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PubMed1996

Diagnosis and management of nocturnal enuresis.

The etiology of primary nocturnal enuresis remains somewhat controversial but may include genetic factors, decreased functional bladder capacity, increased diuresis at night, and constipation. Deep sleep and emotional illness usually play only a minimal role. A detailed description of the enuretic episodes should be obtained, and a neurologic examination should be performed as part of the physical evaluation of a child with nocturnal enuresis. In uncomplicated cases, urinalysis and a urine culture are the only required laboratory tests. The specific cause of the nocturnal enuresis usually is not determined. Treatment options include the urine alarm system, pharmacotherapy and complex regimens such as dry-bed training. Treatments are often combined. Nocturnal enuresis eventually resolves in the majority of cases.

Algorithms↗
PubMed1997

Oral desmopressin: a randomized double-blind placebo controlled study of effectiveness in children with primary nocturnal enuresis.

PURPOSE: Desmopressin nasal spray has proved to be efficacious treatment of primary nocturnal enuresis. Oral desmopressin tablets would be a more easily used, convenient vehicle for our patients and their parents. We evaluated the effectiveness of oral desmopressin in decreasing the number of wet nights in patients with primary nocturnal enuresis. MATERIALS AND METHODS: We performed a double-blind, placebo controlled, parallel group trial of oral desmopressin in 141 children 5 to 17 years old with documented primary nocturnal enuresis at 14 sites. Patients were screened for number of wet nights for 2 weeks before study entry. A minimum of 3 wet nights weekly for 2 consecutive weeks was required for study entry. Patients were randomized to receive 200, 400 or 600 mcg. desmopressin or placebo before bedtime. Fluids were restricted 2 hours before bedtime based on body weight. The primary efficacy variable was mean decrease in the number of wet nights recorded during the last 2-week treatment period. The percentage of responding patients and mean decrease from baseline in number of wet nights at 2, 4 and 6 weeks were also assessed. RESULTS: The decrease in wet nights was 9, 20, 30 and 36% for placebo, and 200, 400, and 600 mcg. desmopressin orally per day, respectively. The 600 mcg. dose of oral desmopressin daily was statistically significantly different (p < 0.05) from placebo in decreasing wet nights. A complete or near complete response (0 to 2 wet nights) was noted in 3, 18, 33 and 24% of the patients who received placebo, and 200, 400 and 600 mcg. oral desmopressin daily, respectively. The 400 and 600 mcg. treatment groups were statistically significantly different (p < 0.05) from placebo. A less than 50% decrease in wet nights was noted in 83, 79, 64 and 61% of the patients who received placebo, and 200, 400 and 600 mcg. oral desmopressin daily, respectively. Oral desmopressin exhibited a dose response in the treatment of primary nocturnal enuresis. The linear trend for the decrease in wet nights was statistically significant (p < 0.05). CONCLUSIONS: A dose of 600 mcg. oral desmopressin daily significantly decreased the mean number of wet nights when administered for 6 weeks. A higher dose may be necessary for an improved response.

Administration, Oral↗
PubMed1997

[Enuresis nocturna--neu studies of genetic, pathophysiologic and psychiatric correlations].

Nocturnal enuresis is characterized by a highly complex interaction of somatic and psychiatric factors. A primary monosymptomatic, a symptomatic (with diurnal rnicturition problems) and a secondary form (following a dry interval) can be differentiated. Despite deep sleep with difficult arousal, the sleep architecture itself is normal and enuretic episodes occur in every sleep stage without urodynamic changes. Changes in the circadian AVP-rhythm with nocturnal polyuria have been demonstrated repeatedly. Formal genetically, many families are compatible with an autosomal dominant mode of inheritance. Linkage studies have shown a linkage of nocturnal enuresis with regions on chromosomes Nr. 8, 12 and 13. There is a significantly increased rate of psychiatric problems. The associations are complex, with psychiatric factors occurring both reactively following the enuresis, as well as being causally involved in secondary, but not in primary monosymptomatic nocturnal enuresis.

Adolescent↗
PubMed1998

Nocturnal enuresis: basic facts and new horizons.

