Not only enuresis: do not disregard organic disorders

Nocturnal enuresis (NE) is a common condition in the pediatric age. NE is defined as an intermittent bedwetting with any frequency while sleeping in children. NE is classified into primary form (patient never had achieved nocturnal urinary control) or secondary form (children with a period of 6 consecutive months of night-time urinary control before incontinence, which is generally associated with organic or psychological causes). Moreover, NE could be monosymptomatic (MNE) or non-monosymptomatic (NMNE), depending on the presence of daytime incontinence or any other lower urinary tract symptoms (LUTS). We report a 7-year- old female with a history of recent onset of sphincter troubles and recurrent low urinary tract infections. She presented urinary urgency associated to daytime incontinence, bedwetting almost every night in the previous 3 months and sometimes encopresis. The physical and neurological examination was silent, no psychological or social problem intercurred. As first approach, she was treated with deamino-delta-D-arginine vasopressin (dDAVP) 120 mcg associated with oxybutynin 5 mg and educational therapy, for 3 months without benefits. So, she underwent a magnetic resonance imaging (MRI) of the spinal cord, that highlighted the presence of hydrosyringomyelia from D6 to D10, lipoma of the terminal filum and the presence of synovial cyst between L5-S1. This case remarks that in secondary NMNE, any possible organic cause must be investigated.

Treating asthma in patients with enuresis: repercussions on urinary symptoms

BACKGROUND

Children presenting enuresis are more likely to be asthmatics. The association between enuresis and sleep-disordered breathing has already been demonstrated and several studies have shown at least partial improvement of two thirds or more of the cases of enuresis adenoidectomy. Studies have already described associations between enuresis and allergies but do not assess the repercussions of allergy treatment in enuretics.

OBJECTIVE

This study aims to evaluated whether asthma treatment alters the course of enuresis and whether there is any predictive factor associated with this improvement.

MATERIALS AND METHODS

Twenty patients (5 - 12 years old) with uncontrolled enuresis and asthma, received treatment for asthma. Children were also assessed for the presence of rhinitis and other allergies. The control of asthma was confirmed by a validated questionnaire and primary enuresis by clinical history and wet night diaries. Patients received only asthma treatment.

RESULTS

At least partial improvement of enuresis was observed in 55% of the patients with an increase in 64.4% in the number of dry nights at the end of the study (p=0.01). The "presence of other allergies" and "obstruction seen in nasal endoscopy" positively influenced the improvement of urinary symptoms (OR = 3.350; CI 0.844-13.306) and (OR=1.272; CI 0.480-3.370), respectively.

DISCUSSION

Until now, only patients presenting upper airway obstruction were known to benefit from the improvement of urinary symptoms when undergoing treatment for their respiratory problems. In our study, we found at least partial improvement in enuresis in 55% of our patients, with only clinical asthma treatment.

CONCLUSION

Controlling asthma in children with primary enuresis resulted in a significant increase in dry nights.

[Evaluation of bladder function and sleep patterns in children with primary mono-symptomatic nocturnal enuresis by polysomnography combined with ambulatory urodynamic monitoring]

