Determinants of nocturnal enuresis in homozygous sickle cell disease

The Role of Hyposthenuria in Enuresis Among Paediatric Patients With Sickle Cell Disease

Objectives

Enuresis is common among children with sickle cell disease (SCD). Many risk factors have been postulated, but its relation to hyposthenuria is debatable. This study aimed to determine the prevalence of enuresis in children with SCD in Basrah, Iraq, and to examine its relation with hyposthenuria.

Methods

A cross-sectional epidemiological study was performed on children with SCD who met the inclusion criteria at the Basrah Center for Hereditary Blood Diseases from December 2020 to May 2021. A questionnaire was used to collect relevant data. Blood samples were tested for haemoglobin genotype, certain blood indices and serum haemoglobin. Urine was tested for albumin and creatinine, and the specific gravity was measured using urine dipsticks. The relationships between enuresis and various sociodemographic and clinical variables were assessed. Binary logistic regression analysis was done to examine the independent risk factors of enuresis.

Results

A total of 161 out of 200 eligible children were included in this study (response rate: 80.5%). The majority of participants (60.9%) were males. The mean age of the participants was 10.9 ± 2.9 years. Enuresis was reported in 50 (31.1%) patients. The independent risk factors for enuresis included family history of enuresis (adjusted odds ratio [OR] = 5.94, 95% confidence interval [CI]: 2.54-13.89; P <0.001), hyposthenuria (OR = 3.76, 95% CI: 1.25-11.30; P = 0.018) and sleep disorders (OR = 2.90, 95% CI: 1.19-7.06; P = 0.019.

Conclusion

Enuresis is common among children with SCD in Basrah, Iraq. Hyposthenuria was significantly associated with enuresis. Family history of enuresis and sleep disorders were also found to be significantly related to enuresis.

Enuresis and overactive bladder in sickle cell patients: a narrative review of the literature

OBJECTIVE

The aim of this review is to clarify the prevalence, pathophysiology and clinical presentation of enuresis and overactive bladder in sickle cell patients.

MATERIALS AND METHODS

This narrative review of the literature was conducted in March 2022 by running a search in PubMed, Embase, Scopus and Cochrane databases without publication date limitation, using the following keywords: enuresis or nocturia or overactive bladder or urinary incontinence or bedwetting and sickle cell.

RESULTS

Eight cross-sectional studies were included, six of which had a non-sickle cell control population. The prevalence of enuresis in children and adolescents with sickle cell disease ranged from 20.3 to 49.4%. It decreased with age to 2.9% in adult sickle cell patients. Enuresis in sickle cell patients has been attributed to several causes, including lack of urine concentration with nocturnal polyuria, reduced bladder capacity, nocturnal bladder hyperactivity, sleep and/or respiratory disorders are likely causes of enuresis in sickle cell patients. The prevalence of overactive bladder is three times higher in sickle cell patients than in control groups. The latter is also observed three times more frequently in men who have had prior episodes of priapism.

CONCLUSION

Enuresis and overactive bladder are common in sickle cell patients. Several mechanisms have been described to try to explain enuresis in sickle cell patients but overactive bladder seems to play a major role. Studies evaluating the efficacy of certain experimentally validated treatments must be carried out to improve the management of these complications which affect the quality of life of sickle cell patients.

Enuresis and Hyperfiltration in Children With Sickle Cell Disease

Nocturnal enuresis is a common symptom in children with sickle cell disease (SCD). Risk factors for development of enuresis are currently unknown. An early manifestation of SCD-associated kidney damage is glomerular hyperfiltration. We test the hypothesis that in a pediatric SCD cohort, individuals with hyperfiltration are more likely to have nocturnal enuresis when compared to children without hyperfiltration. To assess the relationship between nocturnal enuresis and hyperfiltration, we retrospectively evaluated children with SCD enrolled in the Evaluation of Nocturnal Enuresis and Barriers to Treatment among Pediatric Patients with SCD study and prospectively identified children who reported nocturnal enuresis and were enrolled in the longitudinal cohort study Sickle Cell Clinical Research and Intervention Program. Nocturnal enuresis occurred in 46.5% of Pediatric Patients with Sickle Cell Disease participants and was more frequent in participants with HbSS/HbSβ 0 thalassemia and in male participants. We did not identify an association between hyperfiltration from 3 to 5 years of age with the later development of enuresis. Severe SCD genotypes and male sex were associated with nocturnal enuresis after age 5 years. We could not identify additional renal or hematologic predictors associated with the diagnosis of nocturnal enuresis. Future studies should incorporate nonrenal risk factors into studies that predict development of enuresis.

