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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.
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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
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Campos RM, Lúcio AC, Lopes MHBDM, Hacad CR, Perissinotto MCR, Glazer HI, D'Ancona CAL. Pelvic floor muscle training alone or in combination with oxybutynin in treatment of nonmonosymptomatic enuresis. A randomized controlled trial with 2-year follow up. EINSTEIN-SAO PAULO 2019; 17:eAO4602. [PMID: 31271608 PMCID: PMC6611091 DOI: 10.31744/einstein_journal/2019ao4602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 12/20/2018] [Indexed: 11/17/2022] Open
Abstract
Objective To compare the results of the standard urotherapy alone and associated with pelvic floor muscle training alone, and in combination with oxybutynin in treatment of nonmonosymptomatic nocturnal enuresis. Methods A total of 38 children aged 5 to 10 years were randomized into three groups: Group I (n=12) that was submitted to standard urotherapy; Group II (n=15), standard urotherapy associated with pelvic floor muscle training; and Group III (n=11), standard urotherapy associated with pelvic floor muscle training and oxybutynin; the treatment lasted 12 weeks. The assessment tools used were playful bladder diary, and a 48-hour bladder diary, before and after treatment. After 2 years, patients were assessed by telephone using a standardized questionnaire. Results The data of children from the three groups were homogeneous at baseline. After 12-week treatment, all children showed improved symptoms and signs of nonmonosymptomatic nocturnal enuresis, but the differences were not significant among the groups. After 2 years, the three groups showed maintenance of treatment results, but no differences among them. Conclusion All treatment modalities were effective regarding improved enuresis and lower urinary tract symptoms, but the sample was not large enough to show differences among groups.
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Affiliation(s)
| | - Adélia Correia Lúcio
- Hospital Universitário Maria Aparecida Pedrossian, Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brazil
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Ravanshad Y, Azarfar A, Ghalegolab-Behbahan A, Mortazavi F, Ahmadzadeh S, Ghorat F, Foji S, Iziy E, Vejdan M. Comparing the efficacy of desmopressin and oxybutynin combination therapy and desmopressin monotherapy in children with primary nocturnal enuresis; a randomized clinical trial. J Renal Inj Prev 2017. [DOI: 10.15171/jrip.2017.49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Ghasemi K, Esteghamati M, Mohammadzadeh M, Zare S. Desmopressin versus Oxybutynin for Nocturnal Enuresis in Children in Bandar Abbas: A Randomized Clinical Trial. Electron Physician 2016; 8:2187-93. [PMID: 27123229 PMCID: PMC4844487 DOI: 10.19082/2187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 09/04/2015] [Indexed: 11/24/2022] Open
Abstract
Background Nocturnal enuresis is among the most common disorders in children. Several pharmacological and non-pharmacological treatments are available for nocturnal enuresis. Studies for reaching the best pharmacological treatment for this disorder are continuing. Objective To compare the effectiveness and safety of Desmopressin and oxybutynin for treatment of nocturnal enuresis in children from Bandar Abbas in 2014. Methods This randomized controlled trial was conducted in 2014 and participants included 66 children with nocturnal enuresis who were more than 5 years old. Patients were randomly assigned into two groups. The first group received 120 microgram Desmopressin daily for 2 months, then 60 microgram daily for 2 months, then 60 microgram every 2 days. The second group received 5 mg oxybutynin twice a day for 6 months. The patients were followed after 1, 3, and 6 months to track treatment response. The study outcomes were frequency of nocturnal enuresis, urinary incontinency, urgency, and frequency. Data were analyzed using SPSS software. Results There were no significant differences between the two groups with respects to sex, age, place of residence, and parents’ education (p<0.05). Nocturnal enuresis, incontinency, urgency, and frequency of nocturnal enuresis was significantly lower with Desmopressin treatment in comparison to the oxybutynin treated group after 1 and 3 months (p<0.05). In addition, constipation and xerostomia were more frequent among the oxybutynin group after 1, 3, and 6 months (p<0.01). Blurred vision was also more frequent among oxybutynin group after 3 months (p<0.01). After 6 months the frequency of nocturnal enuresis and its frequency was higher in oxybutynin group in comparison to the Desmopressin group (p<0.05). Conclusion Desmopressin is more effective and has lower rate of side effects in comparison to oxybutynin for treatment of nocturnal enuresis. We recommend using Desmopressin for treatment of nocturnal enuresis in children. More studies are needed to achieve the best pharmacological treatment option for treatment of nocturnal enuresis. Trial registration The trial is registered at ClinicalTrials.gov with a ClinicalTrials.gov Identifier: NCT02538302 Funding The funder of this research is Hormozgan University of Medical Sciences.
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Affiliation(s)
- Kambiz Ghasemi
- M.D., Assistant Professor, Department of Pediatric Nephrology, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Maryam Esteghamati
- M.D., Assistant Professor, Department of Pediatric Nephrology, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Malihe Mohammadzadeh
- M.D., Pediatric Resident, Department of Pediatrics, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Shahram Zare
- Ph.D., Associate Professor, Department of Statistics, Faculty of Medicine, Hormozgan University of Medical Sciences, Hormozgan, Iran
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Desmopressin alone versus desmopressin and an anticholinergic in the first-line treatment of primary monosymptomatic nocturnal enuresis: a multicenter study. Pediatr Nephrol 2014; 29:1195-200. [PMID: 24477979 DOI: 10.1007/s00467-014-2751-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 12/31/2013] [Accepted: 01/02/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The aim of this study was to compare the efficacy of combination therapy with desmopressin and an anticholinergic to desmopressin monotherapy for the first-line treatment of children with primary monosymptomatic nocturnal enuresis (PMNE). METHODS A total of 98 children with PMNE (male:female 71:27) aged 5-16 (mean age 7.18 ± 1.8) years were retrospectively analyzed. The patients were divided into two groups: the monotherapy group (n = 49) was given oral desmopressin alone, and the combination therapy group (n = 49) was given desmopressin plus an anticholinergic (propiverine 10 mg) as a first-line treatment. The two groups were matched according to the following criteria: age, gender, and baseline frequency of nocturnal enuresis. The efficacy was evaluated by International Children's Continence Society criteria at 1 and 3 months after treatment initiation. RESULTS The combination therapy group showed a higher rate of complete response than the monotherapy group (20.4 vs. 6.1% at 1 month of treatment; 46.9 vs. 22.4% at 3 months of treatment). In terms of success (response and complete response), there was a significant difference between the two groups after 3 months of treatment (P = 0.002). CONCLUSIONS Our results indicate that combination therapy with desmopressin plus an anticholinergic is quicker and more effective than desmopressin monotherapy in reducing PMNE.
