Association between constipation and childhood nocturnal enuresis in Taiwan: a population-based matched case-control study

Risk factors, urodynamic characteristics, and distress associated with nocturnal enuresis in overactive bladder -wet women

Patients with overactive bladder syndrome-wet (OAB-wet) experience urgency urinary incontinence, particularly urinary frequency and nocturia. Nocturnal enuresis (NE) is less addressed among OAB-wet patients. The study evaluated the prevalence of NE, lower urinary tract symptoms (LUTS), urodynamic factors, and social factors in OAB-wet patient. Over three years, adult women with urgency urinary incontinence were enrolled. A comprehensive questionnaire, including baseline characteristics, LUTS, fatigue, stress, and partner relationship was completed by the participants. NE was defined as complaint of intermittent incontinence that occurs during the main sleep period. Urodynamics was performed on every patient to assess bladder function. Of 203 OAB-wet patients (age: 64.45 years), 46.4% had NE. Patients with NE had higher scores of intermittency, slow stream, straining, hesitancy, post micturition dribble, nocturia, and stress urinary incontinence than non-NE. NE patients had a more parity numbers, diuretic, hypnotic, and prokinetic use, and smoking. NE patients more likely reported fatigue, anxiety, and distress. Urodynamic studies revealed more detrusor overactivity, detrusor underactivity, and low bladder compliance in NE patients. In conclusion, OAB-wet women with NE had more detrusor overactivity, detrusor underactivity, and a lower compliance bladder on urodynamic studies than those without NE. NE impacts the patients' life in aggravating fatigues, anxiety, and distress in OAB-wet women.

The impact of constipation on lower urinary tract function and treatment response in patients with non-monosymptomatic enuresis

PURPOSE

The purpose of this study was to compare the differences in lower urinary tract function and treatment response between non-monosymptomatic nocturnal enuresis (NMNE) pediatric patients with and without constipation.

METHOD

We retrospectively analyzed pediatric patients diagnosed as NMNE from our enuresis database. Inclusion criteria were children aged 5 years or older with a follow-up duration of at least one month. Basic evaluation included the Rome IV questionnaire, Dysfunctional voiding score questionnaire (DVSS), two-day voiding diary, one-week enuresis diary and uroflowmetry with post-void residual (PVR) measurement. Constipation was defined as a Rome IV score of ≥ 2. We compared the results of evaluations and treatment response between groups with and without constipation.

RESULTS

From July 2005 to December 2021, we enrolled 128 children who met the diagnostic criteria for NMNE. The median age was 7 years (interquartile range [IQR]: 6-9), and the median follow-up duration was 8.6 months (IQR: 3.5-15.6). NMNE patients with constipation had significantly higher scores on the daytime incontinence, holding maneuver, urgency, and total scores of the DVSS questionnaire. No significant differences were found between those with and without constipation in terms of daytime maximal voided volume and voiding frequency as recorded in the voiding diary. Although the group without constipation showed a relatively higher maximum flow rate, there was no significant difference observed in the PVR between the two groups. Patients in the constipation group exhibited a higher proportion requiring the combination of more medications for enuresis treatment. However, constipation did not affect the time to achieve partial or complete response in NMNE patients. The use of laxatives also did not affect the treatment response in the constipation group.

CONCLUSION

Constipation in NMNE patients is associated with increased severity of daytime lower urinary tract symptoms and requires more medications to achieve treatment response. However, with proper treatment, the time to partial or complete response is comparable to those without constipation.

CLINICAL TRIAL NUMBER

Not applicable.

Evaluation of bladder capacity in pediatric patients with nocturnal enuresis using voiding diary and uroflowmetry: A retrospective study

OBJECTIVE

This retrospective study was conducted in a tertiary hospital in Turkiye, it was aimed to evaluate the results of kidney and bladder ultrasonography, uroflowmetric study and volume frequency chart in children diagnosed with bedwetting at night.

METHODS

This study focused on patients aged 5-17 years who were treated for nocturnal enuresis in the single-center pediatric urology clinic of a tertiary hospital between 2017-2021. Patients' comorbidities, surgical history, urinary ultrasonography findings, uroflowmetry examination results, and two-day voiding diary were requested.

