1
|
Capalbo D, Guarino S, Di Sessa A, Esposito C, Grella C, Papparella A, Miraglia Del Giudice E, Marzuillo P. Combination therapy (desmopressin plus oxybutynin) improves the response rate compared with desmopressin alone in patients with monosymptomatic nocturnal enuresis and nocturnal polyuria and absence of constipation predict the response to this treatment. Eur J Pediatr 2023; 182:1587-1592. [PMID: 36693995 DOI: 10.1007/s00431-023-04824-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 12/21/2022] [Accepted: 01/14/2023] [Indexed: 01/26/2023]
Abstract
UNLABELLED Combination therapy (CT) (desmopressin plus oxybutynin) has been considered for the treatment of monosymptomatic nocturnal enuresis (MNE). We designed our study with the aim to evaluate the response rate to CT compared with desmopressin alone (primary outcome) and to identify factors associated with the response to CT (secondary outcome). We prospectively enrolled children with MNE with absent/partial response after 3 months of evening treatment with 240 mcg of desmopressin. We defined the response rate to CT compared with desmopressin alone according to the standardization of terminology document of the International Children's Continence Society: no-response, < 50% reduction; partial response, 50 to 99% reduction; and complete response, 100% reduction of wet nights. Both partial response and complete response to CT were clustered for the analyses of this manuscript. The enrolled children treated with 240 mcg/evening of desmopressin had also an additional evening administration of 0.3 mg/kg oxybutynin. A follow-up was scheduled at 3 and 6 months after the beginning of CT. At 3 months, oxybutynin dose was augmented to 0.5 mg/kg in case of absent/partial response to CT. Nocturnal diuresis was measured in 5 wet nights prior the beginning of therapy with desmopressin. Nocturnal polyuria (NP) was defined as nocturnal urine production > 130% of the expected bladder capacity. All patients with constipation were treated with macrogol. We enrolled 81 children (35.8% females) with a mean age of 8.4 ± 2.3 years. Seventy-eight patients completed the follow-up. After the CT, 59/78 (75.6%) patients showed an improvement of the response with CT compared with desmopressin alone. At multivariate analysis, both NP in more than 1 night (OR = 8.5; 95% CI, 1.4-51.6; p = 0.02) and absence of constipation (OR = 7.1; 95% CI, 1.6-31.0; p = 0.009) resulted significant after Bonferroni correction. CONCLUSIONS CT determines an improvement of response compared to therapy with desmopressin alone in 75.6% of patients. Significant predictive factors of response to CT were presence of NP and absence of constipation. WHAT IS KNOWN • Combination therapy (CT) (desmopressin plus anticholinergic drug) has been described as a therapeutic option for patients with monosymptomatic nocturnal enuresis (MNE) not responding to desmopressin alone as first-line treatment. • Variable protocols and variable combination of drugs have been described with a response rate ranging from 44 to 76%. WHAT IS NEW • We found that 59 patients (75.6%) treated with evening administration of 240 mcg of sublingual desmopressin plus 0.3-0.5 mg/kg of oxybutynin had an improvement of response compared to treatment with desmopressin alone. • We add evidence that presence of frequently recurring nocturnal polyuria and absence of constipation are predictors of response to CT.
Collapse
Affiliation(s)
- Daniela Capalbo
- Department of Woman, Child and of General and Specialized Surgery, Università Degli Studi Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, Naples, 80138, Italy
| | - Stefano Guarino
- Department of Woman, Child and of General and Specialized Surgery, Università Degli Studi Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, Naples, 80138, Italy.
| | - Anna Di Sessa
- Department of Woman, Child and of General and Specialized Surgery, Università Degli Studi Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, Naples, 80138, Italy
| | - Claudia Esposito
- Department of Woman, Child and of General and Specialized Surgery, Università Degli Studi Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, Naples, 80138, Italy
| | - Carolina Grella
- Department of Woman, Child and of General and Specialized Surgery, Università Degli Studi Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, Naples, 80138, Italy
| | - Alfonso Papparella
- Department of Woman, Child and of General and Specialized Surgery, Università Degli Studi Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, Naples, 80138, Italy
| | - Emanuele Miraglia Del Giudice
- Department of Woman, Child and of General and Specialized Surgery, Università Degli Studi Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, Naples, 80138, Italy
| | - Pierluigi Marzuillo
- Department of Woman, Child and of General and Specialized Surgery, Università Degli Studi Della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, Naples, 80138, Italy
| |
Collapse
|
2
|
Gonda Y, Fujinaga S, Miyano H. Combination treatment with vibegron and solifenacin for refractory non-monosymptomatic enuresis. Pediatr Int 2023; 65:e15651. [PMID: 37804057 DOI: 10.1111/ped.15651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/12/2023] [Accepted: 08/07/2023] [Indexed: 10/08/2023]
Affiliation(s)
- Yusuke Gonda
- Division of Nephrology, Saitama Children's Medical Center, Saitama, Japan
- Department of Pediatrics, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Shuichiro Fujinaga
- Division of Nephrology, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroki Miyano
- Division of Nephrology, Saitama Children's Medical Center, Saitama, Japan
- Department of Pediatrics, Juntendo University Nerima Hospital, Tokyo, Japan
| |
Collapse
|
3
|
Nevéus T. Problems with enuresis management-A personal view. Front Pediatr 2022; 10:1044302. [PMID: 36405838 PMCID: PMC9671946 DOI: 10.3389/fped.2022.1044302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
Much has happened since the end of the era when enuresis was blamed on the parents or the children themselves. Still, there are large gaps in our knowledge and large parts of modern enuresis management guidelines are (still) not based on firm evidence. In this review I will question the following commonly made assumptions regarding enuresis evaluation and treatment: •It is important to subdivide enuresis according to the presence of daytime symptoms•Voiding charts are crucial in the primary evaluation of the enuretic child•All children with enuresis need to be screened for behavioral or psychiatric issues•Concomittant daytime incontinence needs to be successfully treated before addressing the enuresis•Concomittant constipation needs to be successfully treated before addressing the enuresis•Urotherapy is a first-line treatment against enuresis In this review I will argue that much of what we do with these children is based more on experience and well-meant but poorly supported assumptions than on evidence. Some advice and therapies are probably ineffective whereas for other treatments we lack reliable predictors of treatment response. More research is obviously needed, but awaiting new results enuresis management could be substantially simplified.
