Nocturnal enuresis: an approach to treatment based on pathogenesis

Circadian rhythm of water and solute excretion in nocturnal enuresis

BACKGROUND

Nocturnal polyuria (NP) due to a suppressed vasopressin circadian rhythm is a well-documented pathogenetic mechanism in enuresis, mainly studied in monosymptomatic enuresis. A substantial percentage of patients do not respond to desmopressin. This suggests that NP may not only be related to vasopressin, but that other kidney components play a role. Solute handling and osmotic excretion have been investigated in the past, especially in refractory patients. Nevertheless, data in treatment-naïve populations with information on timing overnight are sparse. This study aims to investigate the diuresis and solute excretion in treatment-naïve patients with or without NP, with emphasis on circadian rhythms.

METHODS

Retrospective analysis of 403 treatment-naïve children 5-18 years with severe enuresis (> 8 nights/2 weeks). Circadian rhythms were evaluated by a 24-h urine collection in 8 timed portions (4 day, 4 nighttime) at in-home settings. Urine volume, osmolality, and creatinine were measured. Patients were subdivided into three groups according to nocturnal diuresis (ND) and Expected Bladder Capacity (EBCage) ratio: (a) < 100%, (b) 100-129%, (c) > 130%.

RESULTS

All groups maintained circadian rhythm for diuresis and diuresis rates. Patients with higher ND (100-129% and > 130% EBCage) had higher daytime volumes and less pronounced circadian rhythm. In the ND group > 130% EBCage, the ND rate was higher during the first night collection and osmotic excretion was significantly higher overnight.

CONCLUSIONS

Overall 24-h fluid intake (reflected by 24-h diuresis) and nutritional intake (24-h osmotic excretion) might play a role in enuresis. Increased diuresis rate early in the night can be important in some patients, whereas the total night volume can be important in others. A higher resolution version of the Graphical abstract is available as Supplementary Information.

Impact of New vs. Old International Children's Continence Society Standardization on the Classification of Treatment Naïve Enuresis Children at Screening: The Value of Voiding Diaries and Questionnaires

Expert consensus papers recommend differentiating enuresis using questionnaires and voiding diaries into non- (NMNE) and monosymptomatic enuresis (MNE) is crucial at intake to decide the most appropriate workout and treatment. This national, Belgian, prospective study investigates the correlation, consistency, and added value of the two methods, the new against the old International Children's Continence Society (ICCS) definitions, and documents the prevalence of the two enuresis subtypes in our population. Ninety treatment-naïve enuretic children were evaluated with the questionnaire, and the voiding diary and the two clinical management tools were compared. Almost 30% of the children had a different diagnosis with each method, and we observed inconsistencies between them in registering Lower Tract Symptoms (κ = -0.057-0.432 depending on the symptom). Both methods had a high correlation in identifying MNE (rs = 0.612, p = 0.001) but not for NMNE (rs = 0.127, p = 0.248). According to the latest ICCS definitions, the incidence of MNE was significantly lower (7 vs. 48%) with the old standardization.

CONCLUSION

The voiding diary and the questionnaire, as recommended by the ICCS at the screening of treatment-naïve enuretic patients, are considerably inconsistent and have significantly different sensitivities in identifying LUTS and thus differentiating MNE from NMNE. However, the high incidence of LUTS and very low prevalence of MNE suggest that differentiating MNE from NMNE to the maximum might not always correlate with different therapy responses.

Association of Sleep Disordered Breathing with Mono-Symptomatic Nocturnal Enuresis: A Study among School Children of Central India

OBJECTIVE

To study the prevalence of primary monosymptopomatic nocturnal enuresis (PMNE) in children aged 5-10 year and to find its association with sleep disordered breathing (SDB) by using a 22 item pediatric sleep related breathing disorder (SRBD) scale.

METHODS

This was a school based cross sectional epidemiological study from July 2015 to November 2015. A questionnaire seeking information on socio-demographic variables, nocturnal enuresis (NE) frequency, school performance and a validated 22 item pediatric sleep related breathing disorder scale (SRBDs) was distributed to 1820 pupils in three primary schools.

RESULTS

A total of 1528(83.95%) questionnaires were retrieved. Out of 1528 forms, 182(11.9%) forms were incomplete for requested information and hence 1346 (73.9%) questionnaires were finally analyzed. The prevalence of NE was found to be 12.7% (95% CI; 11-14.6), whereas prevalence of primary nocturnal enuresis (PMNE) was 8.2% (95% CI; 7.1-10.1). SRBD scale score >0.33 (adjusted OR: 2.87; 95%CI: 1.67-4.92), paternal history of enuresis in childhood (adjusted OR:4.96; 95% CI: 2.36-10.45), and inappropriate toilet training (adjusted OR: 1.64; 95% CI: 1.01-2.66) were independently associated with PMNE.

CONCLUSION

Sleep disordered breathing, inappropriate toilet training and a history of childhood NE in father were found to be significant risk factors for PMNE in the present study. Thus, these findings suggest that it is imperative to rule out SDB in PMNE patients as they may require different therapeutic interventions.