Nocturnal enuresis in children is quite seldom due to psychological factors. Instead, it is caused by a hereditary delay in maturation of the somatic mechanisms (reduction of nocturnal urine production, relaxation of the bladder during sleeping hours, and a normal arousal to a full bladder) which prevent the child from wetting the bed. Doctors treating bedwetting children have often used an expectant attitude because nocturnal enuresis has been looked upon as self-limiting and innocent. According to recent research, this is not true. In children aged 7 years, more than 5% and in the adult population 0.5% report nocturnal enuresis. Thus, many enuretic children will remain bedwetters for life if left untreated. Furthermore, the child is ashamed and feels guilt because of his nocturnal enuresis which threatens to give a significant impairment of self-esteem at an age when an intact self-image is extremely important for an optimal development of the child's personality. Treatment should be given when the enuretic child wants to sleep dry.

Arousal↗
PubMed1998

Hyponatremic seizure in a child using desmopressin for nocturnal enuresis.

BACKGROUND: Intranasal desmopressin has been used extensively to treat primary nocturnal enuresis. While it has proven to be a safe, effective agent for many who are affected by this condition, the potential for complications exists. OBJECTIVES: To report a case of severe hyponatremia associated with a generalized tonic-clonic seizure in a 10-year-old boy who had been receiving intranasal desmopressin nightly for nocturnal enuresis and to briefly review therapeutic options for nocturnal enuresis; and to present the role of desmopressin. SETTING: Georgetown University Medical Center, Washington, DC. INTERVENTION: Fluid restriction and intravenous isotonic saline solution with 5% dextrose was administered to raise the serum sodium level. OUTCOME: Prevention of further seizures with normalization of serum sodium levels without any obvious neurological sequelae. CONCLUSIONS: This case illustrates the importance of weighing the benefits and risks of intranasal desmopressin therapy.

Child↗
PubMed1998

Do children with primary nocturnal enuresis have clinically significant behavior problems?

OBJECTIVE: To determine if primary nocturnal enuresis (PNE) is accompanied by significant behavioral comorbidity. DESIGN: A survey design using a standardized behavioral rating scale. SETTING: Behavioral pediatric clinics in the Midwest. PARTICIPANTS: Subjects with PNE (n=92) were selected from 122 consecutive referrals for enuresis. Criteria included age 5 years or older, PNE status, and wetting frequency of at least once per week. The clinical sample without PNE (n=92) was randomly selected from 429 consecutive referrals to the same pediatric clinics, stratified for age and sex. The nonclinical sample (n=92) was randomly selected by strata from the standardization sample (N=614) of the behavioral checklist used in the study. MAIN OUTCOME MEASURE: The Eyberg Child Behavior Inventory (ECBI), a standardized parent report scale, was used to measure the degree of behavioral comorbidity. The ECBI yields 2 scores, Problem Intensity and Problem Number. RESULTS: Results from 2 separate 3 (group) x 2 (sex) analyses of variance indicated a significant main effect for group on Problem Intensity and Problem Number (P<.001). For Problem Intensity, post hoc comparisons indicated the mean of the PNE sample was significantly higher than the mean of the nonclinical sample (P<.05), but the mean scores of the clinical sample were significantly higher than those of both the PNE and nonclinical samples (P<.05). For Problem Number, post hoc comparisons revealed the means of the PNE and nonclinical samples did not differ from each other (P>.05) but were lower than the mean of the clinical sample (P<.05). CONCLUSION: Primary nocturnal enuresis does not present with significant behavioral comorbidity in most cases. The results suggest that, with the exception of an extraordinary clinical presentation, pediatricians should treat PNE as a common biobehavioral problem without a psychiatric component.

Child↗
PubMed1981

Parental perceptions of enuresis. A collaborative study.

Of 1,379 children 4 years of age and older who were patients in nine medical centers across the country, 346 (25.1%) were found to be enuretic. Their parents considered heavy sleeping and emotional problems as the main causes of enuresis in children; physical causes rarely were believed to be important. "Waking up the child" from sleep to urinate and "talking about the problem" were the main methods that parents used to treat enuresis. Very few used medication. Parents with a grade school level of education punish bed-wetting children at twice the rate of high school- and college-educated parents. Physicians need to be more aware that enuresis is an important problem for parents and that there are many widely held beliefs about cause and management.

