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Abstract
The authors do not have all of the data about enuresis, and many children are subject to relapses or failure of treatment. There is no cause for despondency, however. Enuresis is no longer a mystery. Good data exist about the natural history, epidemiology, and etiology of enuresis. In addition, multiple treatment modalities are available to practitioners. This article has sought to review the scientific literature and to relate the authors' experience with enuresis. The authors recommend a treatment program for children with monosymptomatic nocturnal enuresis that includes removal of caffeine from the diet. Enuretic children do not consume enough fluid, and the authors recommend that the daily fluid requirement be divided during the day: 40% in the morning, 40% in the afternoon, and 20% in the evening, with no restriction of fluid. Normalization of small functional bladder capacities may help to cure enuresis and has an effect on the efficacy of other therapies. Treatment of enuretics with antibiotics is effective in children with UTI, bacteriuria, or cystitis cystica. DDAVP has been shown to be effective in the treatment of enuresis, especially in children who have achieved a normal functional bladder capacity. Bladder alarm systems also offer a potential cure of enuresis, are inexpensive, and show a low relapse rate.
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Affiliation(s)
- M W Jalkut
- Division of Pediatric Urology, University of California Los Angeles School of Medicine, Division of Pediatric Urology, Clark-Morrison Children's Urological Center, University of California Los Angeles Children's Hospital, Los Angeles, California, USA
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Wolfish N. Sleep arousal function in enuretic males. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY. SUPPLEMENTUM 1999; 202:24-6. [PMID: 10573786 DOI: 10.1080/003655999750169402] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Enuretic children are described as difficult to arouse from sleep. This paper reports on the clinical implications of auditory sleep arousal thresholds in 15 enuretic and 18 control subjects (7-12-year-old males). All children were studied in a sleep laboratory for four consecutive nights using standard polysomnographic recording techniques. Sleep was undisturbed for the first two nights and waking thresholds were measured on the following two nights. Enuretic children were found to wet most frequently in the first two-thirds of the night. Arousal attempts were successful in 39.7% of controls and 9.3% attempts were successful in enuretics. The results of this study suggest that enuretic males were more difficult to arouse than age-matched controls. The elevated arousal thresholds may have been the result of delayed maturation. Therefore, treatment programs that rely on awakening should be cognizant of these features.
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Affiliation(s)
- N Wolfish
- Division of Nephrology, Children's Hospital of Eastern Ontario, Ottawa, Canada
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Hoekx L, Wyndaele JJ, Vermandel A. The role of bladder biofeedback in the treatment of children with refractory nocturnal enuresis associated with idiopathic detrusor instability and small bladder capacity. J Urol 1998; 160:858-60. [PMID: 9720576 DOI: 10.1016/s0022-5347(01)62821-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Not all children with primary nocturnal enuresis, an unstable detrusor and small bladder capacity can be treated successfully with anticholinergics and bladder drill. We report our use of bladder biofeedback in patients who did not respond to 3 months of such treatment. MATERIALS AND METHODS A total of 24 patients (median age 10.4 years) were studied. For bladder biofeedback a transurethral catheter was placed and connected with a 3-way connector. The bladder was slowly filled through this catheter and the intravesical pressure could be seen on a vertical tube, which was also connected to the transurethral catheter. The perineal bulbar detrusor inhibiting reflex was used in cases of involuntary bladder contraction. During the day patients retained urine as long as possible and completed a micturition chart. RESULTS Of the 24 patients bed-wetting stopped completely in 17 and decreased in 6, and treatment failed in 1. All patients were followed for at least 6 months after treatment. There were 2 cases of recurrence in the group that was cured. CONCLUSIONS Intravesical biofeedback can successfully treat patients with refractory primary enuresis associated with unstable detrusor and small bladder capacity.