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Campos RM, Gugliotta A, Ikari O, Perissinoto MC, Lúcio AC, Miyaoka R, D'Ancona CAL. Comparative, prospective, and randomized study between urotherapy and the pharmacological treatment of children with urinary incontinence. EINSTEIN-SAO PAULO 2014; 11:203-8. [PMID: 23843062 PMCID: PMC4872895 DOI: 10.1590/s1679-45082013000200012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 06/05/2013] [Indexed: 11/21/2022] Open
Abstract
Objective: To verify and compare the results of behavioral modification plus pelvic floor muscle training and behavioral modifications plus oxybutynin chloride in children with nonmonosymptomatic enuresis. Methods: A total of 47 children were randomized using opaque and sealed envelopes sequentially numbered. Group I was composed of 21 children who underwent antimuscarinic treatment (oxybutynin), and Group II was composed of 26 patients who underwent pelvic floor muscle training. Both groups were instructed as to behavioral modifications. Results: The voiding diary results were compared each month between Groups I and II. In the first month of treatment, children in Group I presented 12.2 dry nights, 13.4 in the second month, and 15.9 in the last month. In Group II, the results were: 14.9 dry nights in the first month, 20.8 dry nights in the second and 24.0 dry nights in the last month. There was a significant difference between the groups in second and third months. Conclusion: Pelvic floor exercises associated with behavioral changes were more effective than pharmacological treatment in children with urinary incontinence.
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Ryu DS, Lee HW, Kwak KW, Park KH, Baek M. Role of Urodynamic Study in Nocturnal Enuresis: Urodynamic Findings and Treatment Outcome Correlation in Children with Pharmacotherapy-resistant Monosymptomatic Nocturnal Enuresis or Severe Non-monosymptomatic Nocturnal Enuresis. Low Urin Tract Symptoms 2013; 6:88-93. [PMID: 26663546 DOI: 10.1111/luts.12024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 04/09/2013] [Accepted: 04/22/2013] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study aimed to determine whether or not a urodynamic study (UDS) is beneficial for management of pediatric nocturnal enuresis (NE), especially in pharmacoresistant monosymptomatic nocturnal enuresis (PRMNE) or severe non-monosymptomatic nocturnal enuresis (NMNE) patients. METHODS Children with PRMNE or severe NMNE who underwent a UDS for the process of NE treatment were retrospectively reviewed. The UDS findings of patients and treatment outcomes of subsequent tailored therapies according to the UDS findings were analyzed. RESULTS A total of 80 children (50 boys and 30 girls, mean age 8.4 ± 2.2 years), 19 of which were diagnosed with PRMNE and 61 of which were diagnosed with NMNE, were included in the final analysis. Of the 19 PRMNE children, 12 (63.2%) demonstrated abnormal UDS findings. Ten demonstrated detrusor overactivity (DO) with or without decreased cystometric bladder capacity (CBC); the treatment outcomes markedly improved in all of the children after anticholinergics were added to the initial desmopressin therapy. Biofeedback was found to be helpful for two children with detrusor-sphincter dyssynergia. All of the total 61 children with NMNE demonstrated abnormal urodynamic findings of DO with or without decreased CBC, and 42 (68.9%) achieved more than partial response (> 50% decrease in the number of wet nights) when given a combination therapy of anticholinergics and desmopressin. CONCLUSIONS The urodynamic findings were helpful for guiding children with PRMNE in the proper choice of further treatment strategies. A routine UDS should not be recommended prior to a first-line combination treatment in children with NMNE.
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Affiliation(s)
- Dong Soo Ryu
- Department of Urology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Hye Won Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Won Kwak
- Department of Urology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Kwan Hyun Park
- Department of Urology, Seoul Samsung Urology Clinic/Gynecology Health Care Center, Ulsan, Korea
| | - Minki Baek
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Desmopressin treatment regimens in monosymptomatic and nonmonosymptomatic enuresis: A review from a clinical perspective. J Pediatr Urol 2011; 7:10-20. [PMID: 20576470 DOI: 10.1016/j.jpurol.2010.04.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2010] [Accepted: 04/13/2010] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate outcomes of desmopressin treatment in monosymptomatic enuresis (ME) and nonmonosymptomatic enuresis (NME). MATERIALS AND METHODS PubMed was searched for all studies investigating enuresis, up to July 2009, in which desmopressin was administered alone or combined with other treatments. Each study was graded according to its respective level of evidence. RESULTS Altogether, 99 studies enrolling 7422 patients were identified as fulfilling the inclusion criteria. In 76 studies, desmopressin was administered as monotherapy; in 29 it was combined with other treatments such as antimuscarinics and enuresis alarm. CONCLUSION Studies incorporating a minor invasive versus a non-invasive diagnostic approach seem to achieve superior long-term success rates. Primary efficacy outcomes following desmopressin treatment are more favourable in ME than NME. Desmopressin administered with adjunct measures achieves superior outcomes compared to monotherapy, especially in NME. Compared to sudden withdrawal, the structured withdrawal programs show better long-term success and lower relapse rates. So far, no superiority has been shown for either time- or dose-dependent structured withdrawal programs. Most studies incorporated only small case series; only 25 studies with level of evidence 1 or 2 have been conducted. The broad range of mono- and adjunct treatments were evaluated according to the evidence based criteria recommended by the European Association of Urology.
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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.
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Butler RJ, Robinson JC, Holland P, Doherty-Williams D. Investigating the three systems approach to complex childhood nocturnal enuresisMedical treatment interventions. ACTA ACUST UNITED AC 2009; 38:117-21. [PMID: 15204391 DOI: 10.1080/00365590410025371] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Nocturnal enuresis is a heterogeneous condition with various treatment options of both pharmacological and psychological origin. The three systems model previously proposed by us suggests a framework to facilitate understanding, identify a child's needs and specify the appropriate treatment option. In this study we sought to investigate the model in clinical practice in a group of children with severe nocturnal enuresis, with particular reference to pharmacological treatment. MATERIAL AND METHODS A total of 66 children were assessed using a schedule for identifying mono- and non-monosymptomatic nocturnal enuresis, and were administered either desmopressin (0.4 mg) or anticholinergic medication (5-10 mg), respectively. Children were assessed at 4 weeks, with those failing to meet the success criterion being offered combination treatment for a further 4 weeks. RESULTS Success rates for monotherapy were 49% and 33% for desmopressin and anticholinergic medication, respectively, with an overall success rate of 74.5%, including those who went on to combination treatment. Good clinical signs were identified for those successfully treated with anticholinergic medication. CONCLUSIONS This study endorses the three systems approach in clinical practice.