Adolescent↗
PubMed1983

Desmopressin response of enuretic children. Effects of age and frequency of enuresis.

To characterize the children with enuresis likely to respond to desmopressin acetate, we performed a double-blind crossover study that included the use of a placebo. During the two weeks of desmopressin administration, six children (12%) had 13 or 14 dry nights, and 15 children (29%) had eight to 12 dry nights. Among the 17 children aged 9 years or older, with four to seven dry nights during the two-week baseline period, 12 children (71%) responded to desmopressin (eight to 14 dry nights). In contrast, none of the 15 children younger than 9 years of age with fewer than three dry nights before therapy responded. During the posttreatment period, only four of the 21 drug responders reported a persistent effect. Desmopressin may be effective in reducing the frequency of enuresis, especially in children older than 9 years of age without nightly enuresis.

Adolescent↗
PubMed1986

Constipation a commonly unrecognized cause of enuresis.

Constipation was confirmed by history, rectal examination, and rectal manometric studies in 22 of 25 children with enuresis. Treatment of constipation resulted in resolution of enuresis. Uninhibited bladder contractions, observed in enuretic constipated children, were also noted in children with constipation alone, suggesting that constipation is a commonly unrecognized etiologic factor in enuresis.

Child↗
PubMed1980

Childhood enuresis. I. Sleep patterns and psychopathology.

Forty severely enuretic boys (mean age, 10.8 years) were selected; 20 had associated psychiatric disturbance and 20 had enuresis as an isolated symptom. Psychiatrically disturbed enuretics had both slightly higher scores on a neurological examination for "soft signs" and more "stressful" background events. Enuretic events were not associated with a particular sleep stage; disturbed and nondisturbed enuretics did not differ from each other with respect to the distribution of enuretic events by sleep stage. The results do not support the concepts of enuresis as an arousal disorder or of there being different sleep profiles of enuresis in relation to behavioral pathology.

Adolescent↗
PubMed2005

Alarm interventions for nocturnal enuresis in children.

BACKGROUND: Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults. OBJECTIVES: To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions. SEARCH STRATEGY: We searched the Cochrane Incontinence Group specialised trials register (searched 22 November 2004) and the reference lists of relevant articles. SELECTION CRITERIA: All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the quality of the eligible trials, and extracted data. MAIN RESULTS: Fifty five trials met the inclusion criteria, involving 3152 children of whom 2345 used an alarm. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95% CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (4/22 (18%) vs 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69). Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94). AUTHORS' CONCLUSIONS: Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.

Absorbent Pads↗
PubMed2002

Simple behavioural and physical interventions for nocturnal enuresis in children.

BACKGROUND: Nocturnal enuresis (bedwetting) is a socially disruptive 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 can be great. Simple behavioural methods of treating bedwetting include reward systems such as star charts given for dry nights, lifting or waking the children at night to urinate, retention control training to enlarge bladder capacity (bladder training) and fluid restriction. OBJECTIVES: To assess the effects of simple behavioural interventions on nocturnal enuresis in children, and to compare these with other interventions. SEARCH STRATEGY: We searched the Cochrane Incontinence Group trials register. The reference list of a previous version of this review was also searched. Date of the most recent search: December 2001. SELECTION CRITERIA: All randomised or quasi-randomised trials of simple behavioural interventions for nocturnal enuresis in children up to the age of 16. Trials focused solely on daytime wetting were excluded. DATA COLLECTION AND ANALYSIS: In a previous version of this review, trials up to 1997 were independently assessed by two reviewers. Previous trials were re-assessed, and further trials were assessed for quality, and data were extracted by another reviewer. MAIN RESULTS: Twelve reliable trials met the inclusion criteria, involving 748 children of whom 365 received a simple behavioural intervention. However, within each comparison each outcome was addressed by single trials only, precluding meta-analysis. In single small trials, reward systems (e.g. star charts), lifting and waking were each associated with significantly fewer wet nights, higher cure rates and lower relapse rates compared to controls. There was not enough evidence to evaluate retention control training (bladder training), whether compared with controls or dry bed training, or used as a supplement to alarms, or versus desmopressin. Cognitive therapy may have lower failure and relapse rates than star charts, but this finding was based on one small trial only. One small trial of poor quality suggested that star charts were initially less successful than amitriptyline but this difference did not persist after the treatments stopped. REVIEWER'S CONCLUSIONS: Simple behavioural methods may be effective for some children, but further trials are needed, in particular in comparison with treatments known to be effective, such as desmopressin, tricyclic drugs and alarms. However, simple methods could be tried as first line therapy before considering alarms or drugs, because these alternative treatments may be more demanding and may have adverse effects.