Advances in the management of enuresis

There are still many undiscovered facts about enuresis, even though it is a very old "symptom". It is a significant health problem with a high prevalence among children and a lower prevalence in adulthood. Many treatment guidelines have been proposed for the management of this problem. The improvement of diagnostic tools, and also treatment modalities, have had a significant impact on success rates; however, the long-term success rates need to be higher, especially in resistant cases. In this report, we summarize the advances made in the diagnosis and treatment of enuresis.

Prevalence of nocturnal enuresis and its associated factors in primary school and preschool children of khorramabad in 2013

Background. Nocturnal enuresis refers to an inability to control urination during sleep. This study aimed to determine the prevalence of nocturnal enuresis and its associated factors in children in the city of Khorramabad. Materials and Methods. In this descriptive-analytic, cross-sectional study, 710 male and female children were divided into two groups with equal numbers. The samples were selected from the schools of Khorramabad using the multistage cluster and stratified random sampling methods based on the diagnostic criteria of DSM-IV. The data was analyzed using the logistic regression. Results. The results showed that 8% of the children had nocturnal enuresis, including 5.2% of primary nocturnal enuresis and 2.8% of secondary nocturnal enuresis. The prevalence of nocturnal enuresis in the boys (10.7%) was higher compared with that in the girls (5.4%) (P = 0.009). There were statistically significant relationships between nocturnal enuresis and history of nocturnal enuresis in siblings (P = 0.023), respiratory infections (P = 0.036), deep sleep (P = 0.007), corporal punishment at school (P = 0.036), anal itching (P = 0.043), and history of seizures (P = 0.043). Conclusion. This study showed that the prevalence of nocturnal enuresis in the boys was higher compared with that in the girls.

Effects of maxillary expansion and placebo effect of appliances on nocturnal enuresis - preliminary results

Introduction

Nocturnal enuresis has been found a common symptom among children with breathing problems and sleep apnea. The purpose of this study was to evaluate the therapeutic and placebo effects of slow maxillary expansion on nocturnal enuresis.

Material and methods

Four children with enuresis aged 7–12 years were selected. Rigid acrylic expansion appliances were fabricated and delivered to them. Frequency of enuresis was recorded by the parents during three stages: 1) before appliance delivery; 2) after appliance insertion without expansion; and 3) during expansion and retention.

Results

The frequency of wetting decreased significantly during the period of appliance use without expansion. During the expansion and retention phase, two patients became completely dry, and two patients improved significantly.

Conclusions

Maxillary expansion can have a positive effect on the treatment of nocturnal enuresis. Also, the placebo effect of the expansion appliance has significant effects on enuresis.

Safety and efficacy of desmopressin for the treatment of nocturia in elderly patients: a cohort study

PURPOSE

Desmopressin is used widely to treat nocturnal polyuria (NP), but there is concern of hyponatremia especially in elderly patients. This study aimed to evaluate the safety and efficacy of long-term desmopressin treatment in elderly patients with NP.

METHODS

Patients who were ≥65 years old with NP were analyzed. All patients were started on 0.1 mg desmopressin, and the dose was escalated to 0.2 mg depending on patient symptoms. All patients were educated the mechanism of desmopressin. The voiding diary and serum sodium levels were evaluated at baseline, 3-7 days after starting treatment and every 3-6 months. Safety was evaluated by hyponatremia, hyponatremic symptoms and other adverse drug events. The mean changes in number of nocturia and nocturnal urine volume (NUV) were evaluated for efficacy.

RESULTS

A total of 68 patients were included. The mean age was 72.6 (66-85) years. The mean night-time frequency was 3.0 ± 1.8 day, and the mean serum sodium level was 141.2 ± 2.1 mEq/L at baseline. The mean follow-up period was 27.9 months. The mean decrease in serum sodium level was 1.3 ± 3.4 mEq/L at the last follow-up (p = 0.003). Hyponatremia incidence was 4.4 %, and all patients recovered by stopping medication. Severe adverse events were not observed. The mean night-time frequency had decreased by 2.1, and the NUV had decreased by 374.2 ± 261.3 mL at the last follow-up (p < 0.001).

CONCLUSIONS

Desmopressin at doses below 0.2 mg is safe and effective in elderly patients with NP if patients are well informed and are closely followed up.

Pharmacotherapy of overactive bladder syndrome

Urinary incontinence is a common and distressing condition that is known to adversely affect quality of life. Overactive bladder (OAB) is the term used to describe the symptom complex of urgency with or without urge incontinence, usually with frequency and nocturia. Drug therapy, in addition to behavioral modification, remains integral in the management of women with OAB, and the development of new drugs, treatment regimens and methods of delivery should improve patient compliance and acceptability. Developments over the last 10 years have led to the launch of several new drugs for the treatment of OAB that may offer greater efficacy while minimizing adverse effects. This article critically reviews the current pharmacological treatment of OAB in addition to providing a rationale for treatment.

The medical management of refractory overactive bladder

Overactive Bladder (OAB) is a clinical syndrome describing the symptom complex of urgency, with or without urgency incontinence and is usually associated with frequency and nocturia. Those women with refractory or intractable symptoms following initial conservative and antimuscarinic medication may benefit from further assessment and investigation of their symptoms prior to considering different approaches to drug therapy. This review is the first of two to cover the management of intractable OAB in women and provides a practical clinical approach to managing women with refractory OAB symptoms. This paper covers the investigation and medical management of this demanding patient group whilst the second paper will focus on the role of more invasive treatments such as Botulinum Toxin, neuromodulation and reconstructive surgery.