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Affiliation(s)
- Richard J Butler
- Child & Adolescent Mental Health Service, East Leeds Primary Care Trust, UK.
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Alloussi SH, Mürtz G, Gitzhofer S, Eichel R, Lang C, Madersbacher H, Strugala G, Alloussi S. Failure of monotherapy in primary monosymptomatic enuresis: a combined desmopressin and propiverine treatment regimen improves efficacy outcomes. BJU Int 2009; 103:1706-12. [PMID: 19154456 DOI: 10.1111/j.1464-410x.2008.08285.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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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.
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Affiliation(s)
- Paul F Austin
- Division of Urology, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri, USA.
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Nevéus T, Tullus K. Tolterodine and imipramine in refractory enuresis; a placebo-controlled crossover study. Pediatr Nephrol 2008; 23:263-7. [PMID: 18004596 DOI: 10.1007/s00467-007-0662-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Revised: 10/08/2007] [Accepted: 10/10/2007] [Indexed: 11/24/2022]
Abstract
The anticholinergic drug tolterodine has been suggested to be useful in therapy-resistant enuresis. Imipramine has a proven efficiency in unselected enuretic patients, but due to its side-effect profile it is only indicated, if at all, in therapy-resistant cases. We therefore compared these two drugs to placebo. Twenty-seven children with enuresis resistant to the alarm and to desmopressin in monotherapy were given placebo, tolterodine 1-2 mg, and imipramine 25-50 mg at bedtime for 5 weeks each in a randomised, double-blind, crossover fashion. The number of wet nights during the last 2 weeks of each treatment period was compared. One patient became spontaneously dry at the start of the study, and one dropped out due to side effects. Among the remaining 25 children, the number of wet nights during placebo, tolterodine and imipramine treatment were 11.0 +/- 3.9, 10.4 +/- 3.9 and 7.8 +/- 5.1, respectively (p < 0.001). Imipramine was significantly better than both placebo (p = 0.001) and tolterodine (p = 0.006). Nine children experienced side effects on imipramine and one on tolterodine (p = 0.001). This is the first study on anticholinergics or imipramine in children with therapy-resistant enuresis. Tolterodine, in monotherapy, had no proven effect. Imipramine was better than placebo, but side effects were common.
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Affiliation(s)
- Tryggve Nevéus
- Nephrology Unit, Uppsala University Children's Hospital, 751 85, Uppsala, Sweden.
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Chertin B, Koulikov D, Abu-Arafeh W, Mor Y, Shenfeld OZ, Farkas A. Treatment of nocturnal enuresis in children with attention deficit hyperactivity disorder. J Urol 2007; 178:1744-7. [PMID: 17707010 DOI: 10.1016/j.juro.2007.03.171] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2006] [Indexed: 11/16/2022]
Abstract
PURPOSE Children with attention deficit hyperactivity disorder disproportionately experience voiding dysfunction and persistent nocturnal enuresis due to a combination of sphincter and detrusor overactivity and nocturnal polyuria. The different treatment approaches to nocturnal enuresis often fail in these patients. Therefore, we performed a prospective study to compare the efficacy of combination therapy with desmopressin and oxybutynin vs the tricyclic antidepressant imipramine in patients with attention deficit hyperactivity disorder who have nocturnal enuresis. MATERIALS AND METHODS A total of 54 patients with attention deficit hyperactivity disorder and nocturnal enuresis were randomly stratified into 2 groups. Demographic data on patient age and gender were identical in the 2 groups. Functional bladder symptoms were judged using the dysfunctional voiding symptoms survey. The initial dysfunctional voiding symptoms survey score was similar in the 2 groups. The total survey score was compared between the 2 groups in aggregate as well as specifically regarding the incidence of nocturnal enuresis following treatment. RESULTS The first group consisted of 27 patients who received desmopressin and oxybutynin, and the second group of 27 was treated with imipramine. Of the 27 children in each group 23 (85%) received methylphenidate for attention deficit hyperactivity disorder. The mean +/- SD initial dysfunctional voiding symptoms survey score in groups 1 and 2 was 20.5 +/- 3.3 and 20.9 +/- 4.1, respectively. Following treatment the mean survey score decreased significantly in groups 1 and 2 (6.5 +/- 2.5 and 9.4 +/- 2.1, respectively, p <0.001). However, between groups analysis showed that the dysfunctional voiding symptoms survey score was significantly lower in group 1 than in group 2 (mean 6.5 +/- 0.5 vs 9.6 +/- 0.4, p <0.001). There was also a statistically significant decrease in the incidence of nocturnal enuresis in group 1 (survey question 2 score 0.9 +/- 0.2 vs 2.9 +/- 0.2). CONCLUSIONS Our data show that there is a high incidence of voiding dysfunction in children with attention deficit hyperactivity disorder. Combination therapy with desmopressin and oxybutynin is a feasible, safe and effective treatment for nocturnal enuresis in these children.
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Affiliation(s)
- Boris Chertin
- Department of Urology, Shaare Zedek Medical Center, Jerusalem.
