Enuresis

Alarm therapy and desmopressin in the treatment of patients with nocturnal enuresis

PURPOSE

The purpose of this study was to compare the rates of success, relapse, and compliance to treatment in patients undergoing alarm therapy or receiving desmopressin for primary monosymptomatic nocturnal enuresis (PMNE).

MATERIALS AND METHODS

This retrospective study was performed by reviewing the medical files of patients undergoing alarm therapy (Group 1) or receiving desmopressin (Group 2) for PMNE, between January 2010 and July 2014. Patients undergoing treatment in the 3^rd and 6^th month as well as 1^st year follow-up data were analyzed. Two groups were compared with regard to treatment success, relapse rate, and compliance to treatment.

RESULTS

Group 1 included 64 and Group 2 included 70 children. Relapse rates at the 3^rd month, 6^th month, and 1^st year were 67.2%, 71.9%, and 17.0% for Group 1 and 74.3%, 80.0%, and 21.4% for Group 2, respectively. There was no statistically significant difference between relapse rates at any point of follow-up.

CONCLUSIONS

Alarm therapy and desmopressin have the same success rate and relapse rates for PMNE. Compliance with alarm therapy is higher and we recommend it as the first-line treatment. On the other hand, desmopressin has low side effects and can also be used.

Efficacy of an enuresis alarm, desmopressin, and combination therapy in the treatment of saudi children with primary monosymptomatic nocturnal enuresis

Purpose

We evaluated and compared the effectiveness of an enuresis alarm, desmopressin medication, and their combination in the treatment of Saudi children with primary monosymptomatic nocturnal enuresis (PMNE).

Materials and Methods

A total of 136 children with PMNE were randomly assigned to receive an enuresis alarm alone (EA group, n=45), desmopressin alone (D group, n=46), or a combination of both (EA/D group, n=45). Patients were followed weekly during treatment and for 12 weeks after treatment withdrawal.

Results

During treatment, wetting frequencies were significantly reduced in all groups and remained significantly lower than pretreatment values until the end of follow-up. In the D and EA/D groups, an immediate reduction in wetting frequencies was observed, whereas a longer time was required to reach a significant reduction in the EA group. The full and partial response rates were 13.3% and 37.8% in the EA group, 26.1% and 43.5% in the D group, and 40.0% and 33.3% in the EA/D group. A significant difference was observed only between the EA and EA/D groups (p=0.025). Relapse rates were higher in the D group (66.6%) than in the EA (16.6%) and EA/D (33.3%) groups. A significant difference was observed between the D and EA groups only (p=0.019).

Conclusions

Desmopressin, an enuresis alarm, and combined therapy are effective in the treatment of Saudi children with PMNE. Desmopressin produced an immediate effect but relapses were common. The enuresis alarm provided gradual effects that persisted posttreatment. The combined therapy was superior to the alarm in achieving an immediate response; however, its effect was not better than that of the alarm long term.

Role of Urodynamic Study in Nocturnal Enuresis: Urodynamic Findings and Treatment Outcome Correlation in Children with Pharmacotherapy-resistant Monosymptomatic Nocturnal Enuresis or Severe Non-monosymptomatic Nocturnal Enuresis

OBJECTIVES

This study aimed to determine whether or not a urodynamic study (UDS) is beneficial for management of pediatric nocturnal enuresis (NE), especially in pharmacoresistant monosymptomatic nocturnal enuresis (PRMNE) or severe non-monosymptomatic nocturnal enuresis (NMNE) patients.

METHODS

Children with PRMNE or severe NMNE who underwent a UDS for the process of NE treatment were retrospectively reviewed. The UDS findings of patients and treatment outcomes of subsequent tailored therapies according to the UDS findings were analyzed.

