Effectiveness of Intra-anal Biofeedback and Electrical Stimulation in the Treatment of Children With Refractory Monosymptomatic Nocturnal Enuresis: A Comparative Randomized Controlled Trial

Physiotherapy intervention on monosymptomatic nocturnal enuresis: a systematic review

INTRODUCTION

Monosymptomatic nocturnal enuresis is the most common voiding disorder and is associated with a decrease in the well-being and quality of life. Physiotherapy intervention has emerged as a second line treatment, and the treatment strategies that have been most commonly used to treat children and adolescents with monosymptomatic nocturnal enuresis are electrostimulation, magnetotherapy, biofeedback, behavioral therapy and pelvic floor muscle training. Establishing the efficacy of these physiotherapy strategies in children and adolescents up to 16 years is the aim of this Systematic Review.

EVIDENCE ACQUISITION

Research was conducted from December 2022 to November 2023 in five databases: PubMed, Web of Science, Academic Search Complete, CINAHL Plus, and PEDro and two independent reviewers assessed titles and abstracts and judged each article for eligibility. Ten randomized-controlled trials written in English remained for analysis. PRISMA guidelines were followed, and the protocol was registered in PROSPERO database.

EVIDENCE SYNTHESIS

Electrostimulation was the most studied therapeutic modality and the one that showed better results, with significant improvements on bladder volumes and wet nights frequency, especially when used in association with Behavioral Therapy, Biofeedback and Pelvic Floor Muscle Training. Magnetotherapy presented less evidence.

CONCLUSIONS

The obtained results demonstrated that physiotherapy treatment strategies may be of added value in clinical practice, as they were well tolerated, and provided a safe and effective contribution to second line treatment options for children and adolescents with refractory Monosymptomatic Nocturnal Enuresis to first line treatments.

Advancing clinical understanding of surface electromyography biofeedback: bridging research, teaching, and commercial applications

INTRODUCTION

Expanding the use of surface electromyography-biofeedback (EMG-BF) devices in different therapeutic settings highlights the gradually evolving role of visualizing muscle activity in the rehabilitation process. This review evaluates their concepts, uses, and trends, combining evidence-based research.

AREAS COVERED

This review dissects the anatomy of EMG-BF systems, emphasizing their transformative integration with machine-learning (ML) and deep-learning (DL) paradigms. Advances such as the application of sophisticated DL architectures for high-density EMG data interpretation, optimization techniques for heightened DL model performance, and the fusion of EMG with electroencephalogram (EEG) signals have been spotlighted for enhancing biomechanical analyses in rehabilitation. The literature survey also categorizes EMG-BF devices based on functionality and clinical usage, supported by insights from commercial sectors.

EXPERT OPINION

The current landscape of EMG-BF is rapidly evolving, chiefly propelled by innovations in artificial intelligence (AI). The incorporation of ML and DL into EMG-BF systems augments their accuracy, reliability, and scope, marking a leap in patient care. Despite challenges in model interpretability and signal noise, ongoing research promises to address these complexities, refining biofeedback modalities. The integration of AI not only predicts patient-specific recovery timelines but also tailors therapeutic interventions, heralding a new era of personalized medicine in rehabilitation and emotional detection.

The effect of biofeedback on nonneurological dysfunctional voiding in children: A meta-analysis and systematic review

OBJECTIVE

This study was conducted to investigate the effect of biofeedback (BF) on the rehabilitation of children with nonneurological dysfunctional voiding (NDV).

METHODS

RCTs were retrieved from various databases (published from inception to February 29, 2024). The effects of the BF and non-BF treatments were compared. A random-effects model was used to evaluate the combined data.

RESULTS

Meta-analysis revealed that BF increased the maximum urinary flow rate (SMD = 3.78, 95% CI 1.33∼6.22), improved urination time (SMD = 5.88, 95% CI 3.75∼8.01), and reduced the postvoid residual (SMD = -19.18, 95% CI -27.03∼-11.33) and urinary tract infection incidence (RR = 0.43, 95% CI 0.21∼0.87). Electromyogram activity (RR = 0.46, 95% CI 0.25∼0.84) and abnormal urination patterns (RR = 0.51, 95% CI 0.35∼0.74) improved, with effects persisting for more than 1 year. However, the effect of BF on the mean urinary flow rate in children with NDV was significant only after 1 year of follow-up (SMD = 1.90, 95% CI 0.87∼2.92).

CONCLUSION

Existing evidence indicates that BF can enhance urinary parameters and patterns in children with NDV. However, its effectiveness in addressing constipation, daytime urinary incontinence, and nocturnal urinary incontinence is not substantial. High-quality randomized controlled trials can offer additional insights.

Posterior tibial nerve stimulation versus desmopressin in treating children with primary mono-symptomatic nocturnal enuresis. A randomized clinical trial

Objective

Assessment of the efficacy of Posterior Tibial Nerve Stimulation (PTNS) versus Desmopressin in treating Primary Mono-symptomatic Nocturnal Enuresis (PMNE).

