Nocturnal enuresis: experience with long-term use of intranasally administered desmopressin

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.

Desmopressin treatment regimens in monosymptomatic and nonmonosymptomatic enuresis: A review from a clinical perspective

OBJECTIVE

To evaluate outcomes of desmopressin treatment in monosymptomatic enuresis (ME) and nonmonosymptomatic enuresis (NME).

MATERIALS AND METHODS

PubMed was searched for all studies investigating enuresis, up to July 2009, in which desmopressin was administered alone or combined with other treatments. Each study was graded according to its respective level of evidence.

RESULTS

Altogether, 99 studies enrolling 7422 patients were identified as fulfilling the inclusion criteria. In 76 studies, desmopressin was administered as monotherapy; in 29 it was combined with other treatments such as antimuscarinics and enuresis alarm.

CONCLUSION

Studies incorporating a minor invasive versus a non-invasive diagnostic approach seem to achieve superior long-term success rates. Primary efficacy outcomes following desmopressin treatment are more favourable in ME than NME. Desmopressin administered with adjunct measures achieves superior outcomes compared to monotherapy, especially in NME. Compared to sudden withdrawal, the structured withdrawal programs show better long-term success and lower relapse rates. So far, no superiority has been shown for either time- or dose-dependent structured withdrawal programs. Most studies incorporated only small case series; only 25 studies with level of evidence 1 or 2 have been conducted. The broad range of mono- and adjunct treatments were evaluated according to the evidence based criteria recommended by the European Association of Urology.

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.

Childhood nocturnal enuresis: Developing a conceptual framework

Nocturnal enuresis has been described as the most prevalent and chronic of all childhood problems. The experience, particularly for the older child, can be extremely distressing and limiting. It is now thought that psychological distress (emotional, behavioural, and self-esteem) arises as a consequence of bedwetting, and reaches clinical importance in only a minority who are vulnerable. Many aetiological theories have been proposed with the cause of nocturnal enuresis now regarded as heterogeneous. Based on empirical findings, a new model, termed 'the three systems,' has facilitated a greater clinical understanding of the problem and identification of the appropriate intervention. The model proposes bedwetting results from excessive nocturnal urine production and/or nocturnal bladder overactivity coupled with an inability to arouse to bladder sensations. Effective treatment arises from identification of the child's particular need and application of the appropriate psychological and pharmacological approach. Treatment methods are reviewed in terms of the new model, the mode of action, effectiveness, and application in combination.

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.

The genetics of enuresis: a review

PURPOSE

Formal studies of the genetics of enuresis have been performed since the 1930s and molecular genetics since 1995, both highlighting the importance of hereditary factors in the etiology of nocturnal enuresis. We summarize the current state of knowledge with respect to the genetics of nocturnal enuresis and its genotype-phenotype interactions.

MATERIALS AND METHODS

A comprehensive review of the published data available on the genetic basis of enuresis was performed.

RESULTS

Genetic factors are the most important in the etiology of nocturnal enuresis but somatic and psychosocial environmental factors have a major modulatory effect. Most commonly, nocturnal enuresis is inherited via an autosomal dominant mode of transmission with high penetrance (90%). However, a third of all cases are sporadic, and the difference between sporadic and familial forms is not known. Four gene loci associated with nocturnal enuresis have been identified but the existence of others is presumed (locus heterogeneity). All likely candidate genes have been excluded so far. There is no specific association among the different loci, type of wetting and other aspects of the phenotype. All subtypes of nocturnal enuresis (primary, secondary, combined day/night wetting) are susceptible to comparable genetic influences. Certain syndromes of day wetting follow their own genetic mechanisms but this association with the genetics of nocturnal enuresis is not known.

CONCLUSIONS

Nocturnal enuresis is a common, genetic and heterogeneous disorder. The associations between genotype and phenotype are complex and are susceptible to environmental influences. Therefore, exact assessment of the clinical phenotype and identification of intermediary phenotypes or traits are needed. Future research will focus on the identification of genes, gene products and their interaction with environmental factors.

An assessment of the clinical efficacy of intranasal desmopressin spray in the treatment of renal colic

OBJECTIVES

To assess the efficacy of desmopressin nasal spray compared with diclofenac given intramuscularly in patients with acute renal colic caused by urolithiasis.