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Radvanska E, Kovács L, Rittig S. The Role of Bladder Capacity in Antidiuretic and Anticholinergic Treatment for Nocturnal Enuresis. J Urol 2006; 176:764-8; discussion 768-9. [PMID: 16813940 DOI: 10.1016/s0022-5347(06)00595-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE We evaluated combination treatment with desmopressin and oxybutynin in patients with enuresis who did not respond to desmopressin monotherapy. Furthermore, we compared 2 methods of estimating bladder capacity and evaluated the ability of these methods to predict the response to desmopressin and oxybutynin. MATERIALS AND METHODS A total of 60 children with a mean age +/- SD of 10.6 +/- 3.0 years who had monosymptomatic nocturnal enuresis completed the study. After a 2-week observation period maximal voided volume during free access to fluid intake was determined by a 2-day frequency-volume chart and maximal voided volume after water load was determined on a separate day. Patients then received 20 mug desmopressin intranasally at bedtime during 2 weeks. In nonresponders to desmopressin with less than a 50% decrease in wet nights 5 mg oxybutynin twice daily was added for another 2 weeks. RESULTS Of the patients 41 (68%) showed more than 50% decrease in wet nights during the 2-week desmopressin treatment period (4.6 +/- 1.6 to 0.7 +/- 0.8, p <0.001). In desmopressin nonresponders combined treatment with desmopressin and oxybutynin resulted in a further decrease in wet nights (4.0 +/- 1.2 to 1.7 +/- 1.4, p <0.001). Maximal voided volume during free access to fluid intake was significantly higher in desmopressin responders than in nonresponders (244 +/- 111 vs 160 +/- 65 ml, p <0.001). In contrast, maximal voided volume after water load was not significantly different between desmopressin responders and nonresponders. CONCLUSIONS The study indicates a role for oxybutynin in combination with desmopressin in children who are not responding to desmopressin monotherapy. Maximal voided volume during free access to fluid intake is a clinically useful predictor of the response to desmopressin but not to oxybutynin.
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Affiliation(s)
- Eva Radvanska
- Department of Pediatrics, Comenius University Medical School, Bratislava, Slovakia
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Fai-Ngo Ng C, Wong SN. Comparing alarms, desmopressin, and combined treatment in Chinese enuretic children. Pediatr Nephrol 2005; 20:163-9. [PMID: 15605283 DOI: 10.1007/s00467-004-1708-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2003] [Revised: 09/03/2004] [Accepted: 09/10/2004] [Indexed: 11/28/2022]
Abstract
The objective of this multicenter randomized controlled trial was to compare the efficacy of enuresis alarms, oral desmopressin, and combined treatment in Chinese children with monosymptomatic primary nocturnal enuresis. We assigned 105 children aged 7-15 years to receive alarms (group 1, 35 patients), oral desmopressin 400 mug (group 2, 38 patients), or combined therapy (group 3, 32 patients) for 12 weeks; patients were then followed for 12 weeks after treatment. The wetting frequency decreased during treatment by 46%, 52%, and 73% in groups 1, 2, and 3, respectively. In groups 2 and 3, but not in group 1, there was rebound post treatment, but significant improvements persisted at 12 weeks. The complete and partial response rates were 22.9% and 20%, respectively in group 1, 42% and 10.5% in group 2, and 62.5% and 15.6% in group 3. By Kaplan-Meier analysis, group 1 had a significantly poorer response than groups 2 and 3. Of the responders, 20%, 60%, and 40% in groups 1, 2, and 3, respectively, relapsed after stopping treatment. In conclusion, enuresis alarms and/or oral desmopressin were less efficacious in Chinese than in Western societies. Desmopressin produced an immediate effect but relapses were common. Alarms took several weeks to produce a benefit, which was persistent on follow-up.
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Affiliation(s)
- Cherry Fai-Ngo Ng
- Department of Pediatrics and Adolescent Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
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Yucel S, Kutlu O, Kukul E, Baykara M. Impact of urodynamics in treatment of primary nocturnal enuresis persisting into adulthood. Urology 2004; 64:1020-5; discussion 1025. [PMID: 15533498 DOI: 10.1016/j.urology.2004.06.067] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2004] [Accepted: 06/03/2004] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate the urodynamic profiles of adults with primary nocturnal enuresis (PNE) and the association of the urodynamic profile findings with the efficacy of desmopressin and/or tolterodine pharmacotherapy. At least 2% of adults are enuretic during the night. The diagnostic and treatment approach for PNE is empirically the same in children and adults. METHODS A total of 20 nocturnal enuretic patients (12 women and 8 men) with a mean age of 27.1 years (range 20 to 42) were studied. They had wet their bed at least twice per week for the past 6 months. Urodynamic studies, including filling and voiding cystometry, pressure-flow study, and pelvic floor electromyography with superficial electrodes, were performed on all patients. Two of them had daytime symptoms, and two had prior failed desmopressin therapy. All patients began taking oral desmopressin 0.4 mg for 1 month. Their continence was assessed and tolterodine 4 mg was added for those in whom desmopressin alone failed. The patients responsive to desmopressin alone or desmopressin plus tolterodine were weaned from medication at 6 and 12 months to reassess continence. The mean follow-up period was 11.6 +/- 3.3 months (range 4 to 14). RESULTS Urodynamic studies of 20 PNE adult patients revealed detrusor instability in 10 (50%), hypocompliance in 8 (40%), nonneurogenic detrusor-sphincter dyssynergy in 1 (5%), and no abnormality in 10 (50%). Of the 20 patients, 19 (95%) had no voiding bladder problems. Of the 10 patients responsive to desmopressin alone, 6 (60%) had a normal urodynamic profile; the remaining 4 (40%) had detrusor instability and/or hypocompliance. Of the 5 patients who received desmopressin and tolterodine, 3 achieved continence. The overall continence rate was 86% (13 of 15), and 12 (92%) of the 15 patients required maintenance therapy. In 2 patients (13.3%), desmopressin and tolterodine therapy failed. The efficacy of desmopressin alone and of desmopressin plus tolterodine were not related to the urodynamic profile findings (P >0.05). The urodynamic profile was also not related to the relapse rate after any form of pharmacotherapy (P >0.05). CONCLUSIONS PNE persisting into adulthood may be associated with abnormal urodynamic findings. Patients may benefit from urodynamic studies, because if the findings are abnormal, they might have the best chance of successful treatment.