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Affiliation(s)
- L Hoekx
- Department of Urology, University Hospital Antwerp, Edegem, Belgium
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Rushton HG, Belman AB, Zaontz MR, Skoog SJ, Sihelnik S. The influence of small functional bladder capacity and other predictors on the response to desmopressin in the management of monosymptomatic nocturnal enuresis. J Urol 1996; 156:651-5. [PMID: 8683752 DOI: 10.1097/00005392-199608001-00022] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE The relationship of functional bladder capacity as well as other variables to the responsiveness to desmopressin in children with monosymptomatic nocturnal enuresis was investigated. MATERIALS AND METHODS A total of 95 children 8 to 14 years old with monosymptomatic nocturnal enuresis (6 or more of 14 nights wet) were evaluated in a double-blind study followed by open label crossover extension using 20 to 40 mcg. desmopressin. Evaluated predictors of response included patient age, gender, race, family history, number of baseline wet nights, urine osmolality parameters and maximum functional bladder capacity (as a percent of predicted bladder capacity based on the formula, patient age + 2 x 30 = cc). Responders to desmopressin were classified as excellent (2 or less of 14 nights wet) or good (50% or greater decrease but more than 2 of 14 nights wet) and nonresponders were defined by a less than 50% decrease in wet nights. RESULTS Of the 95 patients 25 (29.5%) achieved an excellent response to desmopressin and 18 (18.9%) had a good response for a cumulative response rate of 45.3%. The remaining 52 patients (54.7%) were nonresponders. There were no significant differences between responders and nonresponders in regard to gender, race, positive family history or baseline urine osmolality parameters. Response to desmopressin was associated with older age, fewer baseline wet nights and larger bladder capacity. Patients with a functional bladder capacity greater than 70% predicted bladder capacity were 2 times more likely to respond to desmopressin. CONCLUSIONS The responsiveness of children with nocturnal enuresis to desmopressin is adversely affected by reduced functional bladder capacity. The results of this study have implications regarding the potential use of combination pharmacotherapy with desmopressin and an anticholinergic for enuretic patients who are nonresponsive to single drug therapy.
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Affiliation(s)
- H G Rushton
- Children's National Medical Center, Washington, D.C. 20010, USA
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Rushton H, Belman A, Zaontz MR, Skoog SJ, Sihelnik S. The Influence of Small Functional Bladder Capacity and and Other Predictors on the Response to Desmopressin in the Management of Monosymptomatic Nocturnal Enuresis. J Urol 1996. [DOI: 10.1016/s0022-5347(01)65775-6] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- H.Gil Rushton
- From the Children's National Medical Center and Walter Reed Army Medical Center, Washington, D. C., and Children's Regional Hospital at Cooper Hospital, Camden, New Jersey
| | - A.Barry Belman
- From the Children's National Medical Center and Walter Reed Army Medical Center, Washington, D. C., and Children's Regional Hospital at Cooper Hospital, Camden, New Jersey
| | - Mark R. Zaontz
- From the Children's National Medical Center and Walter Reed Army Medical Center, Washington, D. C., and Children's Regional Hospital at Cooper Hospital, Camden, New Jersey
| | - Steven J. Skoog
- From the Children's National Medical Center and Walter Reed Army Medical Center, Washington, D. C., and Children's Regional Hospital at Cooper Hospital, Camden, New Jersey
| | - Stephen Sihelnik
- From the Children's National Medical Center and Walter Reed Army Medical Center, Washington, D. C., and Children's Regional Hospital at Cooper Hospital, Camden, New Jersey
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Dittmann RW, Wolter S. Primary nocturnal enuresis and desmopressin treatment: do psychosocial factors affect outcome? Eur Child Adolesc Psychiatry 1996; 5:101-9. [PMID: 8814416 DOI: 10.1007/bf01989502] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Twenty-three patients (5 to 15 years of age) with primary nocturnal enuresis were treated with desmopressin (DDAVP) according to a four-step protocol with weekly reductions of daily doses (1 to 0.25 microgram/kg body weight) thus including aspects of behavior-oriented "bladder retention training". The rate of wet nights was significantly reduced while patients were on medication (p < 0.02), but the sample as a whole returned to baseline levels after medication was stopped. Six subjects (26%) were non-responders. A variety of psychological and psychosocial single factors did not significantly affect the outcome. However, a subgroup of seven patients assessed as "psychologically non-distressed" revealed better results both on medication (p < 0.02; reduction 73%) and off medication (p > or = 0.05; reduction 39%) compared to a "distressed" subgroup (N = 16). Both groups showed significant changes in wet nights over the treatment course (p < 0.02 and p > or = 0.002, respectively). There was no clear-cut relationship between laboratory data (urine volume, osmolality, vasopressin) and outcome in wet nights. Data did not suggest a subgroup of patients with particularly low nocturnal vasopressin (AVP) secretion and, thus, high rates of wet nights. Our results corroborated the finding that DDAVP is an effective substance in reducing wet nights in patients with primary nocturnal enuresis. However, with respect to major reductions and long-term results (off medication), these preliminary findings suggest that "psychological distress" seems to be a very important confounding outcome variable. Thus, careful consideration and assessment of psychological and psychosocial aspects of distress are recommended. Eventually, a combination of DDAVP treatment with counseling and/or psychotherapy may significantly improve results for the majority of patients and families.