PATIENTS AND METHODS

The study included 61 patients randomized into three different groups; group A received desmopressin (40 microg, nasal spray), group B diclofenac (75 mg) intramuscularly and group C, both desmopressin and diclofenac. Pain was assessed using a visual analogue scale (a 10-cm horizontal scale ranging from 'no pain' to 'unbearable pain') at baseline, 10, 20 and 30 min after administering the treatments.

RESULTS

On admission, the pain level was the same in all three groups. At 10 min the pain decreased in all groups to a level that was not significantly different. At 20 min groups B and C had similar mean pain levels (3.7), whereas in group A it was 5.0. At 30 min, groups B and C scored 2-3, and group A 5.6. All three treatments were equally effective at 10 and 20 min but at 30 min there was a stabilization/slight increase in pain level in group A.

CONCLUSIONS

Desmopressin has several advantages, e.g. ease of administration, simplicity of delivery and apparent lack of side-effects, which makes it suitable for ambulatory use. Desmopressin acts rapidly and seems to be effective in both single and combined therapy with diclofenac; it decreases the need for a second treatment and increases the analgesic effect of diclofenac. Some patients responded well to desmopressin, with rapid and complete pain relief. These results indicate that desmopressin may be used to treat renal colic either alone or combined, increasing the analgesic effect of other drugs. More studies are needed to validate and confirm the results; it would also be useful to determine factors that may identify the subgroup of patients who respond quickly and with almost complete pain relief.

[Endocrine theory of idiopathic nocturnal enuresis]

Body fluid homeostasis is maintained by the kidney. Such an accurate control in achieved via the secretion of antidiuretic hormone (ADH), the secretion of which is regulated by hypothalamic osmoreceptors. Both urine flow rate and the excretion of most electrolytes have a diurnal rhythm; they increase during daytime and decrease during nighttime. Such a rhythm seems to be absent in some subjects who suffer from bedwetting because of relative polyuria. In these cases, the polyuria is associated with a decreased nocturnal secretion of ADH and the subsequent excretion of dilated urine. A deficit in the nocturnal secretion of ADH thus appears to explain the response to desmopressin of children with a polyuric form of enuresis.

Desmopressin for nocturnal enuresis in children

BACKGROUND

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 to the children can be great.

OBJECTIVES

To assess the effects of desmopressin on nocturnal enuresis in children, and to compare desmopressin with other interventions.

SEARCH STRATEGY

The following electronic databases were searched: MEDLINE to June 1997; AMED; ASSIA; BIDS; BIOSIS Previews (1985-1996); CINAHL; DHSS Data; EMBASE (1974 to June 1997); PsycLIT and SIGLE. Organisations, manufacturers, researchers and health professionals concerned with enuresis were contacted for information. The reference sections of obtained studies were also checked for further trials. Date of the most recent search: July 1997.

SELECTION CRITERIA

All randomised trials of desmopressin for nocturnal enuresis in children were included in the review. Trials were eligible for inclusion if: children were randomised to receive desmopressin compared with placebo, other drugs or other conservative interventions for nocturnal bedwetting; participants with organic causes for their bedwetting were excluded; and baseline assessments of the level of bedwetting were reported. 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

Twenty one randomised trials involving 948 children treated with desmopressin, met the inclusion criteria. The quality of many of the trials was poor. Desmopressin was compared with a tricyclic drug in two trials, and with alarms in one. Desmopressin was effective in reducing bedwetting in a variety of doses and forms. Each dose of desmopressin reduced bedwetting by at least one night per week during treatment (eg 20microg: 1.56 fewer wet nights per week, 95% CI -1.94 to -1.19). Participants on desmopressin were 4.6 times more likely to achieve 14 consecutive dry nights (95% CI 1.38 to 15.02) compared with placebo. However, there was no difference after treatment was finished. There was no apparent dose-related effect of desmopressin, but the evidence was limited. Data which compared oral and nasal administration were too few to be conclusive. Desmopressin and imipramine (a tricyclic drug) were equally effective in one small trial. Amitriptyline (another tricyclic) was not consistently better than desmopressin either alone or when used as a supplement. In a single trial, desmopressin was initially superior to using an alarm in reducing the number of wet nights per week: WMD -1.7 (95% CI: -2.96 to -0.45), but this result was not sustained; after three months of treatment, patients using the alarm had 1.4 fewer wet nights per week than with desmopressin: (95% CI: 0.14 to 2.65). Participants receiving the alarm intervention were also nine times less likely to relapse than those given desmopressin: RR 9.2 (95% CI: 1.28 to 65.9). Combining alarm and drug therapy was found to be superior to alarm treatment alone. The addition of desmopressin to an alarm schedule resulted in one less wet night per week: (95% CI: -1.55 to -0.45).