Collapse
Affiliation(s)
- Tryggve Nevéus
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| |
Collapse
|
4
|
Abdovic S, Cuk M, Hizar I, Milosevic M, Jerkovic A, Saraga M. Pretreatment morning urine osmolality and oral desmopressin lyophilisate treatment outcome in patients with primary monosymptomatic enuresis. Int Urol Nephrol 2021; 53:1529-1534. [PMID: 33774753 DOI: 10.1007/s11255-021-02843-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/22/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine the association between urine osmolality (Uosm) in patients with primary monosymptomatic enuresis (PMNE) and response to desmopressin (dDAVP) lyophilisate. METHODS This was a prospective cohort study that included 419 children with enuresis seen in outpatient clinic between October 2017 and October 2019. Patient workup included symptom checklist, 48 h frequency/volume chart, kidney and bladder ultrasound, uroflow, urinalysis and culture, spot urine Ca/creatinine, and first-morning Uosm. Patients < 5 years, with secondary enuresis, or loss of follow-up were excluded. Oral dDAVP lyophilisate was recommended to all with PMNE and normal bladder capacity. After 1 month of therapy, initial success was assessed according to ICCS. Significant predictor variables for complete response were identified and analyzed using correlation coefficients and binary logistic regression. RESULTS There were 48 patients with PMNE who received dDAVP and were followed for treatment success. Partial and complete responses were achieved for 14 (29.2%) and 20 cases (41.7%), respectively. Older age and lower Uosm were found to be significantly in favor of complete response to dDAVP lyophilisate, P = 0.007 and 0.033, respectively. ROC analysis determined the Uosm of ≤ 814 mOsm/kg as a cut-off value for complete success (sensitivity 65% and specificity 75%, AUC = 68.2%). The odds ratio for complete success for selected cut-off value was 5.57 (95% CI 1.588-19.551, P = 0.007). CONCLUSION High pretreatment morning Uosm (> 814 mOsm/kg) might be suggestive of an alternative treatment to dDAVP lyophilisate in PMNE because of the higher risk of treatment failure.
Collapse
Affiliation(s)
- S Abdovic
- Department of Pediatric Nephrology, Children's Hospital Zagreb, Klaiceva 16, 10000, Zagreb, Croatia.
| | - M Cuk
- Department of Pediatric Nephrology, Children's Hospital Zagreb, Klaiceva 16, 10000, Zagreb, Croatia
| | - I Hizar
- Department of Pediatric Nephrology, Children's Hospital Zagreb, Klaiceva 16, 10000, Zagreb, Croatia
| | - M Milosevic
- Andrija Stampar School of Public Health, University of Zagreb School of Medicine, Zagreb, Croatia
| | - A Jerkovic
- Department of Pediatric Nephrology, Children's Hospital Zagreb, Klaiceva 16, 10000, Zagreb, Croatia
| | - M Saraga
- Department of Pediatric Nephrology, University Hospital Center Split, Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| |
Collapse
|
5
|
Reddy NM, Malve H, Nerli R, Venkatesh P, Agarwal I, Rege V. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian J Nephrol 2017; 27:417-426. [PMID: 29217876 PMCID: PMC5704404 DOI: 10.4103/ijn.ijn_288_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Nocturnal enuresis is a common problem affecting school-aged children worldwide. Although it has significant impact on child's psychology, it is always under-recognized in India and considered as a condition which will outgrow with advancing age. Nocturnal enuresis classified as primary or secondary and monosymptomatic or nonmonosymptomatic. Factors that cause enuresis include genetic factors, bladder dysfunction, psychological factors, and inappropriate antidiuretic hormone secretion, leading to nocturnal polyuria. Diagnosis consists of detailed medical history, clinical examination, frequency-volume charts, and appropriate investigations. The frequency-volume chart or voiding diary helps in establishing diagnosis and tailoring therapy. The first step in treating nocturnal enuresis is to counsel the parents and the affected child about the condition and reassure them that it can be cured. One of the effective strategies to manage enuresis is alarm therapy, but currently, it is not easily available in India. Desmopressin has been used in the treatment of nocturnal enuresis for close to 50 years. It provides an effective and safe option for the management of nocturnal enuresis. This review covers the diagnosis and management of nocturnal enuresis and introduces the concept of “bedwetting clinics” in India, which should help clinicians in the thorough investigation of bedwetting cases.
Collapse
Affiliation(s)
- N M Reddy
- Department of Urology, Rainbow Hospitals, Hyderabad, Telangana, India
| | - H Malve
- Medical Affairs, Ferring Pharmaceuticals Pvt. Ltd., Mumbai, Maharashtra, India
| | - R Nerli
- Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum, India
| | - P Venkatesh
- Department of Pediatric Urology, NU Hospitals, Bengaluru, Karnataka, India
| | - I Agarwal
- Department of Child Health Unit II, Christian Medical College, Vellore, Tamil Nadu, India
| | - V Rege
- Department of Pediatric Urology, Wadia Hospital for Children, Mumbai, Maharashtra, India
| |
Collapse
|
6
|
Charalampous S, Printza N, Hashim H, Bantouraki M, Rompis V, Ioannidis E, Papacristou F. Bladder wall thickness and urodynamic correlation in children with primary nocturnal enuresis. J Pediatr Urol 2013; 9:334-8. [PMID: 22652388 DOI: 10.1016/j.jpurol.2012.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Accepted: 04/19/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To investigate the correlations between ultrasonographic bladder wall thickness (BWTh) and urodynamic study (UDS) findings and estimate the diagnostic value of BWTh for prediction of DO in children with monosymptomatic and non-monosymptomatic primary nocturnal enuresis (PNE). PATIENTS AND METHODS Ultrasound measurements (US) and UDS were performed on a total of 100 children, 50 consecutive boys and 50 consecutive girls, 6-14 years old, with monosymptomatic PNE (group 1, n = 75), and non-monosymptomatic PNE (group 2, n = 25). The US Protocol was specially designed for the evaluation of BWTh. All children underwent urodynamic studies for detailed assessment of any underlying bladder overactivity. Findings were compared between the two groups of patients. RESULTS The mean BWTh was increased in the group 2 compared to the group 1 (mean ± SD = 2.4 ± 0.41 mm, mean ± SD = 1.52 ± 0.18 mm respectively, p < 0.05). Detrusor overactivity (DO) occurred in 23/75 (30.5%) children of the group 1 and in 17/25 (68%) children of the group 2 (p < 0.05). Comparing the BWTh between the two groups of patients and the UDS findings, it was found that BWTh was significantly correlated with DO(r = 0.92 and p < 0.001), children with DO presented significantly increased BWTh compared to those without (mean ± SD = 2.1 ± 0.4 mm, mean ± SD = 1.5 ± 0.4 mm respectively, p < 0.05) and the maximum amplitude of DO occurred in 20 children who had non-monosymptomatic PNE. CONCLUSIONS We suggest that BWTh could be applied as a screening tool to identify the cases of DO between the children with PNE. Children with non-monosymptomatic PNE presented increased BWTh and higher percentages of DO.
Collapse
|
7
|
Elmissiry M, Abdelkarim A, Badawy H, Elsalmy S, Ali GA. Refractory enuresis in children and adolescents: how can urodynamics affect management and what is the optimum test? J Pediatr Urol 2013; 9:348-52. [PMID: 22682547 DOI: 10.1016/j.jpurol.2012.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 04/24/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE After failure of medical and behavioral therapy in enuresis, the usual next step is to investigate using urodynamics. The aim of this study was to determine the actual benefit and optimal method of urodynamics in the treatment of refractory enuresis. METHODS This prospective randomized study included 56 patients: 17 males and 39 females with an age range of 7-16 years. All had tried multiple courses of medical treatment for enuresis for at least 6 months without response. Thirty patients underwent investigation by cystometrogram, uroflowmetry and electromyogram (UFM/EMG), while 26 patients underwent pressure/flow/EMG (P/F/EMG) studies. RESULTS Bladder filling abnormalities were found in 25 out of the 56 patients (44.6%) and included low bladder capacity in 39%, hypocompliance in 32%, and detrusor overactivity in 45%. With regard to voiding dysfunction, 70% of the UFM/EMG group had detrusor‒sphincter dyssynergia and 67% of the P/F/EMG group had bladder outlet obstruction. CONCLUSIONS Urodynamics can help in cases of refractory enuresis by detecting dysfunctional voiding, which is present in a large percentage of these patients. This can be diagnosed by UFM/EMG, rather than P/F/EMG, as a non-invasive test. UFM alone may be misleading. Alpha adrenergic blockers may be of benefit in treating these patients.
