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

Increased renal concentrating ability after long-term oral desmopressin lyophilisate treatment contributes to continued success for monosymptomatic nocturnal enuresis

OBJECTIVES

To investigate renal concentrating ability after long-term fast-melting oral desmopressin lyophilisate treatment in children with monosymptomatic nocturnal enuresis.

METHODS

The present retrospective study involved 58 children (43 boys, 15 girls; aged 6-12 years) with nocturnal enuresis receiving oral desmopressin lyophilisate. After treatment for 4 weeks with a complete response, patients were placed on a reduced dose of 120 μg on alternate days. Moring urine osmolality was measured using urine samples obtained after medication and non-medication dry nights. Patients who experienced ≥1 wet nights/month during alternate-day oral desmopressin lyophilisate treatment or within 6 months after its cessation were assigned to the relapse group, whereas those who experienced <1 wet night/month were assigned to the continued success group.

RESULTS

The continued success and relapse groups included 41 and 17 patients, respectively. The mean duration of treatment was 18.5 and 18.3 months in the continued success group and relapse group, respectively. There was no significant difference in morning urine osmolality after medication nights between the continued success and relapse groups; however, morning urine osmolality after non-medication nights was significantly higher in the continued success group than in the relapse group (P < 0.0001). Similarly, nocturnal urine volume was significantly higher in the relapse group than in the continued success group (P = 0.046).

CONCLUSIONS

These results suggest that patients receiving long-term oral desmopressin lyophilisate treatment develop increased nocturnal renal concentrating ability, which results in sustained dryness even after treatment cessation.

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.

[Evaluation and management of enuresis. An update]

Enuresis is defined as nocturnal bed wetting for at least 2 nights per month in children older than 5 years. At this age the prevalence of enuresis is about 15-20%. More than 50% of these children show day time symptoms, such as frequency, urgency and incontinence (non-monosymptomatic enuresis). The other children are asymptomatic during day time and wet the bed during the night time (monosymptomatic enuresis). The main pathogenetic factors are nycturia, detrusor overactivity and reduced arousability. Psychological and psychiatric aspects, genetics and obstipation play an additional role in the etiology. Basic diagnostic investigations are mandatory before treatment. Clinical history, physical examination, sonography of the urinary tract, urinalysis and bladder diary are prerequisites before any therapeutic steps are taken. The cornerstones of primary enuresis therapy are general lifestyle advice, pharmacotherapy and alarm devices. Therapy-resistant children deserve further evaluation and a multidisciplinary therapy approach. After careful evaluation specific therapy is efficient in approximately 80% of patients.

Structured desmopressin withdrawal improves response and treatment outcome for monosymptomatic enuretic children

PURPOSE

In this national, multicenter, retrospective survey we tested whether structured withdrawal of desmopressin, in which dose frequency rather than dose quantity was gradually decreased, would improve outcome.

MATERIAL AND METHODS

Enrolled in the study were 487 monosymptomatic enuretic patients from a total of 181 centers (The Enuresis Algorithm of Marschall Survey Group). At study outset 41% of patients had 7 wet nights per week, 45% had 3 to 6 and 14% had fewer than 3. All patients were treated with desmopressin, which was abruptly terminated or tapered with analogue by a structured scheme. Response rates were compared in the groups according to International Children's Continence Society guidelines.

RESULTS

The 173 children with abrupt termination had a 51% response rate, including a full and partial response in 44.1% and 27%, respectively, and no response in 22%. The 314 children with tapering had a 72% response rate, including a full and partial response in 66.8% and 24%, and no response in 4% (p <0.0001). Enuresis frequency with abrupt termination decreased from 21 wet nights per month before treatment to 6. The tapering group had 21 wet nights per months before and 2 after treatment (p <0.0001). Followup at 1 month showed fewer than 2 wet nights per month in 57% of cases with abrupt termination and in 80% with tapering (p <0.0001). Pretreatment had no influence. No severe side effects occurred.

CONCLUSIONS

This national, multicenter, retrospective analysis proves that antidiuretic treatment followed by a structured withdrawal program is superior to regular treatment with abrupt termination in enuretic children. Hence, desmopressin followed by structured withdrawal should be the standard. It is also superior to published outcomes of alarm treatment.

An exploration of outcome criteria in nocturnal enuresis treatmentThe way forward

This paper is a review of outcome definitions and criteria for nocturnal enuresis treatment. A search of the literature published between 1991 and 2001 highlighted 97 papers. Although the International Children's Continence Society and the World Health Organization have published outcome criteria, different, often idiosyncratic, outcome criteria and/or definitions have been adopted in published research on treatment for nocturnal enuresis in recent years. There remains a debate as to what constitutes successful treatment and how to document improvement. Lack of an agreed definition of outcome reduces confidence in comparing studies, with serious clinical and research implications. This paper reviews aspects of importance in determining outcome, including a suggestion to focus on the establishment of dry nights rather than the reduction of wet nights. A new set of criteria is suggested, consisting of a banding system referred to as a "dryness scale", which focuses on the percentage of dry nights accomplished at a point in time, thus eliminating the need to compare current levels of dryness with a baseline.