RESULTS

The number of pediatric patients diagnosed with enuresis nocturna was 956. Abnormal ultrasonography findings were observed in 13.9% of patients. Almost half of the patients had a positive family history, and 13.4% had a history of previous surgical procedures. While the voiding diary indicated that 54.2% of patients had bladder volumes equivalent to the expected bladder capacity, uroflowmetry examination revealed low bladder capacity in 65% of patients.

CONCLUSION

This study underscores the significance of comprehensive evaluations, including detailed ultrasonography and voiding diary measurements, in pediatric patients with monosymptomatic enuresis nocturna. Our study suggests that bladder volume measured through a two-day weekend voiding diary may provide more effective information for estimating optimal bladder capacity compared to measurements obtained through uroflowmetry.

Overview of clinical status, treatment, and long-term outcomes of pediatric autosomal-dominant polycystic kidney disease: a nationwide survey in Taiwan

This retrospective study investigated the incidence, medication use, and outcomes in pediatric autosomal-dominant polycystic kidney disease (ADPKD) using Taiwan's National Health Insurance Research Database (NHIRD). A 1:4 matched control group of individuals included in the NHIRD during the same period was used for comparative analyses. A total of 621 pediatric patients were identified from 2009 to 2019 (mean age, 9.51 ± 6.43 years), and ADPKD incidence ranged from 2.32 to 4.45 per 100,000 individuals (cumulative incidence, 1.26-1.57%). The incidence of newly developed hypertension, anti-hypertensive agent use, nephrolithiasis, and proteinuria were significantly higher in the ADPKD group than the non-ADPKD group (0.7 vs. 0.04, 2.26 vs. 0.30, 0.4 vs. 0.02, and 0.73 vs. 0.05 per 100 person-years, respectively). The adjusted hazard ratios for developing hypertension, proteinuria, nephrolithiasis and anti-hypertensive agent use in cases of newly-diagnosed pediatric ADPKD were 12.36 (95% CI 4.92-31.0), 13.49 (95% CI 5.23-34.79), 13.17 (95% CI 2.48-69.98), and 6.38 (95% CI 4.12-9.89), respectively. The incidence of congenital cardiac defects, hematuria, urinary tract infections, gastrointestinal diverticulosis, dyslipidemia, and hyperuricemia were also higher in the ADPKD group. Our study offers valuable insights into the epidemiology of pediatric ADPKD in Taiwan and could help in formulating guidelines for its appropriate management.

Constipation: A Pristine Universal Pediatric Health Delinquent

Constipation suffered by children is a global public health problem. Functional constipation (FC) brings about deteriorating effects in the children's lives who suffer from it. The risk factors for the development of constipation include the consumption of a diet low in fiber and high in calories (such as the consumption of fast food), a sedentary lifestyle with a lack of exercise, a family history of constipation, and emotional and psychological stress endured by children in their families. It is one of the most common causes of stomachaches in children. FC may lead to fecal incontinence (FI), anal fissures, recurrent urinary tract infections (RUTI), and enuresis in children. Severe constipation may result in stool becoming rock-hard and inflexible in the rectum, which is clinically identified as fecal impaction. It is imperative to perform clinical evaluation and treatment, including pharmacological (the use of stimulant and osmotic laxatives) and non-pharmacological (education, changes in diet, intervention to promote positive behavior and address any emotional issues, toilet training, and physiotherapy for the pelvic floor) interventions. In the case of refractory patients, neuromodulation, the irrigation of the anal canal, and surgical management may be needed. It is essential to lead a healthy, stress-free lifestyle with plenty of exercise and a balanced diet rich in fiber (such as fruits and vegetables) so children can have regular bowel habits and thrive.