Adolescent↗
PubMed2004

Simple behavioural and physical interventions for nocturnal enuresis in children.

BACKGROUND: Nocturnal enuresis (bedwetting) is a socially disruptive 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 can be great. Simple behavioural methods of treating bedwetting include reward systems such as star charts given for dry nights, lifting or waking the children at night to urinate, retention control training to enlarge bladder capacity (bladder training) and fluid restriction. OBJECTIVES: To assess the effects of simple behavioural interventions on nocturnal enuresis in children, and to compare these with other interventions. SEARCH STRATEGY: We searched the Cochrane Incontinence Group trials register (searched 18 September 2003). The reference list of a previous version of this review was also searched. SELECTION CRITERIA: All randomised or quasi-randomised trials of simple behavioural interventions for nocturnal enuresis in children up to the age of 16. 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: Thirteen trials met the inclusion criteria, involving 702 children of whom 387 received a simple behavioural intervention. However, within each comparison each outcome was addressed by single trials only, precluding meta-analysis. In single small trials, reward systems (e.g. star charts), lifting and waking were each associated with significantly fewer wet nights, higher cure rates and lower relapse rates compared to controls. There was not enough evidence to evaluate retention control training (bladder training), whether compared with controls or dry bed training, or used as a supplement to alarms, or versus desmopressin. Cognitive therapy may have lower failure and relapse rates than star charts, but this finding was based on one small trial only. One small trial of poor quality suggested that star charts were initially less successful than amitriptyline but this difference did not persist after the treatments stopped. Another suggested that imipramine was better than fluid deprivation and avoidance of punishment. REVIEWERS' CONCLUSIONS: Simple behavioural methods may be effective for some children, but further trials are needed, in particular in comparison with treatments known to be effective, such as desmopressin, tricyclic drugs and alarms. However, simple methods could be tried as first line therapy before considering alarms or drugs, because these alternative treatments may be more demanding and may have adverse effects.

Adolescent↗
PubMed2005

Complementary and miscellaneous interventions for nocturnal enuresis in children.

BACKGROUND: Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults. OBJECTIVES: To assess the effects of complementary interventions and others such as surgery or diet on nocturnal enuresis in children, and to compare them with other interventions. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Register (searched 22 November 2004), the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) (January 1984 to June 2004) and the reference lists of relevant articles. SELECTION CRITERIA: All randomised or quasi-randomised trials of complementary and other miscellaneous interventions for nocturnal enuresis in children were included except those focused solely on daytime wetting. Comparison interventions could include no treatment, placebo or sham treatment, alarms, simple behavioural treatment, desmopressin, imipramine and miscellaneous other drugs and interventions. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the quality of the eligible trials, and extracted data. MAIN RESULTS: In 15 randomised controlled trials, 1389 children were studied, of whom 703 received a complementary intervention. The quality of the trials was poor: four trials were quasi-randomised, five showed differences at baseline and ten lacked follow up data. The outcome was better after hypnosis than imipramine in one trial (relative risk (RR) for failure or relapse after stopping treatment 0.42, 95% confidence interval (CI) 0.23 to 0.78). Psychotherapy appeared to be better in terms of fewer children failing or relapsing than both alarm (RR 0.28, 95% CI 0.09 to 0.85) and rewards (0.29, 95% 0.09 to 0.90) but this depended on data from only one trial. Acupuncture had better results than sham control acupuncture (RR for failure or relapse after stopping treatment 0.67, 95% CI 0.48 to 0.94) in a further trial. Active chiropractic adjustment had better results than sham adjustment (RR for failure or relapse after stopping treatment 0.74, 95% CI 0.60 to 0.91). However, each of these findings came from small single trials, and need to be verified in further trials. The findings for diet and faradization were unreliable, and there were no trials including homeopathy or surgery. AUTHORS' CONCLUSIONS: There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture and chiropractic but it was provided in each case by single small trials, some of dubious methodological rigour. Robust randomised trials are required with efficacy, cost-effectiveness and adverse effects carefully monitored.