Is there any correlation between hypercalciuria and nocturnal enuresis?

Nocturnal enuresis is a common problem among children. Hypercalciuria has been proposed as an important etiology of bedwetting. We investigated the incidence of hypercalciuria among children with nocturnal enuresis and age- and sex-matched healthy controls. In this case–control study 118 children with nocturnal enuresis and 100 age-, sex-, and educational district-matched healthy controls were recruited. Urine samples were obtained from each subject twice: immediately after awakening and 2 hours later at school. Urinary calcium and creatinine levels were measured and the subjects with a urinary calcium/creatinine ratio more than 0.2 were considered as hypercalciuric. Serum Ca, P, Na, K, and PTH levels were measured for all hypercalciuric subjects. The mean urine calcium to creatinine ratio in the second urine sample was 0.070±0.06 mg/mg and 0.050±0.046, respectively in the case and control groups (P=0.008). There were 12/118 and 3/100 hypercalciuric subjects in the case and control groups respectively (P=0.032). The serum Ca, P, Na, K, and PTH levels were in normal range in all hypercalciuric subjects. In our study there was a significant difference in the frequency of hypercalciuria among children with nocturnal enuresis and healthy controls, so we can suggest adding the measurement of urine electrolytes especially the calcium level in patients with nocturnal enuresis.

Systematic review of overactive bladder therapy in females

Although the prevalence of overactive bladder (OAB) is similar in both male and female populations, females have a greater tendency to seek medical advice regarding their symptoms. A review of the evidence of therapy among women shows that a variety of modalities has been shown to be effective for symptom improvement in women with OAB. Bladder retraining/re-education should be considered for all women with OAB. With respect to first-line pharmacotherapy with antimuscarinic agents, the development of extended release preparations, bladder selective M3 antagonists and alternative routes of delivery, have improved compliance and persistence. Other pharmacotherapeutic options with potential for providing benefit include antidepressants, vasopressin analogues, alpha-adrenoceptor antagonists and beta-adrenoceptor agonists. There are also a number of newer agents currently being investigated, including calcium channel blocking agents, potassium channel opening drugs, beta agonists and neurokinin receptor antagonists. Intravesical injections of botulinum toxin may be an alternative, while surgery can be considered for truly intractable cases.

Prevalence and risk factors of monosymptomatic nocturnal enuresis in Turkish children

Objectives

To determine the prevalence of primary monosymptomatic nocturnal enuresis (PMNE) and assess risk factors that can cause this disease.

Methods

After the determination of 15 primary schools in the provincial center of Ankara, questionnaires were given to 15,150 students to be answered by their parents. Detailed urologic history was obtained and physical examination applied to the students whose parents answered the questionnaire. After excluding children with polysymptomatic NE, 14060 questionnaires of MNE patients were evaluated. Demographic features with social and medical history of students and their parents, general approach of family to the children, school success of the students and general behavioral attitudes, method of toilet training and the presence of nocturnal enuresis were questioned.

Results

MNE was determined in 9.0% (n: 1266) of the students and nocturnal enuresis frequency was higher in boys than girls (P<0.05). Univariate analysis revealed gender, method of toilet training, sleep problems, school success, and general approach of the family to children and general behavioral attitudes of the children as significant factors. In logistic regression analysis; age, male gender, toilette training with threatening method, deep sleeper, sleep walking, being introverted and shy, significantly increases the risk of nocturnal enuresis.

Conclusions

The current study suggests that the methods of toilet training are extremely important to prevent bedwetting and behavioral disorders due to enuresis. Parents should be well-informed about the appropriate toilet training method.

Urinary incontinence: pharmacotherapy options

The impact of incontinence is felt by millions of people worldwide, with tremendous decrement in quality of life and enormous cost reaching billions of dollars. Urinary incontinence is defined as 'involuntary leakage of urine' and is categorized into two main types: urgency urinary incontinence (UUI) and stress urinary incontinence (SUI). Behavioral modifications and pharmacologic therapies, primarily antimuscarinic agents, are the mainstay of treatment for UUI. These drugs are moderately efficacious but have troublesome side-effects, the combination resulting in poor compliance and persistence with therapy. There are several agents on the market today, each with some variation in pharmacologic properties. Whether these translate into meaningful differences in clinical efficacy and tolerability remains a matter of debate. Treatment of SUI has seen little success with pharmacologic therapy. In Europe, duloxetine is approved for treatment of SUI with marginal success rates; this drug, although available in the United States for treatment of depression, is not approved for SUI. The search for newer and better pharmacologic options and novel therapies is on-going, fueled primarily by the high prevalence of bothersome incontinence and the tremendous number of health care dollars spent on current therapy. This review addresses pharmacologic options for treatment of urinary incontinence.