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Affiliation(s)
- Selcuk Yucel
- Department of Urology, Akdeniz University School of Medicine, Kampus, Antalya, Turkey
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Barkin J, Corcos J, Radomski S, Jammal MP, Miceli PC, Reiz JL, Harsanyi Z, Darke AC. A randomized, double-blind, parallel-group comparison of controlled- and immediate-release oxybutynin chloride in urge urinary incontinence. Clin Ther 2004; 26:1026-36. [PMID: 15336467 DOI: 10.1016/s0149-2918(04)90174-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2004] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy and safety of a new PO controlled-release (CR) QD oxybutynin tablet relative to PO immediate-release (IR) TID oxybutynin in patients with urge urinary incontinence (UI). METHODS In this multicenter, double-blind trial, patients with UI (> or = 7 episode/wk) and frequency (> or = 8 micturitions/d) were randomized to CR or IR oxybutynin for 6 weeks. Patients initiated treatment at 15 mg/d and the dose was adjusted (in 5-mg/d increments) over 2 weeks according to tolerability. Efficacy (UI episodes, voids, absorbent pads used, urgency, and volume voided per micturition) was assessed during the final 2 weeks of treatment. Tolerability was assessed by evaluating adverse events and treatment withdrawals. RESULTS Of the 125 patients randomized, 94 (75%) were evaluable for efficacy; tolerability was assessed in all patients. In the CR group, 48 patients (91%) were women and 5 (9%) were men; the mean (SD) age was 58.0 (12.4) years (range, 26-78 years). In the IR group, 37 patients (90%) were women and 4 (10%) were men; the mean (SD) age was 60.6 (14.8) years (range, 26-83 years). Both CR and IR oxybutynin significantly reduced the mean number of total UI episodes per week (both P < 0.001 vs baseline). Both treatments produced equivalent reductions in mean voiding frequency and urinary urgency (all P < 0.001 vs. baseline). Significantly more patients rated CR oxybutynin tolerable on the initial dose of 15 mg/d (P = 0.020) and completed the study at a dose of > or = 15 mg/d (P = 0.018). Dry mouth was the most common adverse event, reported by 68% and 72% of patients in the CR and IR oxybutynin groups, respectively. CONCLUSIONS Among the patients with urge UI included in this study, CR oxybutynin was as effective as IR oxybutynin for improving primary symptoms, with the additional benefit of QD administration.
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Affiliation(s)
- Jack Barkin
- University of Toronto, Toronto, Ontario, Canada
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21
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Marschall-Kehrel AD, Mürtz G, Kramer G, Jünemann KP, Madersbacher H. AN EMPIRICAL TREATMENT ALGORITHM FOR INCONTINENT CHILDREN. J Urol 2004; 171:2667-71. [PMID: 15118448 DOI: 10.1097/01.ju.0000109641.77820.46] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Successful response rates of monotherapeutic strategies in urge incontinent children are limited. We evaluate whether adjuvant treatment improves outcomes. MATERIALS AND METHODS Incontinent children were evaluated according to International Consultation on Incontinence standards. Propiverine (0.4 mg/kg) was applied 2 times daily for 4 weeks (treatment period 1) before reevaluation. Primary outcome was achievement of continence and secondary outcome was improvement of functional bladder capacity. In partial responders an alternative adjuvant treatment was initiated for another 12 weeks (treatment period 2). RESULTS Of 70 enrolled patients 29 achieved continence (responders) and 35 responded partially and were assigned to adjuvant treatment, which consisted of selective alpha-blocker for functional bladder outflow obstruction (6), desmopressin for excessive nocturnal urine production (19) and biofeedback for increased pelvic floor activity during micturition (10). Only 6 nonresponders (9%) were assigned to specialized management. After treatment 2, 20 of the 35 partial responders achieved continence, thus avoiding specialized management. CONCLUSIONS Propiverine monotherapy for incontinent children is effective. However, applying adjuvant treatment modalities to partial responders increases overall efficacy rates.
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Affiliation(s)
- Jack S Elder
- Division of Pediatric Urology, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Del Gado R, Aceto G, Del Gaizo D, Del Gado G, Polidori G, Chiozza ML. DESMOPRESSIN FOR THE TREATMENT OF NOCTURNAL BEDWETTING IN PATIENTS WITH NEURAL TUBE CLOSURE DEFECTS. J Urol 2004; 171:1656-8. [PMID: 15017260 DOI: 10.1097/01.ju.0000117802.33591.f5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We evaluated desmopressin (DDAVP) treatment in patients with neuropathic bladder secondary to neural tube closure defects (NTDs) and nocturnal incontinence. MATERIALS AND METHODS We selected 25 patients, that is 10 males (40%) and 15 females (60%), between ages 7 and 16 years (mean 9.8) with neuropathic bladder secondary to NTDs without a ventricular-peritoneal shunt. All had a low pressure bladder and presented with daytime continence between catheterizations but had persistent nocturnal urine loss 7 nights weekly. They underwent treatment with oral DDAVP according to a certain design, namely an initial dose of 0.2 mg for 3 weeks, which was increased to 0.3 or 0.4 mg for another 3 weeks in nonresponders. The average dose was 0.2 mg. At the effective minimal dose (bedwetting decrease greater than 50%) patients continued for 6 months and then decreased by intervals of 0.05 mg every 2 weeks. In the event of recurrence treatment continued for 1 year. RESULTS All patients responded to treatment during the nighttime hours except 1 who suspended treatment after 4 weeks. There were no adverse effects from DDAVP. CONCLUSIONS Treating nocturnal bedwetting with DDAVP in patients with NTDs was effective and safe. Nevertheless, to our knowledge treatment duration has not yet been determined.
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Affiliation(s)
- R Del Gado
- Paediatrics Department, University of Bari, Bari, Italy.
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Radomski SB, Caley B, Reiz JL, Miceli PC, Harsanyi Z, Darke AC. Preliminary evaluation of a new controlled-release oxybutynin in urinary incontinence. Curr Med Res Opin 2004; 20:249-53. [PMID: 15006020 DOI: 10.1185/030079903125002955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To conduct a preliminary evaluation of a new oral formulation of controlled-release (CR) oxybutynin tablet taken once-daily in patients with urinary urge incontinence. RESEARCH DESIGN AND METHODS A single-centre, open-label, 8-week study was conducted. Patients with urodynamically-confirmed detrusor instability, micturition frequency (>/= 8 voids/day) and/or urinary incontinence (>/= 2 incontinence periods/day) were enrolled. The study duration was 8 weeks: patients received IR oxybutynin (2.5-5 mg bid) for 2 weeks, followed by a 2-week washout/baseline period to avoid carryover effects, and oral CR oxybutynin (15 mg OD) for 4 weeks. Daily void frequency, fluid intake, urinary incontinence episodes, and spontaneously reported adverse events were recorded in a daily diary for five consecutive days in each treatment period. RESULTS Of 12 enrolled patients, 9 patients efficacy; all patients were evaluable for safety. completed the study and were evaluable for Compared to baseline/washout, CR oxybutynin reduced UI episodes/day by 45% (p = 0.13) and micturitions/day by 15% (p = 0.07). Treatment with IR oxybutynin (mean dose: 6.7 +/- 2.5 mg/day) reduced UI episodes/day from baseline by 7% (p = 0.58) and voids/day by 6% (p = 0.29). Fluid intake remained consistent at approximately 2 litres/day during all study periods. The most common adverse event was dry mouth. CONCLUSIONS Based on the reductions in daily frequency of incontinence and micturition following 4-weeks treatment, CR oxybutynin (15 mg OD) was at least as effective as the patients' previous dose of IR oxybutynin (mean dose: 6.7 +/- 2.5 mg/day). These improvements were achieved without restriction of fluid intake. Initial 15 mg doses of CR oxybutynin appear to be well tolerated.