Patients and methods

This randomized clinical trial was conducted at the Urology department of Abo Elreesh pediatric hospital, Cairo University on 80 children, aged between 5 and 13 years old, diagnosed to have PMNE between June 2020 and November 2020. Children were divided into two equal groups; those who underwent PTNS (as one session per week for 12 weeks) (Group A) and those who received Desmopressin 0.2 mg. single evening dose for 12 weeks (Group B). Both groups were constructed to adhere to behavioral therapy and were statistically evaluated regarding the frequency of nocturnal enuresis (NE) before, after treatment, and after 1 month of follow-up.

Results

Both groups showed statistically significant improvement in the frequency of NE before and after treatment (p < 0.001), but there were no statistically significant differences between them (p = 0.763). There was a statistically significant relapse of NE frequency after 1 month of follow-up after completion of treatment in both groups (p < 0.001), with no statistically significant differences between the two groups (p = 0.075).

Conclusion

Posterior tibial nerve stimulation and Desmopressin are viable treatment options for children with primary mono-symptomatic nocturnal enuresis. However, relapse in some responders with time suggests the need for maintenance therapy.

Nocturnal Bladder Function and Sleep in the Children with Refractory Nocturnal Enuresis: A Prospective Study

OBJECTIVE

To prospectively investigate the nocturnal bladder function and sleep in children with refractory primary monosymptomatic nocturnal enuresis (RPMNE).

MATERIALS AND METHODS

Fifty-three children diagnosed with RPMNE and 30 controls who had upper urinary tract abnormality but without any voiding problems were included in the study. RPMNE patients underwent a standardized investigation protocol, including the Pittsburgh Sleep Quality Index (PSQI) questionnaire, a 7-day bladder diary, and the simultaneous ambulatory urodynamic monitoring and polysomnography (PSG); controls were evaluated using the PSQI questionnaire and PSG.

RESULTS

The children with RPMNE were subdivided into the nocturnal detrusor overactivity (NDO) case group and the non-NDO case group. The children in the NDO case group had a higher percentage of total sleep time in light sleep and a lower percentage in the N3 sleep stage than those in the non-NDO case group and control group (P <.05). The cortical arousal index and PSQI scores of both RPMNE subgroups were higher compared to the control group (P <.05). The incidences of reduced nocturnal bladder capacity (NBC) in the NDO case group were higher than in the non-NDO case group (P <.05). The frequency of involuntary detrusor contractions during sleep was positively correlated with cortical arousal index in the NDO case group (r = 0.811, P <.0001).

CONCLUSION

In addition to the reduced NBC, the RPMNE is related to abnormal NDO, increased light sleep period, and cortical arousal dysfunction. Moreover, there is a certain correlation between the abnormal degrees of NDO and cortical arousal dysfunction.

Electrical nerve stimulation therapy in refractory primary monosymtomatic enuresis - A sistematic review

OBJECTIVE

To analyze the effect of electrical nerve stimulation on urinary symptoms in pediatric patients with monosymptomatic primary enuresis refractory to conventional treatment.

METHODS

Three databases (Medline, Embase, and Cochrane) were searched and 160 studies were identified by July 15, 2020. After establishing and applying the inclusion and exclusion criteria, a step-by-step analysis was performed using the title, abstract and full text. The Cochrane Collaboration Tool was then used to analyze the biases of the selected studies.

RESULTS

Of the 160 articles found, 03 were selected for this systematic review. In 02 studies there was a significant reduction in the number of wet nights/week after electrical nerve stimulation. Urodynamic pattern was evaluated in 01 study, with improvement of maximum cystometric capacity in the intervention group. About maximum voided volume, there was no improvement in 01 study, but in other, there was increase in the intervention group.

CONCLUSION

Electrical nerve stimulation might promote improvement in partial and total response scores over the number of dry nights, with no improvement in urodynamic parameters, and could be considered as an feasible option in the management of refractory monosymptomatic primary enuresis. However, it is worth emphasizing the need to conduct more RCTs with a larger sample for better evaluation of the role of neurostimulation.

The efficacy of electrical stimulation in treating children with nocturnal enuresis: A systematic review and meta-analysis

AIM

We performed a systematic review and meta-analysis to evaluate the efficacy of electrical stimulation (ES) in treating children with nocturnal enuresis (NE).

METHODS

Randomized controlled trials (RCTs) of the use of ES for the treatment of NE in children were searched using EMBASE, MEDLINE, and the Cochrane Controlled Trials Register. The references of related articles were also searched. The systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-analyses.

RESULTS

Four RCTs involving 171 patients were studied. We found that there was statistically significant difference in the wet nights per week (mean difference [MD], -0.70; 95% confidence interval [CI], -0.89 to -0.51; P < .00001), the number of patients with clinical response (MD, 26.88; 95% CI, 11.16 to 64.74; P < .00001), and bladder capacity (MD, -0.70; 95% CI -0.89 to -0.51; P < .00001) in the ES group compared with the placebo group with the exception of maximum voided volume (MVV) (MD, 19.48; 95% CI, -9.18 to 48.14; P = .18).

CONCLUSIONS

The study provides a significant improvement in statistics in the wet nights per week, the number of patients with clinical response and bladder capacity for children with NE compared with the placebo group with the exception of MVV.