Objective: To evaluate the bladder function and sleep pattern in the children with primary mono-symptomatic nocturnal enuresis (PMNE) by the polysomnography (PSG) and ambulatory urodynamic monitoring (AUM). Methods: From October 2019 to October 2021, forty-three patients with PMNE were selected as PMNE group from the First Affiliated Hospital of Zhengzhou University and further subdivided into the severe PMNE group (enuresis>4 times/week) and the non-severe PMNE group (enuresis times 4 times/week) according to the severity. The conventional urodynamics (CUD), AUM, and PSG examinations and bladder diary were completed in the PMNE group. The control group consisted of 23 children with normal PSG findings and without the lower urinary tract symptoms. Results: The severe PMNE group included 9 males and 14 females, aged(12.1±3.2)years, and nocturnal enuresis number per week is 6.7±1.7. The non-severe PMNE group included 9 males and 11 females, aged(12.0±3.4)years, and nocturnal enuresis number per week is 2.3±1.0. The incidences of nocturnal polyuria and the reduction in maximum bladder capacity in the PMNE group was 34.9% and 11.6%, respectively. The incidence and frequency of detrusor overactivity (DO) in the severe PMNE group were significantly higher than those in the non-severe PMNE group [78.3% vs 45.0%, (5.5±1.8) times/h vs (3.4±1.0) times/h, respectively, all P<0.05]. It was found by the PSG that the severe PMNE group had significantly higher cortical arousal index, apnea hypopnea index (AHI), and percentage of N1+N2 phase in total sleep time, compared with the control group[(58.6±9.8)% vs (49.3±9.5)%, (9.4±4.4) times/h vs (3.1±1.5) times/h, (2.7±0.9) times/h vs (0.9±0.7) times/h] (all P<0.05). While the sleep efficiency of the severe PMNE group was substantially lower than that of the non-severe PMNE group [(86.4±4.3)% vs (91.0±3.9)%], the cortical arousal index and AHI were significantly greater than those of the non-severe PMNE group[(9.4±4.4) times/h vs (5.7±3.2) times/h, (2.7±0.9) times/h vs (1.9±0.7) times/h] (all P<0.05). In the PMNE group, there were positive correlations between cortical arousal index and nocturnal DO frequency or AHI (r=0.705, 0.765, P=0.001). Conclusions: Children with PMNE have nocturnal bladder dysfunction and abnormal sleep pattern, and there is a certain correlation between them. PSG and AUM are necessary for the evaluation and treatment of children with PMNE.

Enuresis and Hyperfiltration in Children With Sickle Cell Disease

Nocturnal enuresis is a common symptom in children with sickle cell disease (SCD). Risk factors for development of enuresis are currently unknown. An early manifestation of SCD-associated kidney damage is glomerular hyperfiltration. We test the hypothesis that in a pediatric SCD cohort, individuals with hyperfiltration are more likely to have nocturnal enuresis when compared to children without hyperfiltration. To assess the relationship between nocturnal enuresis and hyperfiltration, we retrospectively evaluated children with SCD enrolled in the Evaluation of Nocturnal Enuresis and Barriers to Treatment among Pediatric Patients with SCD study and prospectively identified children who reported nocturnal enuresis and were enrolled in the longitudinal cohort study Sickle Cell Clinical Research and Intervention Program. Nocturnal enuresis occurred in 46.5% of Pediatric Patients with Sickle Cell Disease participants and was more frequent in participants with HbSS/HbSβ 0 thalassemia and in male participants. We did not identify an association between hyperfiltration from 3 to 5 years of age with the later development of enuresis. Severe SCD genotypes and male sex were associated with nocturnal enuresis after age 5 years. We could not identify additional renal or hematologic predictors associated with the diagnosis of nocturnal enuresis. Future studies should incorporate nonrenal risk factors into studies that predict development of enuresis.

A Case of Nocturnal Enuresis Associated with Attention-deficit/hyperactivity Disorder Successfully Treated with Guanfacine Monotherapy

Nocturnal enuresis (NE) is a syndrome associated with abnormal nocturnal urine production, urination mechanism, and sleep arousal. NE is strongly associated with attention-deficit/hyperactivity disorder (ADHD), and it has been reported that NE occurs in approximately 30% of children with ADHD. There have been several reports on the efficacy of atomoxetine as treatment for NE with ADHD, while the efficacy of guanfacine is still limited. We report our experience of treating an 10-year-old girl with NE with ADHD with a single dose of guanfacine. The patient first visited our hospital because of difficulty concentrating, restlessness at home and school, and nocturnal incontinence. She was diagnosed with NE with ADHD based on a review of her personal history from her mother. Her NE symptoms improved with guanfacine monotherapy (1 mg/day. The patient weighed 28 kg).