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Affiliation(s)
- Sidney B Radomski
- Department of Urology, University Health Network, Toronto, Ontario, Canada
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25
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El-Radhi AS, Board C. Providing adequate treatment for children with nocturnal enuresis. Br J Community Nurs 2003; 8:440-6. [PMID: 14581847 DOI: 10.12968/bjcn.2003.8.10.11696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Nocturnal enuresis is the most common urological problem in children. With increasing age and persistence of enuresis, children may experience psychological problems. Active treatment is therefore required not only to achieve dryness but also to prevent and treat such an experience. Although nocturnal enuresis has multiple causes, in recent years emphasis has focused on three main causes: lack of arousal, lack of antidiuretic hormone secretion and lack of bladder stability. This article stresses the importance of applying a specific treatment based on this ‘three system approach’ for every child presenting with enuresis.
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Honjo H, Kawauchi A, Ukimura O, Soh J, Mizutani Y, Miki T. Treatment of monosymptomatic nocturnal enuresis by acupuncture: A preliminary study. Int J Urol 2002; 9:672-6. [PMID: 12492950 DOI: 10.1046/j.1442-2042.2002.00550.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study was designed to clarify the clinical usefulness of acupuncture as a treatment option for monosymptomatic nocturnal enuresis, and evaluate the mechanisms of its effect. METHODS Subjects comprised 15 patients (10 males, 5 females) with monosymptomatic nocturnal enuresis who were treated by acupuncture using a disposable stainless steel needle (0.3 mm in diameter, 60 mm in length) inserted into bilateral BL-33 (Zhongliao) points on the skin of the third posterior sacral foramina and rotated manually for 10 min reciprocally. Bladder capacities and number of wet nights per week were compared before and after treatment. Patients in whom wet nights decreased 50% or more compared with the baseline were considered responders. RESULTS Nocturnal enuresis improvement rates following acupuncture treatment were 40% (6/15) just after treatment and 47% (7/15) 2 months after. In 6 responders, just after treatment the nocturnal bladder capacity (NBC) increased significantly, from 201 mL to 334 mL (P < 0.05). No side-effects were recognized throughout the treatment period. CONCLUSION Acupuncture may be beneficial in the treatment of nocturnal enuresis by increasing NBC, and provide a promising alternative to conventional therapies for monosymptomatic nocturnal enuresis.
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Affiliation(s)
- Hisashi Honjo
- Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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27
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Abstract
PURPOSE A review of the scarce literature concerning oxybutynin treatment for nocturnal enuresis reveals that its success is greatest when enuresis is combined with daytime incontinence. The renal and bladder related characteristics of children with monosymptomatic enuresis responsive to oxybutynin were evaluated. MATERIALS AND METHODS Renal concentrating capacity and functional bladder capacity were compared between 55 dry children who served as controls, and children with monosymptomatic enuresis who responded to desmopressin only (group 1, 27), oxybutynin only (group 2, 11), combination desmopressin and oxybutynin (group 3, 7) or were resistant to all treatment alternatives (group 4, 23). RESULTS Renal concentrating capacity was lowest in groups 1 and 3 (939 +/- 147 mOsm./kg. controls, 856 +/- 158 group 1, 1,073 +/- 71 group 2, 762 +/- 119 group 3 and 970 +/- 146 group 4; p <0.01), whereas they had high urinary output (15.4 +/- 73.4 ml./kg. per hour controls, 22.2 +/- 10.2 group 1, 13.5 +/- 4.3 group 2, 21.5 +/- 11.2 group 3 and 15.0 +/- 6.9 group 4; p <0.01). Forced functional bladder capacity of that expected for age was lowest in groups 2 to 4 (107 +/- 43% controls, 88 +/- 43 group 1, 71 +/- 25 group 2, 68 +/- 22 group 3 and 59 +/- 22 group 4; p <0.01). CONCLUSIONS Children responding to oxybutynin have small bladders and probably hyperactive detrusors, whereas those responding to desmopressin or who need both drugs to achieve dryness have polyuria.
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Affiliation(s)
- T Nevéus
- Uppsala University Children's Hospital, Uppsala, Sweden
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28
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EXAMINATION OF THE STRUCTURED WITHDRAWAL PROGRAM TO PREVENT RELAPSE OF NOCTURNAL ENURESIS. J Urol 2001. [DOI: 10.1097/00005392-200112000-00123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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OXYBUTYNIN, DESMOPRESSIN AND ENURESIS. J Urol 2001. [DOI: 10.1097/00005392-200112000-00122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Butler R, Stenberg A. Treatment of childhood nocturnal enuresis: an examination of clinically relevant principles. BJU Int 2001; 88:563-71. [PMID: 11678752 DOI: 10.1046/j.1464-410x.2001.02373.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- R Butler
- Department of Clinical Psychology, High Royds Hospital, West Yorkshire, UK.
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Butler RJ. Combination therapy for nocturnal enuresis. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 2001; 35:364-9. [PMID: 11771862 DOI: 10.1080/003655901753224413] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Nocturnal enuresis (NE) is a multifactorial condition of childhood affecting both children and their parents. NE may result from a vasopressin deficiency, bladder instability or lack of arousal from sleep to bladder sensations. The development of the three-systems model offers increased understanding of the multifactorial aetiology of NE and may aid the development of a tailored treatment regimen for the individual child. For decades, treatment of NE has focused on pharmacological, behavioural and combination therapies, and many studies provide supporting evidence for each of these treatment approaches. However, many of these studies were performed on unselected patient populations. without assessment of the cause of the patients' enuresis, and therefore both the methodologies and results of these studies are questionable. This paper reviews the efficacy of combined treatment interventions and assesses when such interventions may be of most benefit to the patient.