RESULTS

A total of 80 children (50 boys and 30 girls, mean age 8.4 ± 2.2 years), 19 of which were diagnosed with PRMNE and 61 of which were diagnosed with NMNE, were included in the final analysis. Of the 19 PRMNE children, 12 (63.2%) demonstrated abnormal UDS findings. Ten demonstrated detrusor overactivity (DO) with or without decreased cystometric bladder capacity (CBC); the treatment outcomes markedly improved in all of the children after anticholinergics were added to the initial desmopressin therapy. Biofeedback was found to be helpful for two children with detrusor-sphincter dyssynergia. All of the total 61 children with NMNE demonstrated abnormal urodynamic findings of DO with or without decreased CBC, and 42 (68.9%) achieved more than partial response (> 50% decrease in the number of wet nights) when given a combination therapy of anticholinergics and desmopressin.

CONCLUSIONS

The urodynamic findings were helpful for guiding children with PRMNE in the proper choice of further treatment strategies. A routine UDS should not be recommended prior to a first-line combination treatment in children with NMNE.

Facilitating adherence to highly active antiretroviral therapy in children with HIV infection: what are the issues and what can be done?

Treatment of HIV infection with highly active antiretroviral therapy (HAART) requires sustained adherence to treatment to maintain efficacy. In pediatric patients, adherence to HAART represents a significant challenge for treated children and for their caregivers and healthcare providers. Many factors can affect adherence to HAART including: (i) factors related to the patient and his/her family; (ii) factors related to the drug/medication; and (iii) factors related to the healthcare system. Different strategies can be employed to tackle the specific obstacles identified in these three groups, and thus to facilitate adherence. Among the key interventions centered on the patient and his/her family are the tailoring of the HAART regimen to the daily activities of the child and his/her family, and the implementation of an intensive education program on adherence for the child and the caregiver, prior to starting the treatment. Specific medication-related problems (depending on drug pharmacokinetic and pharmacodynamic properties, taste and palatability, food interactions, etc.) exist; such problems can not be solved solely by clinicians or by families. Greater commitment of the pharmaceutical industry is needed, and innovative solutions have to be identified by clinicians in partnership with drug manufacturers. Furthermore, the development of an 'adherence strategy/program' can be recommended to all institutions working in pediatric HIV infection. Most of the necessary interventions to be included in such programs can be easily implemented, but they require trained and committed staff (and institutions), and time to be spent with patients and their caregivers.

DOUBLE-BLIND PLACEBO CONTROLLED STUDY OF α-ADRENERGIC RECEPTOR ANTAGONISTS (DOXAZOSIN) FOR TREATMENT OF VOIDING DYSFUNCTION IN THE PEDIATRIC POPULATION

PURPOSE

We sought to determine whether the alpha-adrenergic antagonist doxazosin could be used as primary therapy in children with voiding dysfunction.

MATERIALS AND METHODS

Children were assigned to maintain a voiding diary and then randomly divided into a double-blind placebo controlled protocol (0.5 mg doxazosin or placebo). Duplicate uroflow studies with post-void residual evaluations and assessment of dysfunctional voiding scores were performed on initiation and completion of the study. At the conclusion parents were asked to rank the perceived improvement of the urinary incontinence (ie parental subjective perception of improvement).

RESULTS

No significant differences between doxazosin (18) and placebo (20) treated patients were found in the number of incontinent days per week, severity of incontinent episodes or alterations in uroflow patterns. Although not significant, 2 findings suggested a beneficial effect of doxazosin over placebo. Specifically, doxazosin decreased the number of incontinent episodes weekly from a median of 18 to 4, while the number of incontinent episodes weekly in the placebo group remained essentially unchanged, decreasing from 15 to 14 (p = 0.13). Doxazosin also improved the dysfunctional voiding scores over placebo, for an improvement of -3 vs 0 points. Further substantiating a doxazosin effect over placebo was the subjective perception of the parents that doxazosin significantly improved urinary continence (p <0.02).

CONCLUSIONS

Compared to placebo, doxazosin did not demonstrate a significant objective benefit, but produced a significant subjective benefit in the treatment of urinary incontinence secondary to voiding dysfunction.