A case of central diabetes insipidus due to neurophysin II gene abnormality diagnosed based on a family history of nocturnal enuresis

The etiology of central diabetes insipidus (DI) is classified into (1) idiopathic, (2) familial, and (3) secondary. Of these, familial central diabetes insipidus shows an autosomal dominant inheritance. We herein report a case in which this disease was diagnosed based on a family history of nocturnal enuresis. A 40-year-old man had had symptoms of polydipsia, polyuria and nocturia since childhood and found that his daughter had the same symptoms. Despite reaching nine years old, his daughter's nocturnal enuresis still had not improved, resulting in her consulting a pediatrician. She was suspected of having familial neurohypophyseal diabetes insipidus (FNDI) based on her family history and was referred along with her father for a detailed examination and treatment. A hypertonic saline load test (HSLT) to evaluate the arginine vasopressin (AVP) reaction was performed in both the proband and his daughter. The results showed no increase in AVP levels in response to high plasma osmolality. The water deprivation test (WDT) revealed he was suffering from partial DI. Based on the above findings and considering the possibility of familial central diabetes insipidus, we performed a gene mutation analysis of AVP-neurophysin II (NPII). Both the father and daughter had an exon 2 abnormality in this gene (c232_234delGAG; pGlu78del), and this gene mutation is known to cause NPII protein abnormality, abolishing the function of AVP as a carrier protein. This case was considered to have provided an opportunity to understand the role of an NPII gene abnormality in familial central diabetes insipidus.

[13-YEAR-OLD GIRL WITH PHEOCHROMOCYTOMA PRESENTING WITH SECONDARY NOCTURNAL ENURESIS]

Pheochromocytoma is a rare, catecholamine secreting tumor arising from chromaffin cells of the adrenal medulla and it is responsible for 0.5-2% of pediatric hypertension cases. We hereby present a case of a 13-year-old girl with obesity, excessive hypertension, prediabetes and secondary nocturnal enuresis, who was eventually diagnosed with pheochromocytoma. Most symptoms significantly improved after treating the tumor. We suggest that this diagnosis should be considered in pediatric patients presenting with similar symptoms.

Enuresis Management in the Primary Care Pediatrics Clinic

Enuresis is a frequent complaint not always volunteered by parents or patients. The pediatric clinician has to inquire about enuresis to break the secrecy surrounding this symptom that could be related to a more serious underlying renal, endocrine, or psychosocial disease. Determining the type of enuresis is crucial to offer optimal treatment. We present a review for the pediatric clinician to optimize their care of the child with monosymptomatic enuresis. [Pediatr Ann. 2018;47(10):e390-e395.].

Obstructive Sleep Apnea in Children with Nocturnal Enuresis

There is increasing evidence on the association of monosymptomatic nocturnal enuresis (MNE) with obstructive sleep apnea. In this communication, we share our experience of four patients with Primary monosymptomatic nocturnal enuresis (PMNE) with positive Sleep-related breathing disorder (SRBD) score who underwent detailed polysomnography, and were either refractory to desmopressin treatment or relapsed on discontinuation of desmopressin.

An adolescent boy progressing insidiously to end-stage renal disease: Questions

Hinman syndrome (HS), or non-neurogenic neurogenic bladder, is a voiding dysfunction of the bladder of neuropsychological origin that is characterized by functional bladder outlet obstruction in the absence of neurologic deficits. The bladder-sphincter discoordination causes damage to the bladder and upper urinary tract if it is not timely diagnosed and adequately treated. This case emphasizes the following important message; nighttime wetting is not a benign condition in every child. Parental awareness should be raised about voiding disorders, so it may be possible to prevent some important renal diseases such as Hinman syndrome.