Clinical observation on the efficacy of Tongdu Tuina manipulation in the treatment of primary enuresis in children

The objective was to explore the efficacy of Tongdu Tuina manipulation in the treatment of primary single-symptom enuresis in children. A total of 102 children aged 5-16 with primary single-symptom enuresis were included in this study and randomly assigned to the Tuina group, the medication group and the control group, with 34 children in each group. The Tongdu Tuina group included manipulation of the Guanyuan, Qihai, Zhongji, Mingmen, kidney, Baihui, Sishencong and bladder acupoints, five times a week, the medication group was treated with 0.1 mg desmopressin acetate every night, and in the control group, the patients were given foods with high water content and underwent water deprivation 2 h before bedtime every night. The intervention time of each group was 1 month. The participants were followed up on Day 1 following treatment, as well as half a month, 1 month and 3 months after the implementation of the intervention measures, and the effective rate, the incidence of enuresis per week and the recurrence rate were calculated. As a result baseline demographic characteristics were comparable among 102 patients. Overall, 32 patients in the Tongdu Tuina group, 30 patients in the medication group and 34 patients in the control group completed the intervention. After half a month of treatment, there was no significant difference in the therapeutic efficacy among the three groups (P = 0.158), but each treatment could effectively reduce the frequency of weekly enuresis. The frequency of weekly enuresis in the Tongdu Tuina group was 3.8 ± 1.1 times, while that in the medication group was 4.0 ± 2.0 times. The frequency of weekly enuresis in the control group was 4.7 ± 1.8 times, and the difference was statistically significant (P = 0.016). After 1 month of treatment, the effective rates of the Tongdu Tuina group and the medication group were significantly increased (87.5% vs 83.33%, P < 0.0001), which was not the case with the control group. The frequency of enuresis was 1.9 ± 2.1 times per week in the Tongdu Tuina group, 2.4 ± 1.8 times per week in the medication group and 4.0 ± 0.9 times per week in the control group after 1 month of treatment. The difference between the three groups was statistically significant (P = 0.021), and there was a difference between the Tongdu Tuina group and the medication group (P < 0.0001). There was no significant difference between recurrence rate and the incidence of adverse events (P = 0.837, P = 0.856). In conclusion, both Tuina manipulation and desmopressin treatment can effectively improve children's primary single-symptom enuresis with safety. However, Tongdu Tuina therapy may be superior to desmopressin treatment.

Association of early childhood constipation with the risk of autism spectrum disorder in Taiwan: Real-world evidence from a nationwide population-based cohort study

Background

Autism spectrum disorder (ASD) is a neurodevelopmental problem that presents with limited interests, repetitive behaviors, and deficits in reciprocal communication and social interactions. Mounting evidence indicates that an imbalanced gut microbiota contributes to autism via the gut-brain axis. Constipation may result in alteration of the gut microbiota. The clinical influence of constipation on ASD has not been fully researched. Thus, in this study we aimed to evaluate whether early childhood constipation influenced the risk of developing ASD using a nationwide population-based cohort study.

Methods

We identified 12,935 constipated children aged 3 years or younger from the National Health Insurance Research Database (NHIRD) in Taiwan from 1997 to 2013. Non-constipated children were also selected from the database and propensity score matching of age, gender, and underlying comorbidities was conducted with a ratio of 1:1. Kaplan-Meier analysis was applied to determine different levels of constipation severity and cumulative incidence of autism. Subgroup analysis was also applied in this study.

Results

The incidence rate of ASD was 12.36 per 100,000 person-months in the constipation group, which was higher than the rate of 7.84 per 100,000 person-months noted in the non-constipation controls. Constipated children had a significantly higher risk of autism when compared to the non-constipation group (crude relative risk = 1.458, 95% CI = 1.116-1.904; adjusted hazard ratio = 1.445, 95% CI = 1.095-1.907).Moreover, among constipated children, a higher number of laxative prescriptions, male gender, constipation during infancy, and atopic dermatitis were significantly associated with higher risks of ASD when compared to the non-constipation group.

Conclusion

Constipation in early childhood was correlated with a significantly increased risk of ASD. Clinicians should pay attention to the possibility of ASD in constipated children. Further research is necessary to study the possible pathophysiological mechanisms of this association.

Effectiveness of game-based core exercise in children with non-neuropathic bladder dysfunction and comparison to biofeedback therapy

OBJECTIVES

This study was planned to evaluate the effectiveness of game-based core exercises in children diagnosed with non-neuropathic bladder dysfunction and compare this effectiveness to that of the biofeedback treatment method.