Is there still a role for desmopressin in children with primary monosymptomatic nocturnal enuresis?: a focus on safety issues

It has recently became apparent that severe primary monosymptomatic nocturnal enuresis (MNE) has a worse prognosis than generally believed, and may have major consequences on the well-being of the child, thus making treatment mandatory. Desmopressin is one of the most widely prescribed medications for MNE, and in this current opinion article we discuss the safety of desmopressin in children with this condition. Following a US FDA request in December 2007 that the prescribing information for desmopressin nasal spray be updated, desmopressin spray is no longer indicated for the treatment of MNE or for use in patients at risk for hyponatraemia. Multiple reports of hyponatraemia in patients with nocturia (mainly the elderly) led to an increased awareness of the risks associated with desmopressin. While the pathogenesis of hyponatraemia in those over 65 years of age relates more to changing renal water and solute handling, we believe that in the young, overdosing and insufficient fluid restriction are usually the major causes. Hyponatraemia is most frequently reported when desmopressin is administered by nasal spray compared with the tablet formulation. This may simply reflect the fact that for more than 10 years the spray was the only available mode of administration in many countries. However, it may also reflect the higher biodisponibility and/or intraindividual variability of pharmacokinetics of the spray compared with the tablet. There are few serious adverse events reported for the melt formulation (oral lyophilisate), but as it has only recently become available on the market, it would be premature to conclude that it has a better safety profile. We believe that desmopressin in all formulations has a good safety profile in children with MNE, provided that treatment is properly prescribed and monitored; improving the training of doctors and patients in the dose-response kinetics of the drug, teaching appropriate restriction of fluid intake and by encouraging the use of desmopressin within a narrow dose range (10-20 microg spray, 120-240 microg melt and 200-400 microg tablet) when used in primary-care settings. Titrating higher doses in therapy-resistant patients should probably be carried out in a specialized enuresis centre, and only after documenting adequate morning urinary diluting capacity. In summary, the risk of hyponatraemia is exacerbated by misuse of the drug rather than an inherent danger associated with the drug, which in our opinion should be addressed with better education rather than withdrawal of a medication that has the potential to benefit children with nocturnal enuresis.

Secondary nocturnal enuresis caused by central sleep apnea from Chiari malformation type 1

OBJECTIVE

To report a novel cause of nocturnal enuresis (NE) and highlight the literature giving insight into this novel mechanism.

PATIENT

A 12-year-old morbidly obese female with 2-year history of nightly secondary monosymptomatic NE.

RESULTS

On evaluation, a history of severe sleep disturbed breathing was elicited. Anticipating obstructive sleep apnea (OSA), polysomnography was performed, detecting severe central sleep apnea (CSA) without OSA. Brain magnetic resonance imaging revealed severe Chiari malformation Type I (CM1) with abnormal cerebrospinal fluid dynamics. She had no other classic signs or symptoms of CM1. Neurosurgical decompression halted the NE and normalized nocturnal breathing and cerebrospinal fluid dynamics, confirming that the CSA was caused by the CM1 and resulted in the NE. A thorough literature review found no prior reports of CSA-induced NE. Since CSA and OSA differ by the absence of negative intrathoracic pressures in CSA, this case suggests that such pressures are not a key mechanistic component of SA-induced NE.

CONCLUSION

This first report of secondary NE caused by CSA from CM1 emphasizes obtaining a sleep history in the enuretic child, introduces a new cause of NE, and challenges hypotheses underlying SA-induced NE.

Exploring the differences between mono- and polysymptomatic nocturnal enuresis

OBJECTIVE

Recently the heterogeneity of nocturnal enuresis has been manifest in the distinction between mono- and polysymptomatic forms, based on the absence or presence of bladder overactivity, respectively. Although this classification has important clinical implications, there is a lack of empirical work relating to associated symptom expression and psychological functioning. The aim of this study was to identify variables associated with the two forms of nocturnal enuresis by means of a large population survey.

MATERIAL AND METHODS

From a cohort of 11,021 parents surveyed as part of the Avon Longitudinal Study of Parents and Children when their children were aged 7(1/2) years, 8242 questionnaires were returned, with 7935 children meeting the inclusion criteria. Parents were invited to complete a questionnaire containing items relating to bedwetting, toileting behaviour, day-time wetting, bowel functioning and psychological variables.

RESULTS

A total of 194 children met the Diagnostic and Statistical Manual of Mental Disorders-IV definition of nocturnal enuresis, of whom 133 (68.5%) were classified as monosymptomatic and 61 (31.5%) as polysymptomatic. Those with the polysymptomatic form were significantly more likely to have multiple episodes of bedwetting, to show signs (such as fidgeting) of needing to urinate during the day, to need a reminder to toilet during the day and to have day-time wetting and soiling.

CONCLUSIONS

The proportion of mono- to polysymptomatic nocturnal enuresis was 2:1. Children with the polysymptomatic form had a number of associated bladder and bowel problems. Clinically it is important to distinguish between the two types of nocturnal enuresis in order to identify the most appropriate treatment intervention.

Desmopressin is a safe drug for the treatment of enuresis

OBJECTIVE

To verify the safety of desmopressin treatment and its associated side-effects in a large number of patients.

MATERIAL AND METHODS

The study was conducted in accordance with the guidelines of the Italian Club for Nocturnal Enuresis, whose criteria are: age >5 years; absence of malformations and infections of the urinary tract; absence of psychological disorders or neurological alterations; number of "wet nights" >5-7; control of liquid intake during the afternoon and evening; monitoring of serum electrolytes before beginning treatment; control of body weight before the beginning of treatment and during the first 4-5 days of therapy; and the informed consent of the parents. The therapeutic regimen provided for a maximum dose of desmopressin of 40 microg/day (four puffs/nostril or two tablets), starting from an initial dosage of 20 microg/day (two puffs/nostril or one tablet) 1 h before going to bed. The study involved two groups of patients with monosymptomatic enuresis: some of them had been administered desmopressin in the form of a spray and others in the form of tablets.