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Affiliation(s)
- R J Butler
- Department of Clinical Psychology, Leeds Community and Mental Health (NHS) Trust, UK
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Jones SE, Shuba LM, Zhabyeyev P, McCullough JR, McDonald TF. Differences in the effects of urinary incontinence agents S-oxybutynin and terodiline on cardiac K(+) currents and action potentials. Br J Pharmacol 2000; 131:245-54. [PMID: 10991917 PMCID: PMC1572333 DOI: 10.1038/sj.bjp.0703595] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
1. The cardiac electrophysiological effects of S-oxybutynin, a single-enantiomer drug under evaluation for the management of urinary incontinence, have been investigated and compared with those of terodiline, an incontinence agent withdrawn following reports of QT lengthening and ventricular tachyarrhythmia. Membrane currents were recorded from whole-cell configured guinea-pig and rabbit ventricular myocytes, and action potentials were recorded from guinea-pig and rabbit papillary muscles. 2. L-type Ca(2+) current (I:(Ca,L)), rapidly-activating K(+) current (I:(Kr)) and slowly-activating K(+) current (I:(Ks)) were unaffected by submicromolar S-oxybutynin and inhibited by higher concentrations; IC(50) values were 17.8 microM for I:(Ca,L), 12 microM for I:(Kr), and 41 microM for I:(Ks). Terodiline IC(50) values were somewhat lower for I:(Ca,L) (15.2 microM) and I:(Ks) (30 microM), but 24 fold lower in the case of I:(Kr) (0.5 microM). 3. The durations of action potentials in guinea-pig and rabbit papillary muscles driven at 1 Hz were unaffected or moderately shortened by 0.1 - 100 microM S-oxybutynin, but lengthened by terodiline. Terodiline (< or =10 microM) also depressed maximal upstroke velocity. 4. The action potential plateau shortened by an average of 23% when control rabbit papillary muscles were driven at 0.4 Hz instead of 1 Hz. Plateau shortening was significantly smaller in the presence of drugs (30 microM S-oxybutynin, 3 and 30 microM terodiline), suggesting that they suppress the transient outward current (I:(to)) involved in rate-dependent shortening. In experiments on rabbit ventricular myocytes, 3 and 30 microM S-oxybutynin inhibited I:(to) by 9+/-2% and 35+/-3%, respectively, whereas 3 and 30 microM terodiline inhibited the current by 31+/-3% and 87+/-3%, respectively. 5. The results indicate that S-oxybutynin has relatively weak non-specific effects on cardiac ion channels, and that clinically relevant submicromolar concentrations are unlikely to have terodiline-like proarrhythmic actions on the myocardium.
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Affiliation(s)
- Stephen E Jones
- Department of Physiology and Biophysics, Dalhousie University Halifax, Nova Scotia, B3H 4H7 Canada
| | - Lesya M Shuba
- Department of Physiology and Biophysics, Dalhousie University Halifax, Nova Scotia, B3H 4H7 Canada
| | - Pavel Zhabyeyev
- Department of Physiology and Biophysics, Dalhousie University Halifax, Nova Scotia, B3H 4H7 Canada
| | - John R McCullough
- Sepracor Inc., 111 Locke Avenue, Marlborough, Massachusetts, MA 01752, U.S.A
| | - Terence F McDonald
- Department of Physiology and Biophysics, Dalhousie University Halifax, Nova Scotia, B3H 4H7 Canada
- Author for correspondence:
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34
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Butler RJ, Holland P. The three systems: a conceptual way of understanding nocturnal enuresis. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 2000; 34:270-7. [PMID: 11095087 DOI: 10.1080/003655900750042022] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Childhood nocturnal enuresis has traditionally been regarded as a multifaceted problem with a variety of treatment interventions. This paper proposes a model based on the notion that nocturnal enuresis arises through the ill functioning of one or more of the following three systems - a lack of vasopressin release during sleep; bladder instability; and/or an inability to arouse from sleep to bladder sensations. Clinical signs of each system are outlined and the appropriate treatment intervention for each is discussed. It is argued that addressing nocturnal enuresis in this way will enhance overall treatment effectiveness.
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Affiliation(s)
- R J Butler
- Department of Clinical Psychology, Leeds Community and Mental Health (NHS) Trust, UK
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35
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Schulman SL, Colish Y, von Zuben FC, Kodman-Jones C. Effectiveness of treatments for nocturnal enuresis in a heterogeneous population. Clin Pediatr (Phila) 2000; 39:359-64. [PMID: 10879938 DOI: 10.1177/000992280003900606] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to determine the effectiveness of various treatments for nocturnal enuresis in a large, diverse population of children. A retrospective cohort review of patients with nocturnal enuresis was undertaken. All patients selected treatment after a single visit that included a history, examination, and demonstration of treatments. Families were contacted 1 year later to determine what treatment they chose and whether their child still wet. Families primarily chose an alarm (31%), followed by desmopressin acetate (22%) and oxybutynin (9%). Some preferred no treatment (23%). Fifty-six percent of patients using the alarm were completely dry compared to 18% using desmopressin acetate (p<0.0001), 16% using oxybutynin, and 28% receiving no treatment. In a heterogeneous population 1 year after a single visit, children whose parents chose the nocturnal enuresis alarm were most likely to be completely dry.