Collapse
Affiliation(s)
- Mostafa Elmissiry
- Section of Voiding Dysfunction and Urodynamics, Urology Department, Faculty of Medicine, Alexandria University, Azarita, 21113 Alexandria, Egypt.
| | | | | | | | | |
Collapse
|
8
|
Raheem AA, Farahat Y, El-Gamal O, Ragab M, Radwan M, El-Bahnasy AH, El-Gamasy AN, Rasheed M. Role of posterior tibial nerve stimulation in the treatment of refractory monosymptomatic nocturnal enuresis: a pilot study. J Urol 2012; 189:1514-8. [PMID: 23103798 DOI: 10.1016/j.juro.2012.10.059] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE We evaluated the early clinical and urodynamic results of posterior tibial nerve stimulation in patients with refractory monosymptomatic nocturnal enuresis. MATERIALS AND METHODS We randomly assigned 28 patients with refractory monosymptomatic nocturnal enuresis to 2 equal groups. Group 1 received a weekly session of posterior tibial nerve stimulation for 12 weeks and group 2 was the placebo group. Evaluation was performed in each group at baseline and after posterior tibial nerve stimulation to compare clinical and urodynamic findings. Another clinical assessment was done 3 months after the first followup. RESULTS The 2 groups were comparable in baseline clinical and urodynamic data. Overall, 13 patients (46.4%) had detrusor overactivity and 14 (50%) had decreased bladder capacity. After treatment 11 group 1 patients (78.6%) had a partial or full response to posterior tibial nerve stimulation but only 2 (14.3%) in group 2 had a partial response (p = 0.002). Also, the average number of wet nights in group 1 was significantly lower than at baseline (p = 0.002). All urodynamic parameters significantly improved in group 1. In contrast, the number of wet nights and urodynamic parameters did not change significantly in group 2. At 3-month followup the number of patients with a partial or full response in group 1 had decreased from 11 (78.6%) to 6 (42.9%). No change was evident in group 2. CONCLUSIONS Posterior tibial nerve stimulation can be a viable treatment option in some patients with refractory monosymptomatic nocturnal enuresis. However, deterioration in some responders with time suggests the need for maintenance protocols.
Collapse
Affiliation(s)
- Ali Abdel Raheem
- Urology Department, Tanta University Hospital, Tanta, El Gharbia, Egypt.
| | | | | | | | | | | | | | | |
Collapse
|
9
|
Kim JM. Diagnostic value of functional bladder capacity, urine osmolality, and daytime storage symptoms for severity of nocturnal enuresis. Korean J Urol 2012; 53:114-9. [PMID: 22379591 PMCID: PMC3285706 DOI: 10.4111/kju.2012.53.2.114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 10/13/2011] [Indexed: 11/25/2022] Open
Abstract
Purpose To investigate the correlation between functional bladder capacity, first morning urine osmolality, daytime voiding symptoms, and severity of nocturnal enuresis. Materials and Methods We assessed a total of 101 children with nocturnal enuresis (mean age, 7.7±2.3 years). Patients were divided into three groups according to the severity of enuresis: (1) one to six episodes per week (46 cases, 45.5%), (2) one episode every day (29 cases, 28.7%), and (3) multiple episodes every day (26 cases, 25.8%). Baseline parameters were obtained from frequency volume charts for 2 days, first morning urine osmolality, and a questionnaire for the presence of frequency, urgency, and daytime incontinence. Results The severity of enuresis increased with younger age (p=0.037) and reduced functional bladder capacity (p=0.007) and daytime symptoms of frequency and daytime incontinence (p=0.012, p=0.036). No statistical difference in urine osmolality or urgency was found among the three groups. Both reduced functional bladder capacity and low urine osmolality increased according to the severity of enuresis (p=0.012). Conclusions In children with nocturnal enuresis, severity was increased by younger age, reduced functional bladder capacity, and the presence of daytime voiding symptoms of frequency and daytime incontinence. The incidence of small functional bladder capacity was increased in children with everyday wetting, and the incidences of both small functional bladder capacity and low urine osmolality were increased in children with everyday multiple wetting.
Collapse
Affiliation(s)
- Jun-Mo Kim
- Department of Urology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, Korea
| |
Collapse
|
10
|
Montaldo P, Tafuro L, Rea M, Narciso V, Iossa AC, Gado RD. Desmopressin and oxybutynin in monosymptomatic nocturnal enuresis: a randomized, double-blind, placebo-controlled trial and an assessment of predictive factors. BJU Int 2012; 110:E381-6. [DOI: 10.1111/j.1464-410x.2011.10918.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
11
|
Okur M, Ozen SF, Kocabay K, Cam K, Ozkan A, Uzun H. The Effect of Maximum Voided Volume on Response to Desmopressin Therapy in Children with Enuresis. J NIPPON MED SCH 2012; 79:255-8. [DOI: 10.1272/jnms.79.255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Mesut Okur
- Department of Pediatrics, Duzce University Medical Faculty
| | | | - Kenan Kocabay
- Department of Pediatrics, Duzce University Medical Faculty
| | - Kamil Cam
- Department of Urology, Duzce University Medical Faculty
| | - Aybars Ozkan
- Department of Pediatric Surgery, Duzce University Medical Faculty
| | - Hakan Uzun
- Department of Pediatrics, Duzce University Medical Faculty
| |
Collapse
|
12
|
Abstract
The surgeon aims at a direct, complete removal of the pathology. In spite of the modern advancements of imaging facilities and precision instrumentations, unsatisfactory results and recurrences are not uncommon. This paper provides a general review of the four specific areas in surgery that would benefit from Chinese medicine. Extensive searches were made on four surgical areas based on available English language journals, viz. low-back pain, chronic ulcers, renal calculus, and enuresis in children, in the past 10 years. The quoted communications are mainly related to clinical evidences, while a smaller number of crucial laboratory reports are also included. Low-back pain, a most frequent orthopaedic problem, would benefit from acupuncture treatment. Chronic leg ulcers could achieve better results of healing using herbal supplements. Problems of renal stones, besides the conventional methods of removal, could be further supplemented with herbal drinks that aim at prevention of recurrences. Enuresis in children, an untreatable common condition, may respond well to acupuncture. Surgeons should keep an open mind. In case of difficulties, they could seriously consider options of traditional treatment.