RESULTS

A small percentage of patients presented mild, transient side-effects; in no case were severe side-effects verified.

CONCLUSION

Desmopressin is a safe drug with a low incidence of side-effects.

Antidiuresis therapy: Mechanism of action and clinical implications

Abnormalities of micturition occur in many different diseases, have a variety of causes and take several forms. This review will focus exclusively on those abnormalities in which antidiuretic therapy may be of benefit. These conditions are primarily characterized by an increase in the total amount of urine produced (polyuria) or a circadian shift in the control of urine production and/or voiding (nocturnal enuresis, nocturia).

Desmopressin acetate for enuresis and diabetes insipidus

Desmopressin is a synthetic agonist of the natural pituitary hormone vasopressin acetate, with enhanced antidiuretic properties. In fact, owing to its selectivity for the V2 receptor, it has a greater antidiuretic activity, but lower pressure effects compared with natural antidiuretic hormone. Desmopressin is used in the diagnosis and treatment of cranial diabetes insipidus, in the treatment of monosymptomatic enuresis and for tests of renal function.

Breastfeeding during infancy may protect against bed-wetting during childhood

OBJECTIVE

Our goal was to test the hypothesis that children who exhibit bed-wetting during childhood were less likely to be breastfed during infancy compared with normal controls.

METHODS

A case-control study was conducted in a pediatric continence center and a general pediatric practice. Cases (n = 55) were recruited from the continence center and defined as children 5 to 13 years of age who experienced lifetime involuntary voiding of urine during nighttime sleep at least 2 times a week in the absence of defects of the central nervous system or urinary tract. Age- and gender-matched controls (n = 117) who did not exhibit bed-wetting were enrolled from a general pediatric practice. Infant feeding practices were measured as breastfeeding (yes/no) and, for those who were breastfeed, by the duration of breastfeeding and the time of formula supplementation.

RESULTS

Among the case subjects, 45.5% were breastfed, whereas among the controls 81.2% were breastfed. The controls reported higher household incomes than the case subjects, and their mean family size (number of children) was slightly lower. After adjusting for race, income, and family size, the odds ratio was 0.283, indicating that case subjects were significantly less likely than controls to be breastfeed. Among all the study subjects who were breastfed, controls were breastfed for a significantly longer period than case subjects (an average of 3 months longer). Although breastfed controls were less likely to be supplemented with formula than breastfed case subjects, this difference was not statistically significant.

CONCLUSIONS

Breastfeeding longer than 3 months may protect against bed-wetting during childhood. Breast milk supplemented with formula did not make a difference in the rate of enuresis.

Resolution of diurnal incontinence and nocturnal enuresis after adenotonsillectomy in children

PURPOSE

Adenotonsillar hyperplasia causes upper airway obstruction, leading to obstructive sleep apnea. We reviewed the incidence of nocturnal enuresis in a population of children with adenotonsillar hyperplasia. In addition, we investigated the rate of resolution or improvement in enuresis following surgery for relief of adenotonsillar hyperplasia.

MATERIALS AND METHODS

We studied 86 consecutive prepubertal children, 46 boys and 40 girls, who underwent adenotonsillectomy. Severity of adenotonsillar obstruction was graded on a scale of 1 to 4. A questionnaire regarding voiding problems, including nocturnal enuresis, voids per day and daytime enuresis episodes, was filled out preoperatively and postoperatively by the patients and their parents.

RESULTS

Among the 86 patients who underwent adenotonsillectomy 36 (42%) had nocturnal enuresis. In patients with nocturnal enuresis the number of episodes was significantly less after adenotonsillectomy. Overall, 12 patients (33%) had complete resolution, 11 (31%) had significant improvement and 13 (36%) showed no change. In addition, we noted a significant decrease in daytime enuresis episodes and voids per day.

CONCLUSIONS

Children with upper airway obstruction have a high rate of nocturnal enuresis that improves at twice the anticipated rate after treatment of the airway obstruction. In addition, we observed that daytime voiding dysfunction improves in these patients.

The role of urine osmolality and ions in the pathogenesis of primary enuresis nocturna and in the prediction of responses to desmopressin and conditioning therapies