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Affiliation(s)
- S L Schulman
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, 19104, USA
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Abstract
BACKGROUND Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. OBJECTIVES To assess the effects of desmopressin on nocturnal enuresis in children, and to compare desmopressin with other interventions. SEARCH STRATEGY The following electronic databases were searched: MEDLINE to June 1997; AMED; ASSIA; BIDS; BIOSIS Previews (1985-1996); CINAHL; DHSS Data; EMBASE (1974 to June 1997); PsycLIT and SIGLE. Organisations, manufacturers, researchers and health professionals concerned with enuresis were contacted for information. The reference sections of obtained studies were also checked for further trials. Date of the most recent search: July 1997. SELECTION CRITERIA All randomised trials of desmopressin for nocturnal enuresis in children were included in the review. Trials were eligible for inclusion if: children were randomised to receive desmopressin compared with placebo, other drugs or other conservative interventions for nocturnal bedwetting; participants with organic causes for their bedwetting were excluded; and baseline assessments of the level of bedwetting were reported. Trials focused solely on daytime wetting were excluded. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the quality of the eligible trials, and extracted data. MAIN RESULTS Twenty one randomised trials involving 948 children treated with desmopressin, met the inclusion criteria. The quality of many of the trials was poor. Desmopressin was compared with a tricyclic drug in two trials, and with alarms in one. Desmopressin was effective in reducing bedwetting in a variety of doses and forms. Each dose of desmopressin reduced bedwetting by at least one night per week during treatment (eg 20microg: 1.56 fewer wet nights per week, 95% CI -1.94 to -1.19). Participants on desmopressin were 4.6 times more likely to achieve 14 consecutive dry nights (95% CI 1.38 to 15.02) compared with placebo. However, there was no difference after treatment was finished. There was no apparent dose-related effect of desmopressin, but the evidence was limited. Data which compared oral and nasal administration were too few to be conclusive. Desmopressin and imipramine (a tricyclic drug) were equally effective in one small trial. Amitriptyline (another tricyclic) was not consistently better than desmopressin either alone or when used as a supplement. In a single trial, desmopressin was initially superior to using an alarm in reducing the number of wet nights per week: WMD -1.7 (95% CI: -2.96 to -0.45), but this result was not sustained; after three months of treatment, patients using the alarm had 1.4 fewer wet nights per week than with desmopressin: (95% CI: 0.14 to 2.65). Participants receiving the alarm intervention were also nine times less likely to relapse than those given desmopressin: RR 9.2 (95% CI: 1.28 to 65.9). Combining alarm and drug therapy was found to be superior to alarm treatment alone. The addition of desmopressin to an alarm schedule resulted in one less wet night per week: (95% CI: -1.55 to -0.45). REVIEWER'S CONCLUSIONS Desmopressin rapidly reduced the number of wet nights per week, but there was some evidence that this was not sustained after treatment stopped. Comparison with alternative treatments suggested that desmopressin and tricyclics had similar clinical effects, but that alarms produced more sustained benefits. However, based on the available evidence, these conclusions can only be tentative. There was some evidence of minor side effects of desmopressin in the included trials, such as nasal irritation and nose bleeds. However, the risk of water intoxication associated with over-drinking before bedtime has been reported. Patients and their families need to be warned of potential adverse effects and advise
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Affiliation(s)
- C M Glazener
- Health Services Research Unit (Flea), University of Aberdeen, Foresterhill Lea, Foresterhill, Aberdeen, Aberdeenshire, UK, AB25 2ZD.
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37
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Nevéus T, Läckgren G, Tuvemo T, Olsson U, Stenberg A. Desmopressin resistant enuresis: pathogenetic and therapeutic considerations. J Urol 1999; 162:2136-40. [PMID: 10569604 DOI: 10.1016/s0022-5347(05)68142-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We tested the role of the bladder in the pathogenesis of desmopressin resistant enuresis by evaluating the influence of urine production on the timing of the enuretic event and the response to anticholinergic medication. MATERIALS AND METHODS We gave 33 children with monosymptomatic nocturnal enuresis resistant to the standard 0.4 mg. oral dose of desmopressin 0.4 and 0.8 mg. desmopressin and placebo tablets for 5 nights each in a double-blind crossover fashion. The time of enuresis or nocturia was documented. All 9 children who had at least 1 dry treatment period during the randomized portion of the study then received open label treatment with 0.8 mg. desmopressin. Nonresponders to this regimen and the remainder of the children were offered anticholinergic treatment. RESULTS Average time between bedtime and voiding was 5.0, 5.6 and 5.0 hours during the nights with placebo, and 0.4 and 0.8 mg. desmopressin, respectively (p = 0.12). Of the 9 children subsequently treated with 0.8 mg. desmopressin 5 became completely dry. Of the remaining 28 children given anticholinergic treatment 20 responded. CONCLUSIONS Antidiuresis does not delay the enuretic event in children with desmopressin resistant enuresis. This finding and the favorable response to anticholinergic medication favor the hypothesis that these children have nocturnal bladder instability. A subgroup of enuretic children responds to high but not normal doses of desmopressin.
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Affiliation(s)
- T Nevéus
- Department of Pediatrics, Uppsala University Children's Hospital, Swedish Agricultural University
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Chiozza ML, Plebani M, Scaccianoce C, Biraghi M, Zacchello G. Evaluation of antidiuretic hormone before and after long-term treatment with desmopressin in a group of enuretic children. BRITISH JOURNAL OF UROLOGY 1998; 81 Suppl 3:53-5. [PMID: 9634021 DOI: 10.1046/j.1464-410x.1998.00009.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the effect of long-term desmopressin therapy in enuretic patients on the levels of antidiuretic hormone (ADH) during and after the end of therapy. PATIENTS AND METHODS The study comprised 25 outpatients (18 boys and seven girls) aged 8-12 years at the start of therapy and 12-16 years at the end. The morning (08.00 hours) plasma ADH level was determined before treatment (T0) with desmopressin and 2 years after (T1) ending the therapy. Seven of the 25 patients evaluated had monosymptomatic (simple enuresis, SE) and 18 had other symptoms (complex enuresis, CE). RESULTS In the patients with SE, the mean (SD) duration of therapy was 305 (183) days and they were reevaluated 2.5 (0.67) years later. Of 18 patients with CE, eight were treated only with desmopressin for 204 (117) days. In 10 with an incomplete response after 30 days with only desmopressin, oxybutynin (5 mg twice daily) was added; the duration of their therapy was 255 (152) days and they were re-evaluated 3.9 (0.6) years later. The mean (SD) ADH level in those with SE and CE was 2.14 (0.93) ng/L and 2.53 (1.16) ng/L), respectively, both significantly lower (P < 0.001) than in controls, at 5.1 (1.6) ng/L. On re-evaluation at T1, there was a significant (P < 0.001) increase in ADH levels over those at T0 in both groups, at 5.2 (0.8) and 5.3 (1.9) ng/L, respectively. CONCLUSION These results seem to confirm the role played by ADH in the pathophysiology of enuresis.
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Affiliation(s)
- M L Chiozza
- Department of Pediatrics, University of Padua, Padova, Italy
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