Dry-bed training without an enuresis machine

The efficacy of standard urotherapy in the treatment of nocturnal enuresis in children: A systematic review

INTRODUCTION

Standard urotherapy in children with nocturnal enuresis (NE) is first-line treatment according to the current International Children's Continence Society (ICCS) guidelines. ICCS defines standard urotherapy as information and demystification, instruction in how to resolve lower urinary tract dysfunction, lifestyle advice, registration of symptoms and voiding habits, and support and encouragement. These interventions often are time consuming and some aspects of urotherapy, such as fluid restrictions, can be a frustrating process for a child, which emphasizes the importance of clarifying their relevance. The purpose of this review is to perform a systematic search in literature to evaluate the use of standard urotherapy in the treatment of children with primary NE (PNE).

STUDY DESIGN

A systematic literature search was conducted in MEDLINE, Embase, and CENTRAL based on the key concepts of standard urotherapy and NE. We identified 2,476 studies. After a systematic selection process using the Covidence tool, 39 studies were included. The quality of the studies was assessed by the QualSyst Checklist. Our protocol adheres to the PRISMA statement and was registered in PROSPERO database (CRD42020185611).

RESULTS

Most of the 39 included studies scored low in quality. All studies combined several urotherapy interventions and studied different study populations. Twenty-two randomized controlled trials (RCTs) were included, which reported 0-92% of children being dry after urotherapy treatment. Three RCTs, all individualizing and optimizing drinking and voiding during the day and practicing optimal toilet posture, scored higher in quality based on the QualSyst score, and reported few children experiencing complete resolution of NE (5-33%). Eight studies compared the efficacy of urotherapy to a control group, however, conflicting results were found.

DISCUSSION

This systematic review presents available literature in the field of standard urotherapy in the treatment of children with PNE. One possible explanation for low efficacy rates of urotherapy in NE is the large heterogeneity of the study populations and interventions. Additionally, the intervention period and the intensity of intervention can have an impact on the outcome.

CONCLUSION

The number of clinical studies on standard urotherapy in children with NE is limited and many of them are of poor quality. High quality research in a well-defined NE population is needed to establish the role of standard urotherapy in first-line treatment of children with NE or as an add-on to other first line treatments. We conclude that at present there is insufficient evidence for recommending standard urotherapy to children with PNE as a first line treatment modality.

Evidence-Based Psychosocial Treatments for Pediatric Elimination Disorders

Pediatric elimination disorders are common in childhood, yet psychosocial correlates are generally unclear. Given the physiological concomitants of both enuresis and encopresis, and the fact that many children with elimination disorders are initially brought to their primary care physician for treatment, medical evaluation and management are crucial and may serve as the first-line treatment approach. Scientific investigation on psychological and behavioral interventions has progressed over the past couple of decades, resulting in the identification of effective treatments for enuresis and encopresis. However, the body of literature has inherent challenges, particularly given the multicomponent nature of many of the treatment packages. This review identified 25 intervention studies-18 for nocturnal enuresis and 7 for encopresis-over the past 15 years and classified them according to the guidelines set forth by the Task Force on the Promotion and Dissemination of Psychological Procedures. For nocturnal enuresis, the urine alarm and dry-bed training were identified as well-established treatments, Full Spectrum Home Therapy was probably efficacious, lifting was possibly efficacious, and hypnotherapy and retention control training were classified as treatments of questionable efficacy. For encopresis, only two probably efficacious treatments were identified: biofeedback and enhanced toilet training (ETT). Best practice recommendations and suggestions for future research are provided to address existing limitations, including heterogeneity and the multicomponent nature of many of the interventions for pediatric elimination disorders.

Bibliotherapy-based Dry Bed Training: A Pilot Study

Dry Bed Training is an effective and rapid method for the elimination of primary nocturnal enuresis. However, like the urine alarm the approach demands very close clinical supervision. This is a Pilot Study to evaluate the effectiveness of a self-help approach (based on Dry Bed Training), administered using a minimum contact self-help manual, and a video in which a young mother and son demonstrated treatment techniques. Ten severe primary nocturnal enuretics, acting as their own controls, were treated using this approach. Results show initial remission in 80% of the cases, with 20% of the subjects dropping out. Of those who completed treatment 25% relapsed. These results were obtained with a significant reduction in staff time. The role of clinical supervision is critically examined. Elements of a cost-benefit analysis are identified in order to highlight the strengths and weaknesses of this approach.

Complex behavioural and educational 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.

OBJECTIVES

To assess the effects of complex behavioural and educational interventions on nocturnal enuresis in children, and to compare them with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles. Date of the most recent searches: December 2002.