Aim of the study was to determine the role of nocturnal and daytime urine volume, osmolality and ion excretions in the pathogenesis of primary monosymptomatic enuresis nocturna (PMEN) and in the prediction of response to desmopressin and conditioning therapies. Fifty-five children with PMEN between the ages 5 and 15 years were included to the study. The patients were randomly divided into three groups Group 1: Twenty enuretics having intranasal desmopressin 1x 20 microg treatment for 2 months Group 2: Twenty enuretics having conditioning therapy for 2 months. Group 3: Fifteen enuretics having intranasal izotonic solutions as placebo. The control group consisted of 15 healthy children. Urine osmolality, sodium, potassium, chloride, magnesium and creatinine levels were investigated in both daytime and nighttime urines. Fractional sodium, potassium, magnesium, chloride excretions were calculated. Wilcoxon, Mann-Whitney U, Kruskal-Wallis, Chi-square, Student's t and Pearson correlation tests were performed. The ratio of night/daytime urine osmolality was significantly decreased in enuretic children. In addition, the ratio of night/daytime urine Cl and K excretions were also significantly decreased in enuretics. Response rate to desmopressin and conditioning treatments were statistically higher than placebo control. The difference between response rates of desmopressin and conditioning therapies was not found statistically significant. Pretreatment values of urine volume osmolality and ions were not observed as predictive factors in response to desmopressin or conditioning therapy. In conclusion, nightly decreased potassium and chloride excretions were found to have a role in the pathogenesis of primary enuresis nocturna. Urine volume, osmolality and ion excretions are not suggested to be used in the prediction of response to desmopressin and conditioning therapies.

[Study of renal morphology and function in children with nocturnal enuresis. Relationship with sensitivity or resistance to desmopressin]

BACKGROUND

In the last few years, there have been reports that children with nocturnal enuresis frequently have hypercalciuria. Likewise, children with desmopressin-resistant enuresis have recently been reported to have a higher renal concentration capacity than patients with desmopressin-sensitive enuresis.

OBJECTIVES

To study renal function and urinary calcium excretion and to register familial history of enuresis and urolithiasis in a group of children with enuresis, whether responders or nonresponders to desmopressin, followed-up in our hospital.

MATERIAL AND METHODS

A cohort of 60 patients (42 boys and 18 girls) who were referred to the hospital because of nocturnal enuresis.

RESULTS

Hypercalciuria was detected in 26 children (43.3 %) and hypocitraturia in eight (13.3 %). The frequency of hypercalciuria was higher in desmopressin-resistant patients than in desmopressin-sensitive patients, but this difference was not statistically significant. Sonographic renal morphological anomalies were detected in 11 children (18.3 %). No differences in renal handling of water were detected when the patients were distributed according to the grade of sensitivity to desmopressin.

CONCLUSIONS

In our cohort we found a high frequency of hypercalciuria in children with nocturnal enuresis. No differences were observed in maximal urinary osmolality among desmopressin-resistant and desmopressin-sensitive children.

Pharmacological treatment for overactive bladder in women

Urinary incontinence is a common and distressing condition that is known to adversely affect quality of life. Overactive bladder is the term used to describe the symptom complex of urinary frequency and urgency, with or without urge incontinence. Drug therapy, in addition to behavioral modification, remains integral in the management of women with overactive bladder, and the development of new drugs, treatment regimens and methods of delivery should improve patient compliance and acceptability. This article critically reviews the current pharmacological treatment of overactive bladder in addition to providing a rationale for treatment.

Nocturnal enuresis at 7.5 years old: prevalence and analysis of clinical signs

OBJECTIVE

To determine the prevalence of nocturnal enuresis (NE) in a large cohort of children at 7.5 years old, and to examine the frequency of variables such as gender, severity, associated elimination problems, and clinical signs within the identified group.

SUBJECTS AND METHODS

Of an original cohort of 13 971 infants alive at 12 months, 11 251 who were still active in the Avon Longitudinal Study of Parents and Children (ALSPAC) survey, were followed at 91 months. The mother or main carer was given a questionnaire which asked, amongst other items, about the presence and frequency of bedwetting, other elimination problems, and signs related to the wetting behaviour; 8269 (73.5%) questionnaires were returned and 8151 contained information on the frequency of bedwetting.

RESULTS

In all, 1260 children (15.5%) at 7.5 years wet the bed, but most wet once or less a week, and only 215 (2.6%) met the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria of NE (wetting at least twice a week). A higher prevalence was reported in boys than girls and 266 children (3.3%) had both daytime wetting and bedwetting, with 189 (2.3%) having both daytime soiling and bedwetting. Daytime urgency increased with severity of bedwetting and occurred in 28.9% of children with NE.

CONCLUSION

At 7.5 years old the incidence of bedwetting is high, but only 2.6% of this large population-based sample wet at a frequency meeting the definition of NE. Although a small percentage of children had both daytime wetting and bedwetting, the evidence suggests that these are discrete problems. Amongst children with NE, indicators of bladder overactivity were present, supporting the view of heterogeneity and the importance of individual assessment in deciding on appropriate treatment.

Practice parameter for the assessment and treatment of children and adolescents with enuresis

Enuresis is a symptom that is frequently encountered in child psychiatric evaluations. Careful assessment is required to identify specific urologic, developmental, psychosocial, and sleep-related etiologies. For most children with enuresis, however, a specific etiology cannot be determined. Treatment then involves supportive approaches, conditioning with a urine alarm, or medications--imipramine or desmopressin acetate. The psychosocial consequences of the symptom must be recognized and addressed with sensitivity during the evaluation and treatment of enuresis.

Enuresis in children and young people: a public health nurse approach in New Zealand

The involuntary passing of urine at age six and older is called enuresis. Wetting during the day is called diurnal enuresis and wetting at night while asleep is called nocturnal enuresis. Nocturnal enuresis is second only to allergy as the commonest chronic disorder in childhood. Many children (adolescents are included in the term 'children') who are nocturnal enuretics exhibit behaviours such as low self-esteem, withdrawal, less ambition and increased anxiety. These children are often low achievers within the school system and become a problem for their family and school. In this article the author discusses a child/adolescent-centred primary nocturnal enuresis program and service that is administered by a group of public health nurses in South Auckland, New Zealand.