REVIEWER'S CONCLUSIONS

Desmopressin rapidly reduced the number of wet nights per week, but there was some evidence that this was not sustained after treatment stopped. Comparison with alternative treatments suggested that desmopressin and tricyclics had similar clinical effects, but that alarms produced more sustained benefits. However, based on the available evidence, these conclusions can only be tentative. There was some evidence of minor side effects of desmopressin in the included trials, such as nasal irritation and nose bleeds. However, the risk of water intoxication associated with over-drinking before bedtime has been reported. Patients and their families need to be warned of potential adverse effects and advise

Primary nocturnal enuresis: a new approach to conditioning treatment

OBJECTIVES

Conditioning treatment is the most effective therapy for nocturnal enuresis, precluding the use of drugs. An ordinary alarm clock can be used as an enuresis alarm. We sought to assess its clinical utility as a new means of conditioning treatment.

METHODS

Using the ordinary home alarm clock, 125 enuretic children were enrolled into two treatment groups. Group I included 70 children who set the alarm so as to get up and void in the toilet at a critical time when the bladder was full and they were still dry. Group II included 55 children who used the alarm to be awakened for voiding after 2 to 3 hours of sleep regardless of whether they were dry or wet. All children were motivated to use the alarm clock continuously for 4 months.

RESULTS

Initial success was achieved in 54 (77.1%) of 70 group I and 34 (61.8%) of 55 group II children. Three months after treatment was stopped, success was still maintained in 46 (65.7%) and 31 (56.4%) children in groups I and II, respectively, but dropped to 41 (58.6%) and 29 (52.7%), respectively, after 6 months. The relapse rate after 3 and 6 months was 14.8% and 24.1% for group I and 8.8% and 14.7% for group II, respectively.

CONCLUSIONS

The ordinary alarm clock performs as well as currently used enuresis alarms. It is an effective, elective, noncontact alarm that does not wait for bedwetting to initiate a conditioning reflex. It is both reliable and safe.

Arginine vasopressin levels in nursing home residents with nighttime urinary incontinence

OBJECTIVES

To examine the relationship between diurnal urine volume and plasma arginine vasopressin levels (AVP) in nursing home residents with nighttime urinary incontinence and a comparison group of frail but nondemented, continent geriatric board and care residents.

DESIGN

Case series.

SETTING

Four nursing homes and two board and care facilities.

PARTICIPANTS

Sixty-two nursing home residents and 27 board and care residents.

MEASUREMENTS

Daytime (7:00 a.m. to 7:00 p.m.) and nighttime (7:00 p.m. to 7:00 a.m.) urine volumes of incontinent nursing home residents were measured over 3 days and 3 nights by reweighing preweighed adults diapers and toileting inserts emptied by research staff for the comparison group. AVP levels were drawn in the early morning (5:00 a.m. to 7:00 a.m.) before subjects arose and in the evening after an hour of lying in bed (8:00 p.m. to 11:00 p.m.), and plasma levels were determined by radioimmunoassay.

RESULTS

Half of the nursing home residents and 82% of the comparison group had night/total urine volume ratios > or = 50%. Forty-nine percent of the total of 89 subjects had undetectable morning AVP levels, 61% had undetectable evening AVP levels, and 42% had undetectable AVP levels in both morning and evening. There were no significant differences in AVP levels between those with night/total urine volume ratios > or = 50% and < 50% in either the nursing home or comparison groups though the small number of comparison group subjects with ratios < 50% may have limited our statistical power to detect differences.