METHODS

The study included 48 children, aged 6-13 years, who were diagnosed with non-neuropathic bladder dysfunction. The children satisfying the inclusion criteria were selected by drawing lots from the population with the method of nonprobability random sampling. The patients were divided into three groups: group I, "game-based core stabilization exercise training"; group II, "biofeedback program"; and group III, "game-based core stabilization exercise training in addition to the biofeedback program." The Dysfunctional Voiding and Incontinence Symptom Scale (DVISS) scores and uroflowmetry values of the patients were evaluated before and after the treatment.

RESULTS

The mean age of the participants was 8.81 ± 2.08 years. There was a statistically significant difference between the pretreatment and post-treatment DVISS scores in all three groups (p < .05). However, no significant difference was found among the groups. There was no statistically significant difference in the uroflowmetry results of the patients in group I and II before and after the treatment. In group III, the time to maximum flow rate after treatment was significantly reduced, and the average flow rate was significantly increased.

CONCLUSIONS

According to the results of this study, the use of game-based exercises along with biofeedback treatment may reduce DVISS scores in children with non-neuropathic bladder dysfunction. A combination of the two methods may have positively affected the uroflowmetry results of the patients. We think that game-based exercises will contribute to the literature as a new treatment option in the treatment of non-neuropathic bladder dysfunction.

Factors associated with response to simple behavioral intervention in primary enuresis nocturna

This 8-week longitudinal study examined predictors of response to simple behavioral intervention in primary enuresis nocturna (PEN). A total of 154 children, aged 8-18 years, diagnosed with PEN were evaluated. The results indicated that lack of constipation, milder enuresis severity, and higher bladder capacity are the primary predictors of good treatment response, and lower family dysfunction is the most robust familial predictor. Lack of constipation is the main predictor with unique variance in multiple regression. Specialists should be aware of conditions that hinder the success of simple behavioral intervention before implementing costly treatments. In treatment-refractory cases, it is important to examine each child for constipation. Family-centered approaches can be helpful if used in parallel with behavioral treatments.

Problems with enuresis management-A personal view

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.

The influence of constipation on asthma: A real-world, population-based cohort study

BACKGROUND

Among respiratory diseases, asthma is one of the most burdensome disorder worldwide. Growing evidence disclose gut dysbiosis may contribute to asthma via the gut-lung axis. Constipation can lead to alteration of the gut microflora. The clinical impact of constipation on asthma has not been researched. Therefore, we aim to assess the risk of asthma in constipated patients by a nationwide population-based cohort study.

METHODS

We analysed 86 860 constipated patients and 86 860 individuals without constipation between 1999 and 2013 from the Taiwanese National Health Insurance Research Database. Analysis of propensity score was utilised to match age, gender, comorbidities and medications at a ratio of 1:1. Besides, multiple Cox regression analysis was performed to evaluate the adjusted hazard ratio of asthma. Furthermore, sensitivity tests and stratified analysis were conducted.

RESULTS

The incidence of asthma was 10.4 per 1000 person-years in the constipation group, which was higher than the rate of 5.7 per 1000 person-years observed in the non-constipation group. After adjustment for age, gender, urbanisation, comorbidities and medications, constipated patients had a 1.81-fold greater risk of asthma compared with those without constipation (adjusted hazard ratio [aHR]: 1.81, 95% CI: 1.74-1.88). In subgroup analyses, patients aged 20-39 years had a 2.01-fold highest risk of asthma in the constipation cohort (aHR: 2.01, 95% CI: 1.82-2.22). Besides, the severity of constipation is associated with an increased risk of asthma; the aHR was 1.92 (1.84-2.00), 2.07 (1.94-2.21) and 2.10 (1.96-2.25) for ≤ 30 days, 31-120 days and >120 days of laxatives prescription within 1 year after the index date, respectively (P < .001).

CONCLUSION

Constipation relates to a significantly increased risk of asthma. Physicians should be aware of the possibility of asthma in constipated people. Further research is warranted to investigate the possible pathological mechanisms of this association.