INTERMITTENT ORAL DESMOPRESSIN THERAPY FOR MONOSYMPTOMATIC PRIMARY NOCTURNAL ENURESIS

PURPOSE

In a prospective study we evaluate the efficacy of intermittent desmopressin (DDAVP) every other day for patients with nocturnal enuresis relapse who need additional therapy.

MATERIALS AND METHODS

Between January 2000 and August 2001, 71 boys and 52 girls 6 to 22 years old (mean age 12.5) were treated with 0.2 mg DDAVP daily for monosymptomatic nocturnal enuresis. After an initial 2 weeks of dose titration the nonresponders were given 0.4 mg DDAVP daily. Those who did not respond to this dose were excluded from study. The remaining patients took desmopressin for 3 months. Patients with persistent enuresis after 3 months of treatment were given intermittent 0.2 or 0.4 mg DDAVP every other day. Followup was performed 6 weeks later.

RESULTS

Of 123 patients 92 completed the study. Mean followup after beginning intermittent DDAVP therapy was 9.2 months (range 6 to 18). Of the 92 patients 45 responded to the 0.2 mg daily dose (group 1) and continued treatment for at least 3 months, while the dose was titrated to 0.4 mg for the remaining 47 (group 2). There were 23 patients who did not respond to 0.4 mg DDAVP and they were excluded from the study. After cessation of the drug 21 group 1 patients (46.6%) and 13 group 2 patients (54%) still had enuresis, and they were placed on intermittent therapy. After 6 weeks 15 of these 34 patients had complete and 13 of the remaining 19 had partial response, while the 6 nonresponders continued on daily DDAVP. Overall the complete and partial response rate of intermittent treatment was 20 of 21 group 1 patients (95%) and 8 of 13 group 2 (61.5%).

CONCLUSIONS

For some enuretic patients with relapse after cessation of initial 3-month therapy, intermittent DDAVP may be an effective alternative long-term treatment.

An overview of the management of nocturnal enuresis in children

Nocturnal enuresis is one of the common conditions of childhood and left untreated can cause increasing stress and anxiety for the child and disruption for the family. This article gives an overview of the potential contributory factors to the cause of bedwetting and highlights the importance of carrying out a focused assessment using the 'three systems' approach, to not only exclude any underlying pathology but also help direct treatment. The different treatment options are discussed and emphasis is placed on involving the child and family in the decision-making process. A child-focused approach will help ensure that whatever treatment is chosen, either the alarm or desmopressin will lead towards the best treatment outcome.

Enuresis in children with sleep apnea

OBJECTIVES

To test the hypothesis that the presence of nocturnal enuresis is related to the severity of sleep apnea, we examined the relation between the Respiratory Disturbance Index (RDI, apneas plus hypopneas per hour of sleep) and the presence and severity of enuresis.

STUDY DESIGN

All children 4 years of age and older who were referred to our sleep center for suspected sleep disordered breathing (SDB) were asked whether and how frequently they currently wet the bed. All patients underwent full overnight polysomnography (PSG). The relation between RDI and enuresis was examined by chi(2) analysis. A value of P <.05 was considered statistically significant.

RESULTS

Ninety boys and 70 girls were studied; 66 children (41%) described current enuresis. At all ages, enuresis was more prevalent in our patients than control patients in the literature. Children with an RDI of < or =1 had a significantly lower prevalence of enuresis (17%) than did children with an RDI >1 (47%) (P <.05). Fourteen percent of children with an RDI < or =1 had frequent enuresis, compared with 32% of children with an RDI >1 (P <.05). There was no significant difference in the prevalence of enuresis in children with an RDI 1 to 5, 5 to 15, or >15 (P =.92).

CONCLUSIONS

There is a high prevalence of enuresis in children with suspected sleep-disordered breathing. Children with an RDI >1 were at higher risk for enuresis than children with an RDI < or =1. This may be due to the effects of obstructive sleep apnea on arousal response, bladder pressure, or urinary hormone secretion.

Enuresis: current concepts

Incontinence disorders are an important group of problems that clinicians manage in children and adolescents. This paper reviews the physiology of micturition, the epidemiology of enuresis, etiologic concepts of incontinence disorders, a general clinical approach to enuretic patients, laboratory evaluation and general principles of management. Neurological and nephrological concepts of enuresis are emphasized in this discussion.

Osmoregulation and desmopressin pharmacokinetics in enuretic children

OBJECTIVE

The aim was to compare responders and nonresponders to antienuretic treatment with desmopressin with respect to pharmacokinetics and renal effects of the drug.

METHODS

Twelve children, aged 7.6 to 16.2 years, with nocturnal enuresis were examined. Six patients were nonresponders and 6 were responders to desmopressin treatment. The children were given 2 mg of desmopressin intravenously and plasma concentrations of the drug were monitored overnight. Urine parameters were followed for 24 hours after desmopressin administration. Ten patients also underwent a thirst provocation test.