Collapse
|
13
|
Austin PF. New directions for the endocrine treatment of bedwetting. Expert Rev Endocrinol Metab 2009; 4:397-399. [PMID: 30736181 DOI: 10.1586/eem.09.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Paul F Austin
- a Pediatric Urology, St Louis Children's Hospital, Washington University School of Medicine, 4990 Children's Place, Suite 1120, Box 8242, St Louis, MO 63110, USA.
| |
Collapse
|
14
|
Fonseca EG, Bordallo APN, Garcia PK, Munhoz C, Silva CP. Lower urinary tract symptoms in enuretic and nonenuretic children. J Urol 2009; 182:1978-83. [PMID: 19695589 DOI: 10.1016/j.juro.2009.04.083] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Indexed: 11/18/2022]
Abstract
PURPOSE We determined the prevalence of lower urinary tract symptoms in enuretic and nonenuretic children and adolescents in an urban community. MATERIAL AND METHODS We performed a cross-sectional survey including 296 children and adolescents in a small urban community. Trained medical students visited all homes and interviewed the parents or guardians. There were no refusals to participate. Results were analyzed using chi-square and McNemar statistics. RESULTS The enuresis rate was 10%, including 16.6% and 3.9% in children 5 to 10 years old and adolescents, respectively. The monosymptomatic enuresis rate was only 1.34%. Of those with vs without enuresis lower urinary tract symptoms were present in 86.7% vs 26.8% (p <0.001). In the nonenuretic group lower urinary tract symptoms were associated with nocturia (p = 0.008). The most common daytime urinary symptoms were urgency in 38.2% of cases, holding maneuvers in 30.4% and daytime incontinence in 27.5%. The prevalence rate decreased with age in the nonenuretic group (p = 0.013). CONCLUSIONS The prevalence of lower urinary tract symptoms was high. Nonmonosymptomatic enuresis was common and monosymptomatic enuresis was rare in this population based survey. In nonenuretic cases daytime symptoms were associated with nocturia, suggesting decreased bladder capacity with a mature arousal reaction.
Collapse
Affiliation(s)
- Eliane G Fonseca
- Department of Pediatrics, Hospital dos Servidores do Estado, Rio de Janeiro, Brazil.
| | | | | | | | | |
Collapse
|
15
|
Korzeniecka-Kozerska A, Zoch-Zwierz W, Wasilewska A. Functional bladder capacity and urine osmolality in children with primary monosymptomatic nocturnal enuresis. ACTA ACUST UNITED AC 2009; 39:56-61. [PMID: 15764272 DOI: 10.1080/00365590510007658] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess functional day-time bladder capacity (DBC) and urine osmolality in children with primary monosymptomatic nocturnal enuresis (PMNE) according to age and sex. MATERIAL AND METHODS A total of 263 children with PMNE were divided into two groups: Group I, 160 children (63 girls, 97 boys) aged 5-9 years (mean age 7.14+/-1.47 years); and Group II, 103 children (25 girls, 78 boys) aged 10-15 years (mean age 12.26+/-1.52 years). DBC (milliliters) was the largest void of the day measured over four 24-h periods, irrespective of the diet applied. Urine osmolality was determined three times: in the evening before bed-time; at night, 2-4 h after falling asleep; and in the morning in the nocturnal void. RESULTS DBC was smaller in Group I than in Group II (151.27 vs 199.46 ml; p<0.05). No statistically significant differences were found in relation to sex (p>0.05). The mean osmolality of the nocturnal void in the morning was 854.15 and 909.22 mOsmol/kg H(2)O in Groups I and II, respectively (p>0.05). Differences between boys and girls were not statistically significant (p>0.05). No correlation was found between DBC and urine osmolality (p>0.05). A detailed analysis of the results revealed DBC below the 5th percentile or above the 95th percentile in 23/263 cases (8.7%), reduced osmolality (< 800 mOsmol/kg H(2)O) in 76/263 (28.8%), a familial nature of nocturnal enuresis in 124/263 (47.1%) and difficulty waking in 86/263 (32.7%). CONCLUSIONS In children with PMNE aged 5-15 years, functional DBC increases with age and does not differ between the sexes; the mean nocturnal urine osmolality is neither age- nor sex-dependent.
Collapse
|
16
|
Nevéus T, Läckgren G, Tuvemo T, Jerker H, Hjälmås K, Stenberg A. Enuresis - Background and Treatment. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/003655900750169257] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Tryggve Nevéus
- Dept of Women's and Children's Health, Uppsala University Children's Hospital, Uppsala, Sweden
| | - Göran Läckgren
- Dept of Women's and Children's Health, Uppsala University Children's Hospital, Uppsala, Sweden
| | - Torsten Tuvemo
- Dept of Women's and Children's Health, Uppsala University Children's Hospital, Uppsala, Sweden
| | - Hetta Jerker
- Dept of Women's and Children's Health, Uppsala University Children's Hospital, Uppsala, Sweden
| | - Kelm Hjälmås
- Dept of Women's and Children's Health, Uppsala University Children's Hospital, Uppsala, Sweden
| | - Arne Stenberg
- Dept of Women's and Children's Health, Uppsala University Children's Hospital, Uppsala, Sweden
| |
Collapse
|
17
|
Wolfish NM, Pham C. Management of Nocturnal Enuresis in Children. Can Pharm J (Ott) 2009. [DOI: 10.3821/1913-701x-142.2.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
18
|
Lottmann H, Baydala L, Eggert P, Klein BM, Evans J, Norgaard JP. Long-term desmopressin response in primary nocturnal enuresis: open-label, multinational study. Int J Clin Pract 2009; 63:35-45. [PMID: 19125991 DOI: 10.1111/j.1742-1241.2008.01956.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Primary nocturnal enuresis (PNE) is a distressing condition, particularly in severe cases (> or = 3 wet nights/week). A prevalent pathophysiological mechanism, especially in monosymptomatic PNE (PMNE), is commonly believed to be an insufficient increase in night-time release of antidiuretic hormone. Desmopressin, a synthetic analogue of antidiuretic hormone, has been shown to reduce the number of wet nights experienced by PMNE patients in several controlled trials. AIM This study was performed to evaluate desmopressin treatment in the real-life clinical setting and was a large-scale, 6-month investigation of efficacy and safety in patients with severe PNE. Predictive factors for desmopressin response were also evaluated. A total of 744 children aged 5 years and above from four countries were involved in the study. RESULTS At baseline, patients had a median of 6 wet nights/week; at 6 months, 41% of patients had experienced > or = 50% reduction in the mean number of wet nights. Long-term desmopressin treatment was consistently well-tolerated across all ages, with 5% of patients experiencing any treatment-related adverse events. The strength of treatment response was associated with nocturnal diuresis (p < 0.0001) and age (p = 0.0167) in logistic regression analyses. Compliance and dosage were also associated with response and more patients experienced > or = 50% reduction in wet nights after 6 months' treatment than earlier in the study, suggesting the value of persistent treatment. CONCLUSION This study shows that long-term desmopressin treatment in the clinical setting is effective and well-tolerated in PNE patients of 5 years and upwards. Early improvements in bedwetting of any appreciable magnitude may be rewarding, may facilitate compliance and enable good long-term response.