Enuresis, voiding dysfunction and neurogenic bladder in children

This review covers bladder dysfunction in children. A significant amount of work has been done in the past year with regard to enuresis. The International Children Continence Society discussed the issues of bladder dysfunction, including enuresis, and this review covers the findings of that meeting. It also covers the articles that have been published on neurogenic bladder dysfunction as well as on posterior urethral valves.

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.

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.

Management of nocturnal enuresis in Greek children

Our experiences of managing nocturnal enuresis in Greek children at our Outpatient Clinics of Pediatric Urology are described. Between March 2001 and October 2003, 142 children with primary nocturnal enuresis (93 boys and 49 girls), aged 7-18 years old (mean: 9.0+/-0.5) were included in this prospective study. Initially, behavioral conditioning therapy, using a body-worn urinary alarm, was instructed in all cases. If no improvement was recorded, 40 microg of intranasal desmopressin was administered, initially for three months. If urodynamic studies demonstrated pure detrusor instability, anticholinergics (5 mg oxybutinine or 2 mg tolterodine) were given instead. Combination medication (desmopressin and anticholinergics) was administered for coexisting diurnal enuresis, which was present in 8 children. Among the 142 children the overall response rate was 51.41%. Successful response was recorded in 16 children practicing conditioning behavioral therapy, in 47 receiving desmopressin (with or without anticholinergics), and in 10 children receiving only anticholinergics. During the follow-up period (mean: 6.2 months), no serious side effect was recorded. The use of desmopressin, and anticholinergics in specific subgroups, was found to be effective and safe for the management of nocturnal enuresis in children.

Comparing alarms, desmopressin, and combined treatment in Chinese enuretic children

The objective of this multicenter randomized controlled trial was to compare the efficacy of enuresis alarms, oral desmopressin, and combined treatment in Chinese children with monosymptomatic primary nocturnal enuresis. We assigned 105 children aged 7-15 years to receive alarms (group 1, 35 patients), oral desmopressin 400 mug (group 2, 38 patients), or combined therapy (group 3, 32 patients) for 12 weeks; patients were then followed for 12 weeks after treatment. The wetting frequency decreased during treatment by 46%, 52%, and 73% in groups 1, 2, and 3, respectively. In groups 2 and 3, but not in group 1, there was rebound post treatment, but significant improvements persisted at 12 weeks. The complete and partial response rates were 22.9% and 20%, respectively in group 1, 42% and 10.5% in group 2, and 62.5% and 15.6% in group 3. By Kaplan-Meier analysis, group 1 had a significantly poorer response than groups 2 and 3. Of the responders, 20%, 60%, and 40% in groups 1, 2, and 3, respectively, relapsed after stopping treatment. In conclusion, enuresis alarms and/or oral desmopressin were less efficacious in Chinese than in Western societies. Desmopressin produced an immediate effect but relapses were common. Alarms took several weeks to produce a benefit, which was persistent on follow-up.

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.

Nocturnal enuresis

Childhood enuresis is a common socially disruptive problem. The possible pathophysiological factors include a disorder of sleep arousal, nocturnal polyuria, and low bladder capacity. The evaluation of a patient with nocturnal enuresis is aimed to exclude any organic pathology, UTI and voiding dysfunction. An approach to management of this common disorder is outlined.

Enuresis and encopresis: ten years of progress

OBJECTIVE

To review the progress made over the past decade with regard to the treatment of enuresis and encopresis, as well as advances in the understanding of etiological mechanisms.

METHOD

Separate computerized literature (English language only) searches of Medline and PsycINFO databases were conducted under the parameter of enuresis and children-adolescents, as well as encopresis and children-adolescents.

RESULTS

There has been a substantial decrease in published research concerning the use of imipramine to treat enuresis compared with the prior two decades, accompanied by a corresponding increase in the number of papers concerning desmopressin acetate (DDAVP), which has become the primary pharmacological treatment. Genetic studies of large pedigrees have further confirmed the importance of heritable factors. With regard to encopresis, the research has focused primarily on pathophysiological factors related to the colon and anal sphincter.

CONCLUSIONS

The widespread use of DDAVP has been the primary addition to treatment strategies over the past decade. The bell-and-pad method of conditioning, the only major treatment that has enduring benefit after being withdrawn, is the most cost-effective and appears to be underutilized. Research into etiological mechanisms has focused primarily on the mechanism of action of DDAVP and advances in the understanding of genetic factors. Advances in the treatment and etiological understanding of encopresis have been less impressive.

The three systems: a conceptual way of understanding nocturnal enuresis

Childhood nocturnal enuresis has traditionally been regarded as a multifaceted problem with a variety of treatment interventions. This paper proposes a model based on the notion that nocturnal enuresis arises through the ill functioning of one or more of the following three systems - a lack of vasopressin release during sleep; bladder instability; and/or an inability to arouse from sleep to bladder sensations. Clinical signs of each system are outlined and the appropriate treatment intervention for each is discussed. It is argued that addressing nocturnal enuresis in this way will enhance overall treatment effectiveness.