Enuresis in children and adolescents with sickle cell anaemia is more frequent and substantially different from the general population

Background

No large studies have examined the prevalence of enuresis, its various forms and risk factors in children with sickle cell anaemia (SCA) in Sub-Saharan Africa using standardised definitions. We determined age and gender-specific prevalence of enuresis and compared the nature of enuresis in children with and without SCA. We also identified predictors of enuresis in children with SCA.

Methods

Caregivers of children with SCA attending a tertiary centre haematology clinic in Nigeria were interviewed using a questionnaire. In addition, a separate questionnaire was completed for every sibling aged 5–17 years whose haemoglobin genotype was known. Enuresis and its various forms were defined using the definitions of the International Children’s Continence Society.

Results

The study involved 243 children with SCA and 243 controls matched for age and sex. The mean age of the study cohort was 9.9 (3.4). Females made up 45.7% of the cohorts. The prevalence of enuresis was 49.4% and 29.6% in children with and without SCA, respectively (p = 0.009). In both groups, the prevalence of enuresis declined with age but remained five times higher at 25% in children with SCA aged 14–17 years compared with controls. Also, children with SCA and enuresis were older, more likely to have non-monosymptomatic enuresis and wet at least three nights per week than controls. Independent predictors of enuresis in children with SCA were a family history of enuresis and young age.

Conclusion

Children with SCA had more frequent and more severe enuresis which persisted to late adolescence than age and sex-matched controls. These features indicate a subset of enuresis that is difficult to treat in the general population. Young age and enuresis in a family member define a subset of children with SCA more likely to have enuresis. Healthcare workers need to discuss enuresis with parents of children with SCA and offer referral to continence services.

[Kidney and hemoglobinopathy]

Sickle-cell disease (SCD), one of the most common severe monogenic disorders into the world, is associated with an increased frequency of chronic kidney disease. SCD is caused by a point mutation in the gene encoding β globin gene which leads to the formation of hemoglobin S that polymerises after deoxygenation. HbS polymerisation is associated with erythrocyte rigidity and vaso-occlusive episodes that play a central role into SCD pathogenesis. The spectrum of renal diseases during SCD is broad and includes various renal manifestations which become more apparent with increasing age. Underlying pathophysiological processes involved in sickle cell nephropathy are multifactorial but endothelial dysfunction related to chronic hemolysis is a key factor contributing to renal involvement. Our review focuses on the pathogenesis and on the spectrum of renal manifestations occurring in SCD patients.

Urinary Bladder Dysfunction in Transgenic Sickle Cell Disease Mice

Background

Urological complications associated with sickle cell disease (SCD), include nocturia, enuresis, urinary infections and urinary incontinence. However, scientific evidence to ascertain the underlying cause of the lower urinary tract symptoms in SCD is lacking.

Objective

Thus, the aim of this study was to evaluate urinary function, in vivo and ex vivo, in the Berkeley SCD murine model (SS).

Methods

Urine output was measured in metabolic cage for both wild type and SS mice (25-30 g). Bladder strips and urethra rings were dissected free and mounted in organ baths. In isolated detrusor smooth muscle (DSM), relaxant response to mirabegron and isoproterenol (1nM-10μM) and contractile response to (carbachol (CCh; 1 nM-100μM), KCl (1 mM-300mM), CaCl₂ (1μM-100mM), α,β-methylene ATP (1, 3 and 10 μM) and electrical field stimulation (EFS; 1-32 Hz) were measured. Phenylephrine (Phe; 10nM-100μM) was used to evaluate the contraction mechanism in the urethra rings. Cystometry and histomorphometry were also performed in the urinary bladder.