CONCLUSION

Our data suggest that a substantial proportion of both nursing home residents with nighttime incontinence and frail geriatric patients with a reversal of the normal diurnal pattern of urine excretion have an accompanying deficiency in AVP production and/or secretion. More detailed physiologic studies are needed to understand better the pathophysiology of geriatric nocturia and nighttime incontinence and the role that AVP deficiency may play in these conditions. Until such studies are carried out, we do not recommend the routine use of exogenous AVP for geriatric patients with unexplained nocturnal polyuria.

Long-term use and tapered dose reduction of intranasal desmopressin in the treatment of enuretic children

OBJECTIVE

To determine the time taken to achieve complete dryness, the management of desmopressin dosage to reduce the relapse rate, the mean dosage in those responding and any side effects of long-term treatment.

PATIENTS AND METHODS

Enuretic children (155, 68% boys and 32% girls, mean age 8 years, range 5-19) were treated with desmopressin and assessed. Treatment (intranasal spray) was started with 20 microg desmopressin and titrated to 40 microg (maximum 50 microg) after 2 days if the child did not become dry within 48 h. The maximum dosage was maintained for at least 4-6 weeks. After 4 weeks of complete dryness, the dosage was reduced by 10 microg initially, and after each additional 4 dry weeks, by a further 10 microg; medication was stopped only after 4 dry weeks at 10 microg.

RESULTS

Of the children, 85% responded to intranasal desmopressin therapy; 71% achieved complete dryness with no relapses, remaining dry with no further treatment, 7% achieved dryness after relapses during or after therapy, 7% improved (no more than two wet nights per week) and 15% did not respond to therapy or improved only slightly (> 2 wet nights per week). The mean duration of therapy was 28 weeks, the mean dose of desmopressin was 30 microg and the median follow-up 18 months. There were no significant side-effects.

CONCLUSION

This study indicates that rapid titration until dryness within 1-3 days, a long maintenance therapy of at least 4-6 weeks and a slow stepwise reduction of dose decreases the frequency of relapse and improves the outcome.

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

OBJECTIVE

To determine the factors that predict the effectiveness of desmopressin in the treatment of childhood nocturnal enuresis.

PATIENTS AND METHOD

Sixty-six children with monosymptomatic nocturnal enuresis were treated with intranasal or oral desmopressin for a 4-week period. starting with a standard dose of 20 microg (0.2 mg oral) and increasing after 2 weeks where no progress was apparent to 40 microg (0.4 mg oral). Before treatment a range of variables (demographic, situational, enuretic history, physiological, parental attitude and child) were recorded. Three parameters of success acted as dependent variables, with stepwise linear regression models used to determine pretreatment predictors of success with desmopressin.

RESULT

Each outcome variable produced a very similar model of predictors. Success, as assessed by the most dry nights over a 14-night period, was associated with less severe enuresis before treatment, a parental belief that the child's enuresis was unstable and higher birthweight.

CONCLUSION

From the analysis, a model of arginine vasopressin release is proposed and the clinical implications of the findings addressed.

Long-term treatment of nocturnal enuresis with desmopressin intranasal spray

The purpose of this study was to determine the efficacy and safety of long-term treatment of nocturnal enuresis with desmopressin intranasal spray. Sixty-five children with primary nocturnal enuresis with a mean age of 11.3 years (range 7-17) underwent a 2-week observation period followed by dose titration period of 1 week. Those children completely dry with desmopressin entered a randomized, placebo-controlled, double-blind phase lasting 2 weeks, followed by a 6-month open treatment. The enuretic status of the children was documented for 2 weeks after the treatment was stopped. Eleven children had no change from baseline wetting with desmopressin. Thirty-two children receiving 20 mg and 9 children with 40 mg desmopressin were completely dry. Thirteen children were wet 1-2 nights per week, which was better than in the pretreatment period. During the 6-month open-treatment period, the effect of desmopressin was found to be stable. No side effects or adverse reactions were encountered. Two weeks after the treatment was stopped, 25 children were still completely dry (38% of the initial study population, 50% of the responders). The cure rate appeared to continue beyond 18 months after discontinuation of the treatment.