Detailed assessment of incontinence in boys with fragile-X-syndrome in a home setting

Fragile-X-syndrome (FXS) is caused by a mutation on the X chromosome (Xq27.3). Males with a full mutation have typical dysmorphic signs, moderate intellectual disability and psychological disorders. Twenty-five to fifty percent are affected by incontinence. The aim of the study was to assess subtypes of incontinence and psychological problems in children with FXS in their home environments. Twenty-two boys with FXS (mean age 11.0 years) and 22 healthy controls (mean age 11.1 years) were examined with sonography, uroflowmetry, 48-h bladder diary, physical examination, IQ test, parental psychiatric interview and questionnaires regarding incontinence and psychological symptoms in a home setting. Boys with FXS had higher rates of incontinence than controls (59.1 vs. 4.8 %). The most common subtypes in FXS boys were primary non-monosymptomatic nocturnal enuresis, urge incontinence and nonretentive faecal incontinence. 90.9 % boys with FXS had a psychological comorbidity. Incontinence and behavioural symptoms were not associated.

CONCLUSION

Boys with FXS have a higher risk for physical disabilities, psychological disorders and incontinence than healthy boys. Constipation is not a major problem in FXS. As effective treatment is available for children with ID, we recommend offering assessment and therapy to all children with FXS and incontinence.

WHAT IS KNOWN

• Boys with fragile-X-syndrome (FXS) have higher rates of incontinence, psychological disorders and somatic conditions than typically developing boys. What is New: • Constipation is a rare condition in FXS in contrast to other genetic syndromes. • Although incontinence rates are higher, urological findings (uroflowmetry, sonography) are not more pathological per se in FXS.

Urodynamic disorders and renal scarring in pediatric patients with nonmonosymptomatic nocturnal enuresis

BACKGROUND/AIM

In nonmonosymptomatic nocturnal enuresis (NMNE), the incidence of organic abnormality and urodynamic disorder is more frequent than the general population. The aim of this study is to identify urodynamic disorders and renal scarring in children with NMNE.

MATERIALS AND METHODS

This study evaluated the urodynamic disorders and renal scarring of a total of 30 patients who were diagnosed with NMNE. A video-urodynamic test and Tc-99m dimercaptosuccinic acid renal scintigraphy were applied.

RESULTS

Records of 605 patients who had been diagnosed with enuresis were analyzed, and 215 (33.5%) of them had been diagnosed with NMNE. Thirty patients older than 6 years old with NMNE were included in the study. Detrusor overactivity was identified in 10 patients. Bladder capacity was low in 5 patients and bladder compliance was low in 2 patients. Renal scarring was identified in 1 patient. Unilateral vesicoureteral reflux was found in 4 patients.

CONCLUSION

Bladder function disorder is also a significant risk factor for the development of renal scarring, besides other risk factors. Organic abnormalities are seen more often in patients with NMNE than patients with monosymptomatic nocturnal enuresis, so urodynamic studies should be remembered for patients with NMNE.

Nocturnal enuresis and nocturia, differences and similarities - lessons to learn?

This review highlights the current views on and differences and similarities between nocturnal enuresis (NE) in children and nocturia in adults, which might be a guidance to elucidate the missing links in our knowledge. In both conditions, a genetic factor is suspected. Reduced bladder capacity and nocturnal polyuria are the main underlying lower urinary tract-related conditions. There is a link with sleep disorders, although it is not clear whether this is a cause or consequence. Physical and mental health are comprised in both conditions, however, in different ways. In NE, constipation and attention deficit disorder are the most important comorbidities and the effect on mental health and quality of life is mainly through the negative impact on self-esteem. In nocturia, cardiovascular disease and fall injuries are important comorbidities, mainly affecting the older nocturia population; personal distress and depression are consequences of the related poor sleep quality. For both conditions, treatment is often inadequate and a more individualized approach seems to be necessary. The main difference between NE and nocturia seems to be the difference in arousal to bladder stimuli, suggesting that sleep characteristics might be a key factor in these conditions.