Results

SS mice present a reduced urine output and incapacity to produce typical bladder contractions and bladder emptying (ex vivo), compared to control animals. In DSM, relaxation in response to a selective β3-adrenergic agonist (mirabegron) and to a non-selective β-adrenergic (isoproterenol) agonist were lower in SS mice. Additionally, carbachol, α, β-methylene ATP, KCl, extracellular Ca²⁺ and electrical-field stimulation promoted smaller bladder contractions in SS group. Urethra contraction induced by phenylephrine was markedly reduced in SS mice. Histological analyses of SS mice bladder revealed severe structural abnormalities, such as reductions in detrusor thickness and bladder volume, and cell infiltration.

Conclusions

Taken together, our data demonstrate, for the first time, that SS mice display features of urinary bladder dysfunction, leading to impairment in urinary continence, which may have an important role in the pathogenesis of the enuresis and infections observed the SCD patients.

Overactive bladder in adults with sickle cell disease

AIMS

To characterize the prevalence and impact of nocturnal enuresis and overactive bladder (OAB) symptomatology in the adult sickle-cell disease (SCD) population.

METHODS

We performed a single-center, cross-sectional study of adult SCD patients from October 2012 to February 2014, using the validated Pfizer OAB short form questionnaire and brief voiding history surveys. Patient responses and scores were compared to that of controls having normal or sickle cell trait hemoglobin genotypes.

RESULTS

A group of 239 SCD patients (116 males, 123 females) were compared with 104 normal and 57 sickle cell trait patients. Seven of 239 (2.9%) SCD patients compared to none of the 161 patients without SCD (P = 0.04) reported current nocturnal enuresis. The median age of nocturnal enuresis cessation was higher in SCD patients (12.0, IQR 9.0-15.0 years) compared to that of both normal (7.5, IQR 6.0-9.8 years) and sickle cell trait (7.5, IQR 6.0-8.8 years) groups (P < 0.0001). Ninety-three of 239 (38.9%) SCD patients compared to 17 of 104 (16.3%) normal and 11 of 57 (19.3%) sickle cell trait had scores indicating OAB symptomatology (P < 0.0001). Patients with SCD had higher OAB symptom severity and lower health-related quality of life (HRQL) scores compared to the normal and sickle cell trait groups (P < 0.0001 and P < 0.0001, respectively).

CONCLUSIONS

We demonstrate an elevated rate of nocturnal enuresis and OAB symptoms in the adult SCD population. An OAB phenotype may be an under-recognized complication of SCD irrespective of age. Neurourol. Urodynam. 35:642-646, 2016. © 2015 Wiley Periodicals, Inc.

The natural history of sickle cell disease

The term sickle cell disease embraces a group of genetic conditions in which pathology results from the inheritance of the sickle cell gene either homozygously or as a double heterozygote with another interacting gene. The spectrum of resulting conditions is therefore influenced by the geography of individual hemoglobin genes, but in most populations, the commonest genotype at birth is homozygous sickle cell (SS) disease. Because this genotype generally manifests a greater mortality, the relative proportion of sickle cell genotypes is influenced by age as well as the geographical distribution of individual genes.

Prevalence of enuresis and daytime urinary incontinence in children and adolescents with sickle cell disease

PURPOSE

There is a known association between sickle cell disease and enuresis. However, the cause of this association is unclear. We tested the hypothesis that children with sickle cell disease would have more symptoms of overactive bladder than a control group.

MATERIALS AND METHODS

Questionnaires were distributed to 155 legal guardians of children and adolescents 5 to 17 years old with sickle cell disease and to 100 legal guardians of a control group of children.

RESULTS

Individuals with and without sickle cell disease were distributed uniformly regarding gender and age. A total of 50 patients (32.3%) in the sickle cell disease group had enuresis vs 5 (5%) in the control group (p = 0.000). Daytime urinary incontinence was observed in 36 individuals with (23.2%) and 11 (11.0%) without sickle cell disease (p = 0.014). A total of 52 patients with sickle cell disease (33.5%) complained of urgency, compared to 10 controls (10%, p = 0.000). A total of 49 patients with sickle cell disease (31.6%) had frequency, compared to 6 controls (6%, p = 0.000). Of all patients who reported enuresis or daytime incontinence only 1 with enuresis had received specific treatment.