Acupuncture Therapy↗
PubMed1991

Functional enuresis: pharmacological versus behavioral treatment.

Treatment of childhood enuresis requires a careful anamnesis, physical examination, urinalysis, and urine culture to determine if a subject is affected with functional or organic enuresis. Functional enuresis (FE) was present in the majority of our patients (168/204). These 168 subjects, aged from 6 to 11 years, were randomly divided into three therapy groups (pharmacological therapy, behavioral therapy, and behavioral therapy with the aid of a personal computer). Our study shows that behavioral therapy gave better results in FE than did pharmacological therapy. We point out the usefulness of combining bladder retention training and behavioral therapy to improve the general maturity and autonomous behavior of the child, and the resultant positive effects on his personality.

Behavior Therapy↗
PubMed1988

Childhood nocturnal enuresis: the prediction of premature withdrawal from behavioral conditioning.

Predictors of premature withdrawal from a 12-week program of behavioral conditioning for childhood nocturnal enuresis were examined for 47 children treated at a university outpatient clinic. All children were administered the Piers-Harris Children's Self-Concept Scale; parents completed the 55-item Behavior Problem Checklist and the Tolerance Scale for Enuresis. Parents also reported the methods (i.e., random awakening, restriction of fluids, rewards, punishment, medication, other) previously used to control their child's wetting. A stepwise discriminant function analysis revealed that the function containing number of previous techniques used, presence of child behavior problems, and parent tolerance of enuresis was a significant predictor of early termination of treatment.

Adolescent↗
PubMed1996

Hyponatraemia and cerebral convulsion due to short term DDAVP therapy for control of enuresis nocturna.

UNLABELLED: Desmopressin (DDAVP) is frequently used in the treatment of primary isolated enuresis nocturna if other approaches have failed. We report a further case of hyponatraemia and cerebral convulsion due to water intoxication after intranasal DDAVP application by a 6 year-old boy with enuresis. CONCLUSION: Although adverse reactions in DDAVP (e.g. hyponatraemia) are rare, it should not be considered as the first choice treatment of enuresis nocturna and only be used with caution.

Child↗
PubMed1999

Somatic correlates of functional enuresis.

Functional enuresis is a heterogeneous group of syndromes with different aetiology and pathophysiology. The aim was to identify specific somatic correlates of enuresis non-invasively in child psychiatric patients after exclusion of neurologic and structural forms of incontinence. One hundred sixty-seven consecutive children, aged 5 to 10 years with day and/or night wetting were examined prospectively with: urinalysis and bacteriology; ultrasonography, including bladder wall thickness and residual volume; uroflowmetry and pelvic-floor-EMG; EEG; and a complete paediatric-neurologic examination. Day wetting children had a significantly higher rate of previous antibiotic prophylaxis, larger residual volume, thicker bladder walls; the uroflow curves were significantly less bell- and more staccato-shaped, the EMG less relaxed. Voiding postponers showed a tendency towards more uroflow anomalies than urge incontinent children. Primary and secondary enuretics did not differ on most parameters, but primary nocturnal enuretics with micturition problems had significantly less relaxed EMGs than monosymptomatic enuretics. Although day wetters had more pathological EEGs and neurological signs, these differences did not reach significance. The overall rate of urogenital anomalies was 10%. In conclusion, enuresis has a high rate functional somatic correlates with clinical and theoretical, classificatory implications.

Child↗