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Affiliation(s)
- R W Dittmann
- Psychosomatic Department, Children's Hospital, University of Hamburg, FRG
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Norgaard J, Jonler M, Rittig S, Djurhuus J. A Pharmacodynamic Study of Desmopressin in Patients with Nocturnal Enuresis. J Urol 1995. [DOI: 10.1016/s0022-5347(01)67385-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- J.P. Norgaard
- Urological Department K, Aarhus University Hospital, Skejby Section and Institute of Experimental Clinical Research, University of Aarhus, Aarhus, Denmark
| | - M. Jonler
- Urological Department K, Aarhus University Hospital, Skejby Section and Institute of Experimental Clinical Research, University of Aarhus, Aarhus, Denmark
| | - S. Rittig
- Urological Department K, Aarhus University Hospital, Skejby Section and Institute of Experimental Clinical Research, University of Aarhus, Aarhus, Denmark
| | - J.C. Djurhuus
- Urological Department K, Aarhus University Hospital, Skejby Section and Institute of Experimental Clinical Research, University of Aarhus, Aarhus, Denmark
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Bonde HV, Andersen JP, Rosenkilde P. Nocturnal enuresis: change of nocturnal voiding pattern during alarm treatment. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 1994; 28:349-52. [PMID: 7886409 DOI: 10.3109/00365599409180511] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In a prospective clinical study of the outcome of alarm treatment in nocturnal enuretics, 60 children were included: 40 boys and 20 girls, mean age 8.2 years (range 5.1-14.4). All were treated with enuresis alarms and had 2 or more enuretic events during the initial 14 days of treatment. None had diurnal enuresis. In each child, the enuretic and voluntary voiding frequencies during the initial 14 and last 14 days of treatment were compared. We found that 43 children had a 75% reduction or more of the enuretic events. 28 children substituted the former enuretic events by sleep, 15 changed the enuresis by voluntary voidings. Only 17 children had no effect of the alarm treatment. No parameters were found to predict the outcome. In conclusion, the outcome of successful alarm treatment occurs in two distinct forms. Either the child is left asleep without wetting his bed; or the child wakes up spontaneously from sleep and goes to the bathroom.
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Affiliation(s)
- H V Bonde
- Surgical Department D, Glostrup Hospital, University of Copenhagen, Denmark
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Abstract
Micturition disorders simulating neurogenic bladder disease have been loosely termed "dysfunctional voiding". No underlying neuropathy can be found. A variety of voiding disturbances have been identified since the early 1970s, each with its own characteristics and clinical relevance. We have classified voiding dysfunctions into mild, moderate and severe, according to their potential impact on the upper tracts. Bladder instability, the Hinman syndrome and the Ochoa syndrome are the only dysfunctional voiding syndromes that are associated with reflux or ureterovesical obstruction. Each syndrome is briefly described.
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Affiliation(s)
- Y L Homsy
- Division of Paediatric Urology, Hôpital Sainte-Justine, Université de Montréal, Quebec, Canada
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Abstract
Nocturnal enuresis is a symptom of environmental, physical, and psychosocial factors. In addition to a physical examination, the initial workup of the enuretic child should include a careful voiding, psychosocial, and family history. Studies have shown that the parents of enuretic children often have a history of enuresis. An increased incidence of enuresis has also been demonstrated in children from large families and lower socioeconomic groups. Daytime voiding symptoms (e.g., frequency, urgency, or enuresis) suggest the possibility of underlying voiding dysfunction. A complete urinalysis and urine culture also should be performed to exclude urinary infection and certain metabolic or nephrologic disorders. Finally, it is important that the treating physician understand the attitudes of both the child and the family concerning enuresis. Parents who feel that the child is at fault need to be educated and reassured. A careful, complete evaluation will allow the physician to tailor treatment to the individual child and family.
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Affiliation(s)
- H G Rushton
- Department of Pediatric Urology, Children's National Medical Center, Washington, D.C. 20010
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Nørgaard JP, Hansen JH, Wildschiøtz G, Sørensen S, Rittig S, Djurhuus JC. Sleep cystometries in children with nocturnal enuresis. J Urol 1989; 141:1156-9. [PMID: 2709503 DOI: 10.1016/s0022-5347(17)41199-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- J P Nørgaard
- Urological Department K, Aarhus Municipal Hospital, Denmark
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