CONCLUSIONS

There is a significant association between sickle cell disease and enuresis and overactive bladder symptoms such as daytime incontinence, urgency and frequency. Thus, all children and adolescents with sickle cell disease should be questioned regarding the presence of these symptoms to facilitate treatment for these conditions.

Enuresis is a common and persistent problem among children and young adults with sickle cell anemia

OBJECTIVES

Enuresis and nocturia are common among children with sickle cell anemia (SCA). The objectives of this study were to describe the prevalence of enuresis and nocturia among children and young adults with SCA and determine the relationship, if any, between these symptoms and SCA-related morbidity.

METHODS

A prospective infant cohort of African-American children with SCA was previously established from the Cooperative Study for Sickle Cell Disease. Included in this cohort were children with SCA enrolled before 6 months of age for whom questions about enuresis and nocturia had been completed.

RESULTS

A total of 213 participants were included in this analysis. Sixty-nine individuals (33%) experienced enuresis over the course of the study. No children under 6 years of age were asked about enuresis. Thereafter, enuresis was most prevalent between the ages of 6 and 8 years (42%) and continued to be common in young adults ages 18 to 20 years (9%). Seventy-nine percent of individuals reported a history of nocturia. There was no association between enuresis or nocturia and an increased rate of pain or acute chest syndrome (ACS) episodes.

CONCLUSIONS

Enuresis and nocturia are common in children with SCA. Among adults with SCA, enuresis and nocturia are more persistent compared with adults in the general population. Enuresis and nocturia are not associated with an increased rate of pain or ACS.

Nocturnal enuresis and psychosocial problems in pediatric sickle cell disease and sibling controls

To evaluate current and lifetime prevalence rates of nocturnal enuresis and psychosocial problems among children with sickle cell disease (SCD) in comparison with sibling controls, a structured interview and the Pediatric Symptom Checklist were administered to primary caretakers regarding 126 of their children aged 5 to 17 with SCD and 47 sibling controls. Lifetime rates of enuresis among children with SCD were comparable to similar studies, and exceeded population prevalence and sibling control rates. In addition, enuretic children had higher levels of total psychosocial problems on the Pediatric Symptom Checklist regardless of group status, although patterns of subscale differences varied by group and enuresis history after controlling for child age. These findings replicate and extend previous findings and provide further evidence to support a need for monitoring of hydration levels and screening for psychosocial problems among children with SCD and enuresis, as well as evaluation of the psychometric properties of psychosocial screening measures and identification of efficacious treatments for enuresis in children with SCD.

Psychosocial and Neurocognitive Aspects of Sickle Cell Disease

Sickle cell disease (SCD) comprises a group of recessively inherited blood disorders and is the most common genetic disorder in the world (Embury et al., 1994). It is a chronic condition of variable severity that mainly affects people of African and African-Caribbean heritage. Over the last 20 years life expectancy has increased significantly, particularly for patients receiving western healthcare so that increasing attention has been directed to the psychosocial adaptation and neurocognitive profile of children and adolescents with SCD. Previously, research suggested that, like children with other chronic health conditions, children and adolescents with SCD were at increased risk for emotional and behavioural disorders. More recent research has not demonstrated increased rates of such difficulties. Increasing evidence suggests that children with severe disease are, however, at significantly increased risk for cerebro-vascular events and neurocognitive difficulties. This paper reviews the literature regarding the psychological and neurocognitive functioning of children with SCD and outlines a number of ways that psychological input may significantly contribute to more effective health care for these children and their families.

Nocturnal enuresis in pediatric sickle cell disease

To assess the prevalence of nocturnal enuresis in children and adolescents with sickle cell disease (SCD) and associated factors, structured telephone interviews were conducted with primary caregivers of 217 children and adolescents with SCD aged 5 years or older. Prevalence, perceived causes, interventions undertaken, and emotional impact were assessed. Nocturnal enuresis was significantly higher for males (28.2% of males) than for females (11% of females), p = .002, and compared with cited population prevalence rates, nocturnal enuresis was significantly higher for children with SCD, p < .01. SCD was the most common reason given by primary caregivers for enuresis. Primary caregivers used a wide range of interventions for nocturnal enuresis, but few used empirically supported treatments for enuresis or spoke with their health care team about the enuresis. These data suggest that systematic assessment and intervention for nocturnal enuresis must be implemented in the follow-up care of children and adolescents with SCD.