Primary nocturnal enuresis and desmopressin treatment: do psychosocial factors affect outcome?

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.

Going Dutch in nocturnal enuresis

Based on several intervention programmes, a strategy for the treatment of nocturnal enuresis has recently been developed by an expert committee in the Netherlands. It consists of three parts. First, two structured interviews are given: one to differentiate between enuresis and incontinence and one to detect associated problems such as diurnal enuresis, constipation or behavioural problems. Secondly, a medical examination is made, confined to the inspection of the external genitalia and lower back, palpation of the abdomen and urine examination. Thirdly, the following guidelines for treatment at different age levels are applied: up to the age of 6 years no intervention is needed; between the ages of 6 and 8 years, lifting out of bed and/or the calendar method; between the ages of 8 and 12 years, enuresis alarm (if not successful, medication with desmopressin is prescribed for a restricted period of time), and ambulatory dry-bed training in a group setting may follow; over 13 years of age, clinical dry-bed training according to the Messer/Azrin method is advised. According to the expert committee, these guidelines offer sufficient possibilities to deal with the problem of nocturnal enuresis.

Beneficial effect of intranasal desmopressin for nocturnal polyuria in Parkinson's disease

Patients with Parkinson's disease (PD) are known to experience autonomic nervous system dysfunction: this disruptive symptomatology includes urinary urgency, frequency, and nocturnal polyuria. Anticholinergic and tricyclic medications can be beneficial in controlling these urinary symptoms, but have unpleasant side effects in some patients. Desmopressin has been used to treat nocturnal polyuria successfully in a number of conditions, such as central diabetes insipidus, enuresis, and autonomic failure. The purpose of the present study was to assess the efficacy of desmopressin in patients with PD with significant nocturia. Eight patients were recruited into the study. They were first asked to establish a baseline of number of nocturnal voids; the patients were then prescribed the intranasal form of desmopressin and asked to continue to record the number of nocturnal voids. The five patients who completed the trial demonstrated clinically and statistically significant reductions in the frequency of nocturnal voids. One patient became hyponatremic and confused during desmopressin administration; his symptoms resolved soon after the desmopressin was discontinued. Two patients failed to complete the trial due to compliance problems. Thus, desmopressin appears to be a safe and effective medication for nocturnal polyuria in PD.

Nocturnal enuresis

Nocturnal enuresis is common. Although its aetiology remains unclear recent evidence increasingly supports the lack of a normal nocturnal increase in ADH leading to nocturnal polyuria exceeding functional bladder capacity. Sleep patterns are probably normal although an arousal disorder might be a factor. Treatment should follow careful evaluation to determine if one is dealing with 'uncomplicated' or 'complicated' enuresis. Complicated enuresis requires further investigation. 'Uncomplicated enuresis' always requires reassurance and patient and parent education. Resource centres such as ERIC can provide information and advice. Active treatment should be tailored to the patients age, motivation and parental wishes. Behavioural modification techniques yield the highest long-term cure rate but require the most commitment and are rarely successful before the age of 7-8 years. Pharmacotherapy has been revolutionized by DDAVP which gives a response rate of up to 70% relatively free from side-effects but at the price of a high relapse rate after medication. Imipramine is less expensive than DDAVP but may be fatal in overdose. Anticholinergics should be reserved for those patients with significant diurnal symptoms or those who fail first-line pharmacotherapy. Overall patients and parents should be reassured by the high spontaneous cure rate.

The role of family history in predicting response to desmopressin in nocturnal enuresis

The response to desmopressin in 71 children with nocturnal enuresis was evaluated to determine whether a family history of nocturnal enuresis could be helpful in predicting which patients would respond. The overall response rate to desmopressin (53 of 71 patients, 75%) was comparable to previous studies. A poor response was associated with a negative family history of nocturnal enuresis (1 of 14 patients, 7%), whereas the response in those with a positive family history was excellent (52 of 57 patients, 91%). We conclude from this preliminary retrospective study that a high rate of success may be predicted when desmopressin is used in patients with familial nocturnal enuresis, whereas less optimism is warranted when no family history of nocturnal enuresis can be elicited. This observation should be validated in a larger, prospective clinical study.

