reduced nighttime bed wetting in a majority of children both during and after treatment. Overlearning or dry-bed training may reduce the relapse rate. Before embarking on alarm treatment, families need to be made aware of both the time and the high level of parental involvement necessary to attain success. Drug therapy, such as desmopressin and tricyclics, reduced the number of wet nights per week compared with placebo but only while the drug was used. Patients and their families need to be warned about possible side effects of some of the drugs. CONCLUSIONS: Alarms are the most effective treatment for nocturnal enuresis in children, but desmopressin may be considered for temporary relief.

Adolescent↗