SELECTION CRITERIA

All randomised or quasi-randomised trials of complex behavioural or educational interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and physical behavioural methods, alarms, desmopressin, tricyclics, and miscellaneous other interventions.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Sixteen trials involving 1081 children were identified which included a complex or educational intervention for nocturnal enuresis. The trials were mostly small and some had methodological problems including the use of a quasi-randomised method of concealment of allocation in three trials and baseline differences between the groups in another three.A complex intervention (such as dry bed training (DBT) or full spectrum home training (FSHT)) including an alarm was better than no-treatment control groups (eg RR for failure or relapse after stopping DBT 0.25; 95% CI 0.16 to 0.39) but there was not enough evidence about the effects of complex interventions alone if an alarm was not used. A complex intervention on its own was not as good as an alarm on its own or the intervention supplemented by an alarm (eg RR for failure or relapse after DBT alone versus DBT plus alarm 2.81; 95% CI 1.80 to 4.38). On the other hand, a complex intervention supplemented by a bed alarm might reduce the relapse rate compared with the alarm on its own (eg RR for failure or relapse after DBT plus alarm versus alarm alone 0.5; 95% CI 0.31 to 0.80).There was not enough evidence to judge whether providing educational information about enuresis was effective, irrespective of method of delivery. There was some evidence that direct contact between families and therapists enhanced the effect of a complex intervention, and that increased contact and support enhanced a package of simple behavioural interventions, but these were addressed only in single trials and the results would need to be confirmed by further randomised controlled trials, in particular the effect on use of resources.

REVIEWER'S CONCLUSIONS

Although DBT and FSHT were better than no treatment when used in combination with an alarm, there was insufficient evidence to support their use without an alarm. An alarm on its own was also better than DBT on its own, but there was some evidence that combining an alarm with DBT was better than an alarm on its own, suggesting that DBT may augment the effect of an alarm. There was also some evidence that direct contact with a therapist might enhance the effects of an intervention.

Behavioral management of toilet training, enuresis, and encopresis

Toileting problems are a matter of great concern to parents and are a frequent source of family discord, but proper handling of toilet training as well as enuresis and encopresis can ameliorate any untoward effects of these problems. Both the pediatrician and the pediatric psychologist can play a major role in this area.

Behavioural treatment of somatic disorders in children and adolescents

During the past decade the field of behavioural medicine has developed rapidly and several somatic disorders in adults have been successfully treated. By contrast, the effects of behavioural interventions of somatic disorders in paediatric populations have been examined less extensively in controlled outcome research. The present review concerns the promising development and application of behavioural methods in the treatment of various somatic disorders in children and adolescents. The studies reviewed were required to be conducted on an individual or group basis and, in addition, to employ quasi-experimental or experimental designs. It is concluded that of psychological treatments, primarily behavioural approaches have proven to be effective for childhood disorders such as obesity, nocturnal enuresis and recurrent headaches. Further, in the treatment of recurrent abdominal pain and asthma in children, behavioural approaches have shown promising outcomes. This progress should alert the clinician and personnel in health care facilities to the contributions of behavioural paediatrics so that behavioural treatment methods may be utilized where appropriate.

Methodological considerations in enuresis-treatment research. A three-treatment comparison

Three treatments for enuresis were evaluated: (a) immediate detection with a urine-sensing alarm with additional operant training procedures, (b) delayed detection with staff activating the alarm and conducting the procedures in the morning, and (c) yoked-schedule awakenings when the awakening times were determined by the performance of a randomly matched participant from the immediate-detection group. Twenty seven people with mental retardation (most profoundly or severely handicapped), whose ages ranged from 13 to 29 years, participated. Nine of the participants were noncompliant with the linen changing and practice walks to the bathroom and thus did not receive consistent treatment. All 7 of the compliant members of the immediate-detection group improved, 2 of the delayed-detection group worsened while 2 improved, and 6 of 7 yoked awakenings participants improved. Improvement negatively correlated with the frequency of baseline bed-wetting. Several methodological issues are raised concerning enuresis treatment.

A comparison of two approaches to the treatment of nocturnal enuresis and the prediction of effectiveness using pre-treatment variables

This study compared the effectiveness of the enuresis alarm alone with a brief version of Dry Bed Training in treating 74 enuretic children. Both procedures were equally effective, and in the total sample a better response to treatment was predicted by the child's report of being teased by siblings. Maternal anger was associated with a greater drop-out rate.

Dry bed training without a urine alarm: lack of effect of setting and therapist contact with child

Three variations in the mode of delivery of Dry Bed Training as a treatment for nocturnal enuresis were investigated. Twenty-three children, ranging in age from 4 to 14, received dry bed training without the additional use of a urine alarm. Treatment variations included: (a) in-home training of parents and child, (b) office based training of parents and child, and (c) office based training of parents only. An additional 7 children served as a waiting list control during the first 8 weeks of the study. A wide variety of outcome measures showed improvement for the entire sample regardless of specific mode of delivery. Implications for the treatment of enuresis using dry bed training and a number of critical methodological issues are discussed.

Dry-bed training in the treatment of nocturnal enuresis in childhood: a research report

After one subject withdrew from an original group of twelve, eleven children with severe nocturnal enuresis were successfully treated by the Dry-Bed method. The children were aged five to nine years. The group median for the duration of treatment was four weeks, dryness being defined as two successive weeks without a bed-wetting incident. Training periods ranged from two to twenty weeks. Subsequently, two subjects relapsed, although organic and psychiatric factors respectively were probably responsible. At nine-month follow-up 73% of subjects were completely dry. The procedure made heavy demands on parents and clinician; especially in its initial phase. It was suggested that further feasibility studies are required of te Dry-Bed method of treatment in everyday service contexts.