Efficacy, safety, and dosing of desmopressin for nocturnal enuresis in Europe

Desmopressin is a potent antidiuretic for nocturnal enuresis with few and mostly insignificant adverse reactions. Almost 80 years ago, the antidiuretic effects of extracts of the posterior pituitary were first reported. The molecular structure of the peptide vasopressin arginine vasopressin (AVP) became known in 1956, and by 1967, a synthesized modification of AVP, known as DDAVP, or desmopressin, was introduced. Toxicity studies performed on experimental animals support the conclusion that desmopressin is considerably more potent as an antidiuretic than AVP and has an exceptional safety margin. Further, clinical experience reveals that from 1974 to June 1992 only 21 patients using desmopressin had serious adverse reactions (water intoxication), and no fatalities occurred. Seven of 10 children with nocturnal enuresis who receive desmopressin stop their bedwetting completely or reduce it significantly, with best results noted in children over 10 years of age. Given these results, the preferred treatment in Europe for children with nocturnal enuresis is the sequential combination of desmopressin and the enuresis alarm.

The American experience with desmopressin

Conclusive evidence of a polyuric etiology from a failure of vasopressin elevation led to a new pharmacologic approach to the treatment of childhood nocturnal enuresis. Desmopressin acetate, a vasopressin analogue, has been used successfully since 1978 to treat this condition. Desmopressin's efficacy at doses of 5 to 40 micrograms has been demonstrated in Europe and the United States. Similarly, its safety has been established, and it is a first-line choice for physicians worldwide.

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.

Low-dose DDAVP in nocturnal enuresis

A five-year experience with the vasopressin analogue desmopressin acetate (DDAVP) for nocturnal enuresis is described in 59 children. The initial starting dose of 5 micrograms at bedtime is lower than that reported in other series. Eighty-one percent of patients required 10 micrograms or less to achieve improvement or resolution of bedwetting.

Diclofenac sodium suppository in the treatment of primary nocturnal enuresis

The prostaglandin synthesis inhibitor diclofenac sodium was given as suppository in the treatment of primary nocturnal enuresis in 24 patients. The statistically significant difference in response to diclofenac sodium and to placebo leads us to use diclofenac sodium in primary nocturnal enuresis.

Pediatric psychopharmacotherapy: a review of recent research

In the past 5 years, we have witnessed the continuation of important trends in clinical research that began earlier in the decade. With regard to the treatment of specific disorders in children and adolescents, the most significant developments have been the examination of the tricyclics for the treatment of depression and the initiation of controlled studies for the treatment of Tourette syndrome. Unfortunately, the findings from the depression studies have been uniformly negative, and the results of research on both depression and tic disorders show a relatively high rate of placebo responsivity, which raises nagging questions about the role of case reports and open trials. Another important trend in pediatric psychopharmacotherapy is the search for substitutes for the neuroleptics. Potential candidates include agents such as lithium, naltrexone, fenfluramine, clonidine, and carbamazepine. The most underresearched disorders are a combination of the least common (e.g. schizophrenia, mania) and those that are apparently perceived as less serious (e.g. sleep disorders, certain anxiety disorders). Not surprisingly, the most studied disorder and treatment is hyperactivity and stimulant medication, respectively. Considerable progress has been made in understanding the social implications of the associated symptoms and their response to stimulant drugs, aided greatly by the use of direct observation procedures. Researchers are beginning to attend to the implications of comorbidity for assessing response to medication. There has been additional confirmation of efficacy of stimulant treatment for preschoolers and adolescents. Dose-response issues remain to some extent unresolved, the primary impediments being interpretive misconceptions associated with trend analysis, an overreliance on the syndromal perspective and too little attention to target behaviors and their clinical implications, and the failure to operationalize the minimal effective dose with regard to the normalization and supranormalization of target and collateral behaviors. Disagreement over whether hyperactivity is a learning or a behavior disorder (or both) and what academic underproductivity means clinically and socially is also impeding progress. With regard to developmental disorders, controlled studies indicate that fenfluramine and naltrexone are effective for managing associated symptoms in some individuals. However, given the limited amount of research on these agents, their status as clinically useful palliatives must be considered tentative.(ABSTRACT TRUNCATED AT 400 WORDS)