Collapse
Affiliation(s)
- H Lottmann
- Service de Chirurgie Viscerale Pédiatrique, Hôpital Necker-Enfants Malades, Paris, France.
| | | | | | | | | | | |
Collapse
|
19
|
Austin PF, Ferguson G, Yan Y, Campigotto MJ, Royer ME, Coplen DE. Combination therapy with desmopressin and an anticholinergic medication for nonresponders to desmopressin for monosymptomatic nocturnal enuresis: a randomized, double-blind, placebo-controlled trial. Pediatrics 2008; 122:1027-32. [PMID: 18977983 DOI: 10.1542/peds.2007-3691] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Desmopressin is an approved medical therapy for the treatment of monosymptomatic primary nocturnal enuresis. In cases of limited response to desmopressin, we have added anticholinergic therapy to desmopressin (combination therapy). To evaluate this treatment strategy, we examined the efficacy of combination therapy for primary nocturnal enuresis in desmopressin-nonresponders. METHODS Only patients with primary nocturnal enuresis refractory to the maximal dosage of desmopressin were enrolled. Children with lower urinary tract symptoms or bowel dysfunction were excluded, on the basis of a 3-day, 24-hour, frequency-volume chart and elimination record. Children continued to take desmopressin and were assigned randomly, in a double-blind manner, to receive either extended-release anticholinergic medication or placebo. Patients were reassessed after 1 month of therapy, with a 1-week nocturnal record. RESULTS Forty-one desmopressin-nonresponders were enrolled, and 7 patients were excluded because of noncompliance. The treatment groups were equally matched with respect to age, gender, functional bladder capacity, and number of wet nights per week. After 1 month of treatment, there was a significant reduction in the mean number of wet nights in the combination therapy group, compared with the placebo group. With a generalized estimating equation approach, there was a significant 66% decrease in the risk of a wet episode, compared with the placebo group. CONCLUSIONS This study represents the first prospective, placebo-controlled trial examining the effect of desmopressin in combination with long-acting, anticholinergic, bladder-relaxing therapy for monosymptomatic primary nocturnal enuresis.
Collapse
Affiliation(s)
- Paul F Austin
- Division of Urology, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri, USA.
| | | | | | | | | | | |
Collapse
|
20
|
Hong CH, Baek M, Lee SH, Lee JW, Pai KS. Diagnosis and treatment of nocturnal enuresis in children. KOREAN JOURNAL OF PEDIATRICS 2008. [DOI: 10.3345/kjp.2008.51.11.1140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Chang Hee Hong
- Department of Urology, Yonsei University College of Medicine, Seoul, Korea
| | - Minki Baek
- Department of Urology, Konkuk University College of Medicine, Seoul, Korea
| | - Seong Ho Lee
- Department of Urology, School of Medicine, Hallym University, Seoul, Korea
| | - Jeong Won Lee
- Department of Pediatrics, Kangnam Sacred Heart Hospital College of Medicine, Hallym University, Seoul, Korea
| | - Ki-Soo Pai
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| |
Collapse
|
21
|
Raes A, Dehoorne J, Van Laecke E, Hoebeke P, Vande Walle C, Vansintjan P, Donckerwolcke R, Vande Walle J. Partial Response to Intranasal Desmopressin in Children With Monosymptomatic Nocturnal Enuresis is Related to Persistent Nocturnal Polyuria on Wet Nights. J Urol 2007; 178:1048-51; discussion 1051-2. [PMID: 17632162 DOI: 10.1016/j.juro.2007.05.060] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Indexed: 01/13/2023]
Abstract
PURPOSE The anti-incontinence effect of desmopressin resides in its concentrating capacity and antidiuretic properties. We compared nighttime urine production on wet and dry nights in a highly selected study population of children with monosymptomatic nocturnal enuresis associated with proved nocturnal polyuria who responded only partially to intranasal desmopressin. MATERIALS AND METHODS We retrospectively analyzed 39 home recordings of nocturnal urine production and maximum voided volume in children 7 to 19 years old (median 8.9) with monosymptomatic nocturnal enuresis with nocturnal polyuria who had a partial response to desmopressin. Nocturnal diuresis volume and maximum voided volume were documented at baseline (14 days) and during 3 months of followup. RESULTS Baseline nocturnal urine output (439 +/- 39 ml) was significantly higher than the maximum voided volume (346 +/- 93 ml, p <0.01). During desmopressin treatment nocturnal urine output on wet nights (405 +/- 113 ml) differed significantly from that on dry nights (241 +/- 45 ml). During treatment nocturnal urine output on wet nights did not differ from baseline values. CONCLUSIONS Persistence of nocturnal polyuria on wet nights in partial desmopressin responders may be related to an insufficient antidiuretic effect. In addition to poor compliance and suboptimal dosing, the poor bioavailability of intranasal desmopressin may be a pathogenic factor. Further prospective studies are needed.
Collapse
Affiliation(s)
- A Raes
- Department of Pediatric Nephrology, University Hospital Ghent, Ghent, Belgium.
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
Nocturnal enuresis (NE) is one of the most frequent paediatric pathologies. The prevalence of primary nocturnal enuresis (PNE) is around 9% in children between 5 and 10 years of age and about 40% of them have one or more episodes per week. Still for too long, PNE has not been recognised as a pathological condition, particularly by the medical community; as a consequence, there was no specific education at medical school, and a poor involvement by the practitioners. Enuretic children have a sense of social difference and isolation; some of them do express a low self-esteem. Also, self-esteem is improved by the management NE even if this management fails to cure the condition. Primary monosymptomatic nocturnal enuresis (PMNE) is an heterogeneous condition for which various causative factors have been identified such as: nocturnal polyuria, sleep disturbances, reduced bladder capacity or bladder dysfunction, upper airway obstruction. The positive diagnosis of PMNE is based on a complete questionnaire and a careful physical examination. A drinking and voiding chart is an essential non-invasive tool: first, to collect information about the initial drinking and voiding habits of the child, then to reassess the accuracy of the diagnosis. Only motivated patients should receive a specific treatment for their NE and the treatment should be proposed based on the type of PMNE. PMNE associated with nocturnal polyuria should be treated with desmopressin, which reduces nighttime urine production. For PMNE with a reduced bladder capacity alarms should be the first-line treatment. Oxybutinin, a drug with anticholinergic properties, is not theoretically indicated for the treatment of PMNE except for a very small subgroup of patients who have an overactive bladder only during sleep. In cases refractory to monotherapy, NE is probably the result of an association of different physiopathological factors (e.g. both a nocturnal polyuria together with a small bladder capacity) some of them are still unknown. In these patients, a combination of treatments may be more effective than monotherapy. Various combination therapies can be proposed to improve the cure rates.
Collapse
Affiliation(s)
- H B Lottmann
- Paediatric Urology Unit, Service de Chirurgie Viscerale Pediatrique, Hôpital Necker-Enfants Malades, Paris, France.
| | | |
Collapse
|
23
|
Dehoorne JLC, Walle CV, Vansintjan P, Raes AM, De Guchtenaere ARP, Van Laecke E, Hoebeke P, Vande Walle JGJ. Characteristics of a Tertiary Center Enuresis Population, With Special Emphasis on the Relation Among Nocturnal Diuresis, Functional Bladder Capacity and Desmopressin Response. J Urol 2007; 177:1130-7. [PMID: 17296432 DOI: 10.1016/j.juro.2006.10.093] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE We evaluated pretreatment values of circadian rhythm of urine production and urine osmolality in children with different subtypes of monosymptomatic nocturnal enuresis, and investigated their predictive value for desmopressin response. MATERIALS AND METHODS We assessed 125 consecutive patients with monosymptomatic nocturnal enuresis, nocturnal polyuria and normal functional bladder capacity who were treated with desmopressin for a median of 17 months (range 3 to 100). Patients were characterized according to the desmopressin response as full responders or nonfull responders. Baseline parameters were obtained from a 2-week home recording diary. Results were compared with 125 consecutive children with monosymptomatic nocturnal enuresis and reduced functional bladder capacity. RESULTS No differences in pretreatment values of functional bladder capacity, circadian rhythm of urine production or urine osmolality were found between desmopressin full responders and nonfull responders. Patients with nocturnal polyuria had a significantly higher 24-hour diuresis volume compared to children with reduced functional bladder capacity. Some children with reduced functional bladder capacity also had nocturnal polyuria. CONCLUSIONS Our findings show that the characteristics of nocturnal polyuria in patients with monosymptomatic nocturnal enuresis and normal functional bladder capacity do not predict desmopressin response. The wide overlap among the different subgroups suggests that dividing patients with monosymptomatic nocturnal enuresis into those with reduced functional bladder capacity and those with desmopressin responsive nocturnal polyuria might be insufficient. Patients with nocturnal polyuria and normal functional bladder capacity have a significantly higher daytime and nighttime diuresis volume compared to children with reduced functional bladder capacity, suggesting a direct correlation between daytime fluid intake and nocturnal diuresis rate. Some children with reduced functional bladder capacity also have nocturnal polyuria.