Impact of urodynamics in treatment of primary nocturnal enuresis persisting into adulthood

OBJECTIVES

To investigate the urodynamic profiles of adults with primary nocturnal enuresis (PNE) and the association of the urodynamic profile findings with the efficacy of desmopressin and/or tolterodine pharmacotherapy. At least 2% of adults are enuretic during the night. The diagnostic and treatment approach for PNE is empirically the same in children and adults.

METHODS

A total of 20 nocturnal enuretic patients (12 women and 8 men) with a mean age of 27.1 years (range 20 to 42) were studied. They had wet their bed at least twice per week for the past 6 months. Urodynamic studies, including filling and voiding cystometry, pressure-flow study, and pelvic floor electromyography with superficial electrodes, were performed on all patients. Two of them had daytime symptoms, and two had prior failed desmopressin therapy. All patients began taking oral desmopressin 0.4 mg for 1 month. Their continence was assessed and tolterodine 4 mg was added for those in whom desmopressin alone failed. The patients responsive to desmopressin alone or desmopressin plus tolterodine were weaned from medication at 6 and 12 months to reassess continence. The mean follow-up period was 11.6 +/- 3.3 months (range 4 to 14).

RESULTS

Urodynamic studies of 20 PNE adult patients revealed detrusor instability in 10 (50%), hypocompliance in 8 (40%), nonneurogenic detrusor-sphincter dyssynergy in 1 (5%), and no abnormality in 10 (50%). Of the 20 patients, 19 (95%) had no voiding bladder problems. Of the 10 patients responsive to desmopressin alone, 6 (60%) had a normal urodynamic profile; the remaining 4 (40%) had detrusor instability and/or hypocompliance. Of the 5 patients who received desmopressin and tolterodine, 3 achieved continence. The overall continence rate was 86% (13 of 15), and 12 (92%) of the 15 patients required maintenance therapy. In 2 patients (13.3%), desmopressin and tolterodine therapy failed. The efficacy of desmopressin alone and of desmopressin plus tolterodine were not related to the urodynamic profile findings (P >0.05). The urodynamic profile was also not related to the relapse rate after any form of pharmacotherapy (P >0.05).

CONCLUSIONS

PNE persisting into adulthood may be associated with abnormal urodynamic findings. Patients may benefit from urodynamic studies, because if the findings are abnormal, they might have the best chance of successful treatment.

Nocturnal enuresis: medical management

Nocturnal enuresis is a problem that affects many children and their families. The etiology seems to be multifactorial and may include a combination of genetic factors,abnormal urodynamics, alterations in vasopressin secretion, sleep factors, psychologic factors, organic disease, and maturational delay. Generally, a complete history and physical examination, with a specific focus on the genitourinary, gastrointestinal, and neurologic systems, is all is that is needed in the evaluation of a patient with enuresis.Currently, the mainstays of medical therapy are DDAVP, imipramine, and oxybutynin. Medications can help to control the symptoms of enuresis, but they generally do not provide a cure; therefore, behavioral therapy is often recommended in conjunction with pharmacotherapy.

Bone mineral density in children with nocturnal enuresis

In enuretic children there is a significantly higher incidence of fine and gross motor clumsiness, delayed developmental milestones, slower and poor linear growth, and these patients are shorter than normal children. Skeletal maturation of enuretic children has been determined with bone age in only two studies before, but to our knowledge bone mineral content of enuretic children has not previously been determined by bone mineral density measurement. Bone mineral density was measured by the dual-energy x-ray absorptiometry method in children with nocturnal enuresis and compared with that of a control group to detect whether there were any delay in bone development and any decrease in bone mass. Thirty enuretic children were compared with a control group of 40 healthy children with respect to body height and weight measurements, daily calcium intake, serum calcium, phosphorus and ALP levels, chronological and bone ages, and bone mineral density measurements. Of the parameters compared, bone age was significantly retarded, and bone mineral density was significantly reduced in children with enuresis (8.3 +/- 1.9 vs 9.7 +/- 2.3 years; p = 0.01, and 0.5476 +/- 0.07 vs 0.6077 +/- 0.05 g/cm2; p = 0.001, respectively). Chronological ages demonstrated a significant correlation with the bone ages in both the study and control groups (r = 0.852, p < 0.001, and r = 0.844, p < 0.001, respectively). However, the mean chronological age was significantly greater than the mean bone age in the study group (p < 0.001), whereas the mean chronological age was not significantly different from the mean bone age in the control group (p = 0.514). To clarify the exact mechanism responsible for these manifestations of skeletal maturation retardation, the relationship between the maturational delay of the central nervous system connections or the effect of any perinatal insult and the retardation in skeletal maturation remains to be determined.

