Time Course of Treatment for Primary Enuresis With Overactive Bladder

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.

The efficacy of standard urotherapy in the treatment of nocturnal enuresis in children: A systematic review

INTRODUCTION

Standard urotherapy in children with nocturnal enuresis (NE) is first-line treatment according to the current International Children's Continence Society (ICCS) guidelines. ICCS defines standard urotherapy as information and demystification, instruction in how to resolve lower urinary tract dysfunction, lifestyle advice, registration of symptoms and voiding habits, and support and encouragement. These interventions often are time consuming and some aspects of urotherapy, such as fluid restrictions, can be a frustrating process for a child, which emphasizes the importance of clarifying their relevance. The purpose of this review is to perform a systematic search in literature to evaluate the use of standard urotherapy in the treatment of children with primary NE (PNE).

STUDY DESIGN

A systematic literature search was conducted in MEDLINE, Embase, and CENTRAL based on the key concepts of standard urotherapy and NE. We identified 2,476 studies. After a systematic selection process using the Covidence tool, 39 studies were included. The quality of the studies was assessed by the QualSyst Checklist. Our protocol adheres to the PRISMA statement and was registered in PROSPERO database (CRD42020185611).

RESULTS

Most of the 39 included studies scored low in quality. All studies combined several urotherapy interventions and studied different study populations. Twenty-two randomized controlled trials (RCTs) were included, which reported 0-92% of children being dry after urotherapy treatment. Three RCTs, all individualizing and optimizing drinking and voiding during the day and practicing optimal toilet posture, scored higher in quality based on the QualSyst score, and reported few children experiencing complete resolution of NE (5-33%). Eight studies compared the efficacy of urotherapy to a control group, however, conflicting results were found.

DISCUSSION

This systematic review presents available literature in the field of standard urotherapy in the treatment of children with PNE. One possible explanation for low efficacy rates of urotherapy in NE is the large heterogeneity of the study populations and interventions. Additionally, the intervention period and the intensity of intervention can have an impact on the outcome.

CONCLUSION

The number of clinical studies on standard urotherapy in children with NE is limited and many of them are of poor quality. High quality research in a well-defined NE population is needed to establish the role of standard urotherapy in first-line treatment of children with NE or as an add-on to other first line treatments. We conclude that at present there is insufficient evidence for recommending standard urotherapy to children with PNE as a first line treatment modality.

The Importance of Understanding Parental Perception When Treating Primary Nocturnal Enuresis: A Topic Review and an Institutional Experience

Primary nocturnal enuresis (PNE) is a common childhood disorder that adversely affects a child’s mental well-being and social life. Our clinical experience showed parents and their child often have significantly different perspective of enuresis, and these differences can affect family dynamics, treatment approaches, and treatment success. Parents’ perception of PNE also influences the likelihood of seeking medical treatment, and we found parents of children with enuresis have markedly different beliefs regarding bedwetting than those of physicians. Because achieving remission for PNE requires parents and their child to actively participate in treatment, assessing their expectancy of success and their beliefs will allow clinicians to adjust treatment goals as necessary. When treating PNE, guidelines consistently recommend incorporating bed alarms as part of the therapy. However, through interviewing parents and treating their children, we found parents preferred medications or other behavioral strategies, such as limiting water intake, because of their convenience. Many parents would complain bed alarms woke them up instead of their child, and they would soon give up on bed alarms. Part of assessing their beliefs includes assessing their confidence in their child being able to wake up to alarms and to persist with treatment. Understanding how they manage and approach setbacks will also determine the treatment modality suited for their child. In this review paper, we detailed our experiences interviewing parents and treating their child with NE with urodynamics and medications at the Changhua Christian Hospital in Taiwan.

Analysis of measurement electrode location in bladder urine monitoring using electrical impedance

Purpose

The aim of this study was to document more appropriate electrode location of a four-electrode-based electrical impedance technology in the monitoring of bladder filling, and to characterize the relationship between bladder filling duration and the measured electrical impedances.

Methods

A simulation study, based on a 2-dimension computational model, was conducted to determine the preferable locations of excitation and measurement electrodes in a conventional four-electrode setup. A human observation study was subsequently performed on eight healthy volunteers during natural bladder urine accumulation to validate the result of the simulation study. The correlation between the bladder filling time and the measured electrical impedance values was evaluated.

Results

The preferable location of measurement electrodes was successively validated by the model simulation study and human observation study. Result obtained via the selected electrodes location revealed a significant negative correlation (R = 0.916 ± 0.059, P < 0.001) between the measured electrical impedance and the urine accumulation time, which was consistent with the result of simulation study.

Conclusions

The findings in this study not only documented the desirable electrodes location to monitor the process of bladder urine accumulation using four-electrode measurement, but also validated the feasibility of utilizing electrical impedance technique to monitor and estimate the bladder urine volume for those with urological disorders.