RESULTS

Desmopressin pharmacokinetics did not differ between the groups. Neither nocturnal urine production nor morning urine osmolality after desmopressin injection differed between responders and nonresponders, whereas the responders produced significantly larger amounts of significantly less concentrated urine during the day after the injection compared with the nonresponders (urine production, 2.02 +/- 0.84 and 0.77 +/- 0.20 mL/kg/h; urine osmolality, 558 +/- 271 and 883 +/- 134 mOsm/kg). Nonresponders voided with smaller bladder volumes (2.43 +/- 0.68 mL/kg body weight) than responders (4.70 +/- 1.21 mL/kg). The responders produced significantly less concentrated urine than the nonresponders during the thirst provocation test (607 +/- 185 and 922 +/- 217 mOsm/kg, respectively).

CONCLUSION

Intravenous desmopressin pharmacokinetics and desmopressin renal effects did not differ between responders and nonresponders to desmopressin treatment. Nonresponders had a smaller spontaneous bladder capacity and responders produced less concentrated urine.

The wet child

Urinary incontinence is one of the most frequent problems seen in pediatric urology. Although there can be serious structural problems that produce wetting, most of the children seen will have nonstructural causes for their incontinence. A systematic approach and persistence with therapy should result in resolution of the problem in most instances.

Pediatric nocturnal enuresis secondary to airway obstruction from cleft palate repair

Nocturnal enuresis in children can at times be alleviated or resolved completely with surgery on the upper airway. We present a report of a 7-year-old boy in whom nocturnal enuresis began immediately after reconstructive surgery of the pharynx that caused upper airway obstruction. Enuresis diminished immediately and stopped following an adenoidectomy but resumed secondary to adenoid regrowth after more than a year of dry nights. Nocturnal enuresis was immediately and permanently relieved by adenoidectomy revision. We review the relevant literature and discuss possible physiologic relationships between upper airway obstruction and bladder and renal function.

Enuresis and common voiding abnormalities

Voiding problems, and in particular nocturnal enuresis, can usually be evaluated and managed without resorting to complex procedures or invasive tests. A good history with attention to toilet habits and the possible presence of infection can help distinguish patients who may have significant organic pathologic conditions who require further investigation. Wetting alarms are effective with a low recidivism rate but are noisy. DDAVP is effective, works rapidly, and is discrete but has a higher recidivism rate. Treatment is aimed at correcting any poor toilet habits and using the appropriate alarm device or medication.

Daytime and nighttime wetting in children: a review of management

PURPOSE

To describe the types of voiding dysfunction common to children, review pertinent literature on enuresis, discuss treatment options, and explore the nurse's role in identifying and managing children with voiding difficulties.

POPULATION

Children beyond the age of normal toileting who continue with uncontrolled urination either during the day, at night, or both.

CONCLUSION

Inappropriate urination in children is a common occurrence. Ninety-five percent of voiding problems are functional, and 5 percent represent pathologic conditions. There is widespread misunderstanding among parents, teachers, and primary care providers on the causes and management options for these children.

PRACTICE IMPLICATIONS

Pediatric nurses are in key positions to identify children with voiding problems. Once the problem has been acknowledged, nurses can assess the problem and its impact on the family; educate parents, children, and others regarding causes; discuss management options; and refer children for medical intervention when necessary.

Elevated sleep arousal thresholds in enuretic boys: clinical implications

Enuretic children are described as difficult to arouse from sleep. We studied auditory sleep arousal thresholds in enuretic boys and report on the clinical implications of these findings. Fifteen enuretic and 18 control subjects (7-12-year-old males) were studied in a sleep laboratory for four consecutive nights using standard polysomnographic recording techniques. Sleep was undisturbed for the initial two nights and waking thresholds were measured on the following two nights. Enuretic children wet most frequently in the first two-thirds of the night. Arousal attempts were successful 39.7% of the time in controls and only 9.3% of the time in enuretics. In conclusion, enuretic males were more difficult to arouse than age-matched controls. The elevated arousal thresholds may be due to delayed maturation. Treatment programmes that rely on awakening should be aware of these features.

Diurnal plasma vasopressin and urinary output in adolescents with monosymptomatic nocturnal enuresis

Plasma arginine vasopressin (AVP) levels, urinary flow and urine osmolality were investigated in a group of adolescents (20 boys and 5 girls), aged 11-21 y, with severe monosymptomatic nocturnal enuresis and a control group of healthy adolescents (16M and 4F) with similar age- and sex-distribution. Half of the control group was investigated twice, with an interval of 6 months. AVP samples were taken every fourth hour in all adolescents and half of the control group were also investigated every second hour to achieve more samples during controlled sleep. After the study the enuretic group were put on long-term oral desmopressin (DDAVP). The difference between day and night values of AVP was significant for both groups, but there was no difference in the day/night ratios of plasma-AVP. All the adolescents produced less urine while asleep, but the controls produced significantly more urine than the enuretics during day. The controls also had a significantly larger nocturnal elevation of urine osmolality than the enuretics, thus a tendency towards polyuria was found. We could not find any significant difference between responders to DDAVP treatment and non-responders in any of the parameters studied. AVP is secreted in a pulsatile fashion and with point hormone samples taken every fourth or second hour we were unable to find any difference in the diurnal AVP secretion between enuretics and normal controls.