Management of urinary incontinence and nocturnal enuresis in attention-deficit hyperactivity disorder

PURPOSE

We sought to determine whether attention-deficit hyperactivity disorder (ADHD) influences the resolution of urinary incontinence (UI, or diurnal and nocturnal wetness) and monosymptomatic nocturnal enuresis (NE).

MATERIALS AND METHODS

We performed a retrospective review of patients with ADHD, UI and NE. Individuals with UI were treated with timed voiding, and anticholinergics were added only after timed voiding failed. Patients with NE were treated with either an enuretic alarm, desmopressin or imipramine. Statistical comparisons used a control population matched for age, sex, IQ, and urinary and gastrointestinal symptoms.

RESULTS

The presence of ADHD had a negative effect on the resolution of incontinence, with 68% of the patients with ADHD becoming continent compared to 91% of controls (p <0.01). Two factors impact the resolution of wetness in patients with ADHD-treatment noncompliance and IQ. Treatment noncompliance was found in 48% of the patients with ADHD compared to 14% of controls (p <0.01). The IQ of patients with ADHD affected success, with 32% of children with an IQ of less than 84 achieving continence compared to 80% of those with an IQ of 84 or greater (p <0.01). Patients with ADHD and NE responded similarly to controls when using desmopressin and imipramine. However, they were less likely to exhibit a durable response following management with an enuretic alarm (19% vs 66%, p <0.01).

CONCLUSIONS

Treatment of urinary incontinence in children with ADHD is impaired compared to those without ADHD, and is directly affected by compliance and IQ.

Nocturnal enuresis

Nocturnal enuresis is a benign condition, yet needs treatment to relieve the child and parents of the accompanying anxiety and the stigma attached to it. It is defined as normal nearly complete evacuation of the bladder at a wrong place and time at least twice a month after the fifth year of life. The underlying cause of enuresis is functional and various proposed pathophysiological mechanisms like maturational delay, genetics, role of sleep, antidiuretic hormone, and bladder capacity are discussed. These factors have a bearing on the management. As no treatment plan is ideal, various treatment modalities currently available including good supportive care are elaborated and a plan of management discussed.

Therapeutic efficacy of extended release oxybutynin chloride, and immediate release and long acting tolterodine tartrate in children with diurnal urinary incontinence

PURPOSE

We compare the tolerability and efficacy of extended release oxybutynin chloride, and immediate release and long acting tolterodine tartrate in children with nonneurogenic diurnal urinary incontinence and symptoms of overactive bladder.

MATERIALS AND METHODS

Children with a history of diurnal urinary incontinence were arbitrarily assigned to extended release oxybutynin, immediate release tolterodine or long acting tolterodine. The dose was titrated until effective (onset of complete diurnal urinary continence), maximal recommended dosage was achieved or bothersome anticholinergic side effects developed. An independent observer recorded the dose used, anticholinergic side effects and efficacy of therapy (incidence of urinary frequency, urgency, posturing and urinary incontinence).

RESULTS

The study included 86 girls and 46 boys. There were no statistically significant differences among the 3 treatment groups regarding the presence of peripheral or central nervous system anticholinergic side effects. Extended release oxybutynin and long acting tolterodine were significantly more effective at reducing daytime urinary incontinence than immediate release tolterodine (p <0.01 and 0 <0.05, respectively). Extended release oxybutynin was significantly more effective then long acting tolterodine for complete resolution of diurnal incontinence (p <0.05).