Collapse
Affiliation(s)
- J L C Dehoorne
- Department of Pediatric Nephrology and Urology, University Hospital Ghent, Ghent, Belgium
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Oh MM, Shim KS, Moon DG. Effectiveness of Two Spots Enuretic Voiding D iary for the Treatment of Nocturnal Enuresis. Korean J Urol 2006. [DOI: 10.4111/kju.2006.47.1.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Mi Mi Oh
- Department of Urology, Korea University College of Medicine, Seoul, Korea
| | - Kang Soo Shim
- Department of Urology, Korea University College of Medicine, Seoul, Korea
| | - Du Geon Moon
- Department of Urology, Korea University College of Medicine, Seoul, Korea
| |
Collapse
|
25
|
Hjalmas K, Arnold T, Bower W, Caione P, Chiozza LM, von Gontard A, Han SW, Husman DA, Kawauchi A, LAckgren G, Lottmann H, Mark S, Rittig S, Robson L, Walle JV, Yeung CK. Nocturnal enuresis: an international evidence based management strategy. J Urol 2004; 171:2545-61. [PMID: 15118418 DOI: 10.1097/01.ju.0000111504.85822.b2] [Citation(s) in RCA: 232] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- K Hjalmas
- Göteborg University, Berzeliigatan, Sweden.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Yeung CK, Sreedhar B, Leung VT, Metreweli C. ULTRASOUND BLADDER MEASUREMENTS IN PATIENTS WITH PRIMARY NOCTURNAL ENURESIS: A URODYNAMIC AND TREATMENT OUTCOME CORRELATION. J Urol 2004; 171:2589-94. [PMID: 15118426 DOI: 10.1097/01.ju.0000112978.54300.03] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Accurate assessment of bladder dysfunction associated with voiding dysfunctions often necessitates invasive urodynamic (UD) studies. We evaluate the use of a special ultrasound (US) protocol for the assessment of bladder dysfunction compared with urodynamic findings, and for prediction of treatment outcome in children with primary nocturnal enuresis (PNE). MATERIALS AND METHODS US measurements were performed on 514 children 5 to 18 years old (mean age 11.2) with PNE, and compared with those of 339 normal age matched children. A US protocol was specially designed for the evaluation of bladder parameters using bladder volume and wall thickness index (BVWI %), and expected percentage bladder volume index for kidney volume. Of the enuretic children 218 had severe enuretic symptoms with more than 3 wet nights a week. They underwent urodynamic studies for detailed assessment of any underlying bladder dysfunction. A standard 4-week course of desmopressin was given to these children after the US and UD studies. The US bladder parameters were then correlated with the UD findings and treatment response to desmopressin. RESULTS Comparing the BVWI in normal and enuretic children in correlation with functional bladder capacities we were able to delineate bladder wall thickness and capacity as BVWI less than 70-small capacity bladder with thick wall, BVWI 70 to 130-normal bladder capacity with normal wall thickness and BVWI greater than 130-large bladder capacity with thin wall. There were statistically significant correlations between BVWI and treatment response. In addition, there was a high predictive value of normal bladder function with a normal BVWI. Patients with good response to treatment had normal BVWI, whereas poor response to treatment was significantly associated with pathological bladder conditions, that is small bladder capacity with thick bladder wall or large bladder capacity with thin bladder wall (p <0.0001). Of note, abnormalities detected by UD correlated well with bladder abnormalities measured by US. CONCLUSIONS PNE comprises a diverse spectrum of conditions resulting in a mismatch of nocturnal urine production in excess of nocturnal functional bladder capacity, and underlying bladder dysfunction has an important role in the pathophysiology especially in refractory cases. This US protocol can provide useful predictive clues, which may be helpful to differentiate treatment subtypes, guide clinical management and minimize the need for invasive urodynamic studies.
Collapse
Affiliation(s)
- C K Yeung
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | | | | | | |
Collapse
|
27
|
Yeung CK, Sihoe JDY, Sit FKY, Bower W, Sreedhar B, Lau J. Characteristics of primary nocturnal enuresis in adults: an epidemiological study. BJU Int 2004; 93:341-5. [PMID: 14764133 DOI: 10.1111/j.1464-410x.2003.04612.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the prevalence and characteristics of primary nocturnal enuresis (PNE) in adults in Hong Kong, as there are currently limited epidemiological data in adults. SUBJECTS AND METHODS After a telephone survey, 8534 respondents (3996 males and 4538 females) aged 16-40 years were selected for the study and stratified in age groups. The questionnaire used comprised two parts; the first started with questions mainly about the general demographic background to decrease the sensitivity of the study and to establish rapport. The second part was conducted through an automated telephone interview service, with the questions being asked by recorded messages and the respondents then keying in their responses with no need to converse with an interviewer. This part included questions about enuretic symptoms and a subjective assessment of social and psychological effects of bedwetting, and measurements of the individual's self-esteem (Rosenberg Self-esteem Scale) and depression (The Centre for Epidemiological Studies Depression Scale). RESULTS Of the 8534 subjects interviewed, 196 had PNE, giving an overall prevalence of 2.3% (2.7% males and 2.0% females); of these 196, 36 (18.4%) also had daytime urinary incontinence. Hence, 1.9% of adults (2.2% males and 1.7% females) had monosymptomatic PNE. Of these, 53% wet >3 nights/week and 26% wet every night. Prevalence rates remained relatively stable among different age groups, with no apparent trend of a reduction with age. Compared with nonenuretic normal controls, significantly fewer enuretics reached tertiary education (33.4% vs 17.8%, P < 0.01). Bedwetters had a significantly higher incidence of depression and lower self-esteem, and a higher incidence of sleep disturbances than the control group. Among bedwetters, 32-40% felt that there was some effect on their choice of job, work performance and social activities, whilst 23% felt the condition affected their family life and in making friends of either sex. However, there was no significant difference in the marital status. Interestingly, only 34.5% of females and half of males used various methods before bedtime to prevent bedwetting. CONCLUSIONS Overall, 2.3% of Hong Kong adults aged 16-40 years have persistent PNE. Unlike PNE in early childhood the prevalence remained relatively unchanged with age, suggesting that enuretic symptoms persisting into adulthood are probably less likely to resolve with time. Also, significantly more patients had more severe enuretic symptoms. These findings therefore highlight the possibility that PNE in adults may represent a more pronounced form of the condition, and with a more serious social and psychological effect on affected individuals. Further work is needed to evaluate the pathogenesis and management strategy.