Night-time polyuria and urine hypo-osmolality in enuretics identified by nocturnal sequential urine sampling--do they represent a subset of relative ADH-deficient subjects?

Early morning urine osmolality was tested in two urinary specimens, one taken immediately upon awakening and the other approximately 30 min thereafter, in 52 enuretic and 15 non-enuretic children. In a follow-up study, using the same study population, urine osmolality and volume were measured sequentially at 3-h intervals at 19.00, 22.00, 01.00, 04.00 and 07.00 h. Thereafter, all enuretics were treated by intranasal DDAVP for a 6-month period. There were no differences in urinary osmolality between enuretic and non-enuretic children when comparing the two early morning specimens. Nor were there any differences between groups in urine osmolalities at 19.00, 01.00 and 07.00 h. In contrast, at 04.00 h, urine osmolality was significantly lower in 17 of 52 enuretics [designated as ADH-negative (ADH-)] compared to the remaining enuretics [designated as ADH-positive (ADH+)] and non-enuretic children (610 +/- 251 vs 995 +/- 195 and 1089 +/- 195 mosmol/kg H2O, respectively, p < 0.05). This decreased osmolality was paralleled by an increase in urine production during the time period 01.00-04.00 (83 +/- 24 vs 52 +/- 18 and 45 +/- 22 ml, respectively, p < 0.05). At the end of the 6-month period of DDAVP treatment, the percentage response was similar between the ADH- and ADH+ enuretics (79% vs 75%). However, the time taken to achieve a response was quicker in the ADH- subjects. These data suggest the existence of a subgroup of enuretics whose underlying pathophysiology is the development of nocturnal polyuria probably due to a relative night-time ADH deficiency. Nocturnal sequential monitoring of urinary osmolality, as described above, allows identification of this subgroup.

Nocturnal enuresis

Nocturnal enuresis is a very common pediatric problem which often has strong genetic roots. In the vast majority of children it resolves spontaneously, with time, therefore research and treatment of bedwetting cannot carry any risk to the child. The research on the etiology of bedwetting has been focused on sleep disturbances, nocturnal urine production and functional bladder capacity. So far it has not provided conclusive evidence of the pathophysiology of the phenomenon. It is possible that different factors may be predominant in different age groups. Although bedwetters are basically mentally healthy, several studies have shown that the problem may cause secondary emotional and social problems which can be alleviated with successful intervention. Of the treatment modalities currently available to the pediatrician, the most effective is the moisture alarm. Combined with its safety and low cost it should become the treatment of choice in most cases.

Diagnosis and treatment for children who cannot control urination

Primary NE is probably a condition rooted in biologic problems. There is a strong hereditary component. Altered nervous system function may lead to disorganization of how bladder function is controlled and how vasopressin is released. In extreme cases, this disorganization may also be reflected in psychologic issues, such as attention-deficit disorder. Primary NE should not be viewed as laziness of the child, but as an obstacle the child needs professional help to hurdle. The practitioner should collaborate with a pediatrician, urologist, and psychologist in managing children who wet. Routine office evaluation should exclude incontinence as a cause of wetting. When a screening ultrasonogram is normal, this helps the practitioner determine that striking birth defects are unlikely. Follow-up of management by interview with interested staff is necessary. Wetting is reliably correctable and probably best addressed by combination treatment structured as an ETP. Specific treatments vary according to personal preferences. The treatment with strongest scientific research, desmopressin, may be the least effective for cure. The most effective treatment for cure, alarm with behavior reinforcement, is the least often prescribed. A miscellany of adjunctive treatments should be suggested when there are abnormalities in functional bladder capacity, defecation, urethritis, vulvitis, diet sensitivity, upper-airway obstruction, and other areas.