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

Retention Control Training for Nocturnal Enuresis: A Case Study

A 13-year-old girl with nocturnal enuresis which had not previously been controlled using a number of different approaches, was treated using Retention Control Training, designed to increase the functional capacity of her bladder. During treatment the frequency of her evening enuretic episodes decreased and she commenced voluntary night-time independent toileting.

Bibliotherapy-based Dry Bed Training: A Pilot Study

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

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: behavioral treatments

Nocturnal enuresis is a common problem. Physiologic and environmental factors are thought to have a role in the etiology and treatment of this condition. This article discusses the association between enuresis and behavioral or emotional problems. Common behavioral treatments are described, and evidence for their efficacy is reviewed. A brief discussion of hypnosis and acupuncture is included.

Complex behavioural and educational interventions for nocturnal enuresis in children

BACKGROUND

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults.

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

REVIEWER'S CONCLUSIONS

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

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.

A behavioral approach to the treatment of nonretentive nocturnal encopresis in an adult with severe learning disabilities

Encopresis is widely assumed to be "normal" among individuals who are learning disabled. Yet, reports on its prevalence, etiology and treatment are rare and mainly confined to secondary encopresis or to populations with milder learning disabilities. The behavioral treatment of a life-long nonretentive, nocturnal encopresis is described for a young adult with severe learning and physical disabilities living at home. Treatment involved waking prior to soiling, time-limited use of suppositories and rewards for appropriate evacuation. Soiling decreased to zero over 20 weeks. Time of waking was then gradually "shaped" back to normal.

A comparison of three nocturnal enuresis treatment methods

To evaluate the efficacy of an operant approach that includes the bell and pad for the treatment of enuresis (Tangible Rewards with Fading), it was compared with an established operant method that includes the bell and pad (the Dry Bed method) and to a conventional Bell and Pad method. Although there were no overall statistically significant differences among the three methods, individual pairwise comparisons were of interest; the Dry Bed method had no advantage, but the Tangible Rewards with Fading method tended to have more patients reach a 14-day dryness criterion (p less than 0.10) and tended to have fewer patients relapse after treatment (p less than 0.08) than the Bell and Pad method.

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

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

Enuresis

Enuresis is often familial, usually disappearing in adolescence, with only 1 per cent of children suffering from it into adulthood. Functional enuresis is considered to be a variation in normal bladder control, rather than a disease, and most enuretic children do not exhibit any emotional problems. A small functional bladder capacity and a maturational delay appear to be the relevant causes, considering the high rate of spontaneous cure. Only some children with primary enuresis show evidence of emotional or behavioral problems. The physician caring for an enuretic patient should remember that in the absence of obvious clinical manifestations (which must be treated immediately) the best treatment for enuresis is giving reassurance, offering supportive counseling and allowing time for spontaneous remission. Only when the presence of enuresis interrupts the sequence of normal social, emotional, cognitive, or motor development, should the use of medication or devices be considered.

Hypnotherapy as a treatment for enuresis

The main objective of this study was to provide an adequately controlled experimental and clinical study to assess the efficacy of hypnotherapy in the treatment of nocturnal enuresis. Subjects were 48 nocturnal enuretic boys, aged 8-13 yr. Treatment consisted of six standardized sessions, one hourly session per subject per week. Results indicated that hypnotherapy was significantly effective over 6 months in decreasing nocturnal enuresis, compared with both pretreatment baseline enuresis frequency and no-treatment controls. It also suggested that trance induction was not a necessary prerequisite for success. Comparison with other methods of treatment provided evidence that hypnotherapy was an effective alternative or adjunctive form of treatment for enuresis.