Collapse
Affiliation(s)
- C K Yeung
- Division of Paediatric Surgery, Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
| | | | | | | | | | | |
Collapse
|
28
|
Hoekx L, Vermandel A, Wyndaele JJ. Functional bladder capacity after bladder biofeedback predicts long-term outcome in children with nocturnal enuresis. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 2004; 37:120-3. [PMID: 12745719 DOI: 10.1080/00365590310008848] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE We previously reported a 70% cure rate for bladder biofeedback in children with primary nocturnal enuresis associated with small bladder capacity and detrusor instability. In this paper we report on bladder capacity and incidence of enuresis after 60 months of follow-up and discuss the role of decreased bladder capacity in nocturnal enuresis. MATERIAL AND METHODS We prospectively evaluated 21 boys and 3 girls (mean age 10.4 years) treated with bladder biofeedback between October 1993 and July 1995. Baseline bladder capacity and capacity at the end of treatment and at 60 months follow-up were determined from a micturition chart. RESULTS At the end of primary treatment 17/24 patients had stopped bedwetting. In 4/17 responders and 4/7 non-responders the bladder capacity was <90% of normal for age. At 60 months, 4 patients had been lost to follow-up, 15 were dry at night and 4 continued bedwetting. One patient underwent surgery and was excluded from the study. Only 2/15 dry patients but 3/4 patients with persistent nocturnal enuresis had a bladder capacity of <90% of normal. CONCLUSIONS Bladder biofeedback can be successfully used to treat children with refractory nocturnal enuresis associated with small bladder capacity and unstable detrusor. Normalization of bladder capacity and continuous growth of the bladder in order to keep the capacity normal would seem to be crucial to the long-term resolution of bedwetting in this select patient population.
Collapse
Affiliation(s)
- Lucien Hoekx
- Department of Urology, University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium
| | | | | |
Collapse
|
29
|
Vlajković M, Ilić S, Bogićević M, Rajić M, Ristić L, Petronijević V, Golubović E, Stefanović V, Artiko V. Radionuclide voiding patterns in children with vesicoureteral reflux. Eur J Nucl Med Mol Imaging 2003; 30:532-7. [PMID: 12536245 DOI: 10.1007/s00259-002-1077-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2002] [Accepted: 11/08/2002] [Indexed: 10/19/2022]
Abstract
The purpose of this study was to evaluate bladder function in children with vesicoureteral reflux (VUR) by means of indirect radionuclide cystography (IRNC), and to investigate whether IRNC can identify those children with voiding dysfunction. The study enrolled 74 neurologically intact children, 14 boys and 60 girls aged 2-14 years, with VUR documented using contrast micturating cystourethrography as the initial method. In all patients, IRNC was performed using technetium-99m diethylene triamine penta-acetate (DTPA). Based on the urodynamic findings, three groups were distinguished: a group with VUR and normal urodynamic findings ( n=27), a group with VUR and detrusor hyper-reflexia ( n=43) and a group with VUR and detrusor-sphincter dyssynergia ( n=4). A control group comprised 64 healthy children, aged 2-13 years, without any symptoms of lower urinary tract dysfunction. The dynamics of bladder emptying were studied in the posterior view after intravenous injection of 37 MBq/10 kg b.w. DTPA, with acquisition of 90 2-s frames during voiding. The parameters evaluated were: voided urine volume (VV), bladder capacity, functional bladder capacity (FBC), residual urine, voiding time, average flow rate, peak flow rate (PFR) and ejection fraction (EF). With regard to the final urodynamic diagnosis, FBC, PFR and EF were found to be significant IRNC predictor variables using the logistic regression method. If abnormality on at least two of the three significant predictor variables was taken as the criterion of voiding dysfunction, the overall sensitivity, specificity and accuracy of IRNC in the detection of voiding dysfunction were 81%, 78% and 80%, respectively. Three radionuclide voiding patterns were detected in children with VUR: (1) a normal voiding pattern characterised by normal FBC with near-normal PFR and EF values, (2) a markedly reduced FBC with significantly reduced VV, PFR and EF values (in children with bladder instability), and (3) a higher bladder volume with a near-normal value for PFR and a slightly reduced or near-normal EF (in children with detrusor-sphincter dyssynergia). This study confirmed the association between lower urinary tract dysfunction and congenital VUR. IRNC was found to be a simple, non-invasive method which allows reliable differentiation of voiding patterns in patients with VUR. IRNC can be used as a first-line method for screening in children with VUR to identify those with abnormal voiding patterns.
Collapse
Affiliation(s)
- Marina Vlajković
- Department of Nuclear Medicine, Clinical Center Nis, Braće Tasković 48, 18000, Nis, Yugoslavia.
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Abstract
PURPOSE We recorded uroflowmetry at home in boys with urinary incontinence and correlated the results with videourodynamics. MATERIALS AND METHODS Thirty-nine boys (mean age 8.4 +/- 2.0 years) with urinary incontinence underwent home uroflowmetry for 1 weekend. Artifactual spikes in 1 or more uroflow curves were present in 16 home uroflowmetry recordings. One patient, in whom none of the uroflow curves was interpretable, was excluded from the study. Of the remaining 38 boys 18 had monosymptomatic nocturnal enuresis, and 20 had nocturnal enuresis and diurnal voiding symptoms. Percentage expected bladder capacity is defined as functional/expected bladder capacity x 100%. Normal and obstructive home uroflowmetry levels are defined as functional bladder capacity at least 50% expected bladder capacity associated with multiple bell-shaped and obstructive uroflow curves, respectively. Small functional bladder capacity is defined as capacity less than 50% expected bladder capacity, regardless of uroflow patterns. Videourodynamics and cystoscopy were performed in 17 patients. RESULTS Normal home uroflowmetry was noted in 5 patients (13%), obstructive uropathy in 8 (21%) and small functional bladder capacity in 25 (66%). Urodynamically 3 boys with normal home uroflowmetry had normal voiding, and 6 with obstructive home uroflowmetry had bladder outlet obstruction (of whom 1 also had detrusor overactivity). In addition, of 8 boys with small functional bladder capacity 4 had detrusor overactivity, 3 had bladder outlet obstruction and 1 had both findings. CONCLUSIONS Normal home uroflowmetry predicted normal voiding, and abnormal recordings implied abnormal voiding function in boys with incontinence. Bladder outlet obstruction and detrusor overactivity were frequently disclosed by obstructive home uroflowmetry and small functional bladder capacity.