CONCLUSIONS

Extended release oxybutynin and long acting tolterodine are more effective than immediate release tolterodine in decreasing diurnal urinary incontinence. Extended release oxybutynin chloride is more effective than either immediate or long acting tolterodine for control of daytime urinary incontinence and urinary frequency.

Acupuncture therapy in the management of persistent primary nocturnal enuresis--preliminary results

OBJECTIVE

This study aimed to assess the comparative therapeutic efficacy of traditional Chinese acupuncture.

MATERIAL AND METHODS

During the period from January 1997 to April 1999, 50 children (23 boys, 17 girls) suffering from primary persistent nocturnal enuresis, aged 9-18 years, were included in the study. The response rate was monitored at 2 and 4 weeks, and then every 3 months by recording dry nights on a calendar.

RESULTS

The efficacy of treatment, which was expressed as a percentage of dry nights, was high. Within 6 months, 43 (86%) patients were completely dry and 2 (10%) patients were dry on at least 80% of nights.

CONCLUSIONS

Treatment using acupuncture in patients with persistent enuresis nocturna appeared to be most efficacious both in terms of the percentage of dry nights at the end of treatment and in relation to the stability of results, even after the end of the study.

Combination therapy in the treatment of persistent nocturnal enuresis

OBJECTIVE

To evaluate, in a retrospective study, the response rate of older children to combination therapy using a sustained-release anticholinergic agent, hyoscyamine, and a synthetic analogue of antidiuretic hormone, desmopressin acetate.

PATIENTS AND METHOD

Twenty-eight patients (20 males and eight females, aged 9-18 years) diagnosed with nocturnal enuresis were evaluated using a questionnaire, history and physical examination. None had success with single-agent pharmacological therapy. All were begun on 0.375 mg of hyoscyamine and 20 microg of desmopressin intranasally at bedtime. The response rate was monitored at 2 and 4 weeks, and then every 3 months by recording dry nights on a calendar. To improve efficacy, the dosage of medication was adjusted up to 0.750 mg of hyoscyamine and 60 microg of desmopressin. Upon achieving dryness and spontaneous awakening to void, medication doses were tapered.

RESULTS

Within 6 months 16 (57%) patients were completely dry and six (21%) were dry at least 80% of nights. Nine patients relapsed during dose tapering and therapy was reinstituted. Presently, 17 (60%) patients are off medication (after a mean of 8 months of medication). Eight patients are still on medication and are dry at least 80% of nights. Combination therapy failed in three patients and they have transferred to a different regimen. None experienced untoward side-effects from the medications.

CONCLUSION

Most older children with nocturnal enuresis responded to combination therapy. These children require long-term follow-up and may need medication for up to 6 months because the relapse rate is fairly high. Combination therapy appears safe and reliable in treating nocturnal enuresis in older children who have had no success with other treatment modalities.

Evaluation and management of primary nocturnal enuresis

Enuresis can be a source of family crisis, and can contribute to a lack of self-esteem in the affected child. It must be stressed to both parent and child that improvement is gradual and largely a function of maturation in cases where no organic problem is identified. Research shows that many enuretic children seem to have small bladder capacities (Long, 1991), and that the majority have a polyuric factor such as a decreased level of AVP that is amenable to replacement therapy with desmopressin (Bloom, 1993; Hamburger, 1993; Hjälmås & Bengtsson, 1993; Nørgaard & Djurhuus, 1993). Utilizing pharmacologic treatment can accelerate spontaneous cure or act as a substitute until time provides nocturnal continence (Nørgaard & Djurhuus, 1993). Nurse practitioners can use multiple modalities in a holistic approach to reframe this problem and to involve children in solving their own problem. The child who is given a basic understanding of the physiology involved in the healing process will be able to identify inner healing resources and utilize external resources available to him or her. This approach begins with children's imaging the desired outcome of urinary control and ends with achieving increased self-esreem and the sense of competence they deserve.