Collapse
Affiliation(s)
- Stephen Shei Den Yang
- Department of Urology, En Chu Kong Hospital, School of Medicine, Taipei Medical University, Taiwan
| | | | | |
Collapse
|
31
|
Yeung CK, Sit FKY, To LKC, Chiu HN, Sihoe JDY, Lee E, Wong C. Reduction in nocturnal functional bladder capacity is a common factor in the pathogenesis of refractory nocturnal enuresis. BJU Int 2002; 90:302-7. [PMID: 12133069 DOI: 10.1046/j.1464-410x.2002.02884.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the diurnal and nocturnal bladder reservoir function in patients with refractory primary nocturnal enuresis (PNE). PATIENTS AND METHODS Ninety-five children (68 boys, 27 girls, mean age 9.3 years) with significant PNE (>/=3 wet nights/week) that was refractory to treatment with desmopressin +/- an enuretic alarm were assessed using detailed recording of voiding frequency and urinary volume both day and night, natural filling cystometry during the day and continuous cystometry with simultaneous electroencephalogram monitoring during sleep at night. RESULTS Patients could be broadly categorized into two groups. Group A comprised those with normal daytime urodynamics and functional bladder capacity (FBC) on detailed frequency-volume recording, but who developed marked detrusor instability associated with a significant reduction in nocturnal FBC and small-volume voiding only after sleep at night (33 patients, 35%); and group B, those with abnormal daytime urodynamics and with reduced FBC and small-volume voiding both day and night, but who somehow managed to mask their bladder symptoms during the day (62 patients, 65%). There was no evidence of nocturnal polyuria in either group and the ratios of day : night urinary output volumes for type A and type B patients were 1.48 and 1.99, respectively. CONCLUSION A reduction in nocturnal FBC, either occurring only after sleep at night in association with the appearance of detrusor instability in patients with normal daytime urodynamics and FBC, or as a manifestation of occult voiding dysfunction or bladder outlet obstruction that affects the bladder reservoir function both day and night, appears to be a common factor and probably the main cause for a mismatch between nocturnal urine output and bladder storage capacity in patients with severe bed-wetting that was refractory to treatment.
Collapse
Affiliation(s)
- C K Yeung
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
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.
Collapse
|
33
|
Cayan S, Doruk E, Bozlu M, Akbay E, Apaydin D, Ulusoy E, Canpolat B. Is routine urinary tract investigation necessary for children with monosymptomatic primary nocturnal enuresis? Urology 2001; 58:598-602. [PMID: 11597547 DOI: 10.1016/s0090-4295(01)01338-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To investigate in a prospective study the role of bladder function and to compare the results of urinary tract ultrasonography and urinalysis in children with and without primary nocturnal enuresis because, although this is a common problem in children, the etiology and mechanisms of the disorder have not been elucidated. METHODS The study included 106 children with monosymptomatic primary nocturnal enuresis and a control group of 57 children with no history of voiding dysfunction, aged 5 to 19 years. All children underwent urinalysis, bladder and upper urinary tract ultrasonography, and uroflowmetry. The bladder capacity, bladder wall thickness, and postvoid residual volume were measured using ultrasonography. The findings were compared between the enuresis and control groups according to age: 5 to 9 years, 10 to 14 years, and 15 to 19 years. RESULTS The mean age was 9.6 +/- 3.1 years in the nocturnal enuresis group and 9.4 +/- 3.3 years in the control group (P = 0.727). The mean number of defecations per week was significantly lower statistically in the enuresis group than in the control group in the age categories of 5 to 9 years and 10 to 14 years (P = 0.038 and P = 0.018, respectively), and the mean number of urinations per day was significantly higher statistically in the enuresis group than in the control group in the age groups of 5 to 9 years and 10 to 14 years (P = 0.002 and P = 0.001, respectively). The bladder capacity, bladder wall thickness, postvoid residual volume, uroflowmetry maximal flow rate, and average flow rate were not significantly different statistically between the children with primary nocturnal enuresis and the control group in the three age brackets. Urinary infection was detected in 2 children (1.88%) in the nocturnal enuresis group and none of the children in the control group (P = 0.547). Upper urinary tract abnormalities detected by ultrasonography were seen in 3 children (2.83%) in the nocturnal enuresis group and 1 child (1.75%) in the control group, revealing no statistical significance (P = 0.671). CONCLUSIONS Our findings show that the ultrasonographic and uroflowmetry findings on bladder function and the upper urinary system and the incidence of urinary infection are similar in children with and without nocturnal enuresis. Obtaining a voiding and elimination diary in conjunction with a good history may be beneficial in children with monosymptomatic primary nocturnal enuresis. In addition, routine urinalysis may be unnecessary in the evaluation of children with monosymptomatic primary nocturnal enuresis after obtaining a careful and complete history of the voiding dysfunction.
Collapse
Affiliation(s)
- S Cayan
- Department ofUrology, University of Mersin School of Medicine, Mersin, Turkey
| | | | | | | | | | | | | |
Collapse
|
34
|
MANAGEMENT OF NOCTURNAL ENURESIS. Nurs Clin North Am 2000. [DOI: 10.1016/s0029-6465(22)02442-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
35
|
Bladder dysfunction in children with refractory monosymptomatic primary nocturnal enuresis. J Urol 1999; 162:1049-54; discussion 1054-5. [PMID: 10458430 DOI: 10.1016/s0022-5347(01)68062-5] [Citation(s) in RCA: 135] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE We studied bladder dysfunction in children with significant primary nocturnal enuresis refractory to treatment. MATERIALS AND METHODS We evaluated 33 Chinese boys and 8 girls with a mean age of 10.4 years, who had significant monosymptomatic primary nocturnal enuresis (3 or more wet nights weekly) after desmopressin treatment with or without an enuretic alarm failed. Daytime cystometry, continuous nighttime cystometry and electroencephalography monitoring during sleep, and detailed recording of daytime and nighttime urinary output were performed. RESULTS We recognized 5 patterns of bladder dysfunction and its association with sleep-arousal status. Pattern 1 was normal daytime urodynamics with significant bladder instability at night with normal volume voiding precipitated by unstable detrusor contractions in 14 boys (34%). Pattern 2 was normal daytime urodynamics with frequent small volume voiding at night, probably representing latent bladder instability, in 4 boys (10%). Pattern 3 involved abnormal daytime urodynamics with small bladder capacity, a discoordinated daytime voiding pattern and marked nighttime bladder instability associated with poor sleep in 6 boys (15%). Pattern 4 was abnormal daytime urodynamics with an obstructive pattern, and marked daytime and nighttime detrusor hypercontractility (mean maximum detrusor pressure 178 cm. water) in 8 boys (20%). Pattern 5 was abnormal daytime urodynamics with a dysfunctional daytime voiding pattern and frequent small volume nighttime voiding in 8 girls and 1 boy (22%). In all patients functional bladder capacity was smaller than expected for age and the majority had no nocturnal polyuria. Despite underlying bladder dysfunction a 4-week course of 400 microg. desmopressin orally at bedtime still produced a significant response with a greater than 50% decrease in the number of wet nights during treatment in 47% of the patients, although enuretic symptoms immediately relapsed on cessation of therapy in all. Notably cystourethroscopy in 7 of the 8 boys with pattern 4 dysfunction revealed bladder trabeculations and abnormal urethral lesions, including congenital obstructive posterior urethral membranes in 4, Moormann's ring in 2 and irregular scarring at the bulbous urethra in 1. CONCLUSIONS Abnormal bladder function, including small functional capacity, instability during sleep and marked detrusor hypercontractility, was common in our enuretic children in whom treatment failed. More importantly, nocturnal enuresis may be the only presenting symptom and there may be a response to desmopressin with a decreased number of wet nights even in cases of significant underlying bladder dysfunction. These findings may have important implications for our management strategy for monosymptomatic primary nocturnal enuresis.
Collapse
|