[Etiology and own experience in the primary monosymptomatic nocturnal enuresis in children]

Primary monosymptomatic nocturnal enuresis (PMNE) is the most frequent (85%) type of enuresis in children. It remains a diagnostic and therapeutic challenge to establish its etiology and implement a proper treatment.

AIM

The aim of the study was to establish the causes of PMNE in children on the basis of own investigations and assess factors having influence over PMNE etiology, which would enable the choice of effective therapy.

MATERIALS AND METHODS

The study concerned 85 children with PMNE aged from 5 to 15 years. The patients were under the care of Nephrology Outpatient Clinic at Institute of Mather and Child in years 2009-2014. The detailed medical history, physical examination as well as laboratory investigations of blood and urine, and radiological investigations of the urinary tract, were carried out. Statistical analysis was performed using R software.

RESULTS

In all patients, we have successfully detected the etiology of children of PMNE. The basic, equally frequent (62.3%), PMNE etiopathogenetic factors turned to be: too small bladder capacity resulting from the detrusor hyperactivity, and night polyuria mainly caused by vasopressin deficiency or abnormal eating and hygienic habits, occurring separately or in conjunction with each other. Too small bladder capacity occurred mainly (37.6%, group C) as the only etiological factor of PMNE, and in 24.7% (group A) in a conjunction with nocturnal polyuria due to decreased excretion of vasopressin. Night polyuria was caused by the deficiency of vasopressin in most cases (37.6%) and occurred mainly (24.7%, group D) in a conjunction with small bladder capacity, and rarely alone (12.9%, group B). In 24.7% (group A) it appeared due to eating and hygienic abnormal habits. We have proved statistically significant differences in mean voiding frequency and volume (p<0.0001) between groups A-B and C-D. Mean morning urine specific gravity (p<0.0001) also differed significantly between group C and B (p<0.0001) as well as C and D (p=0.0004).

CONCLUSIONS

PMNE in all patients was attributed to specific causes outside the circle of psychological disorders what reduced patient stigmatization. PMNE etiology is very complex and diverse. It still remains a challenge and requires and individual diagnostic and therapeutic approach. Voiding frequency above 8 daily with voiding volumes usually below 100 ml suggest etiology connected with small bladder capacity, while morning urine specific gravities below 1.021 g/ml can be connected with vasopressin deficiency or excessive fluid intake before the bedtime. The developed diagnostic approach along with borderline values are hints that can aid physicians in establishing PMNE causes.

Secondary nocturnal enuresis related to central diabetes insipidus as an early manifestation of intracranial germinomatous germ cell tumors in a series of male youngsters

Nocturnal enuresis is a common symptom in children. It is usually attributed to benign causes and diagnostic evaluation is not carried out. We report three male young patients initially presenting with short stature and nocturnal enuresis, related to diabetes insipidus, caused by intracranial germinomatous germ cell tumors. In all three cases, water deprivation tests confirmed diabetes insipidus. Extensive endocrinological investigation also showed further hormone deficiencies. Magnetic resonance imaging of the brain revealed the presence of a central nervous system lesion and histology confirmed the final diagnosis. Surgery, radiation with or without chemotherapy was conducted and the patients were treated with hormone replacement therapies. The patients after a long follow-up were free of disease. We present these cases to alert clinicians to bear in mind that the presence of an intracranial germinomatous germ cell tumor should at least be considered in a child presenting with bed wetting, especially if additional symptoms and signs, including late onset puberty and growth delay or morning hypernatremia, may coexist.

Enuresis in children: a case based approach

Enuresis is defined as intermittent urinary incontinence during sleep in a child at least five years of age. Approximately 5% to 10% of all seven-year-olds have enuresis, and an estimated 5 to 7 million children in the United States have enuresis. The pathophysiology of primary nocturnal enuresis involves the inability to awaken from sleep in response to a full bladder, coupled with excessive nighttime urine production or a decreased functional capacity of the bladder. Initial evaluation should include a history, physical examination, and urinalysis. Several conditions, such as constipation, obstructive sleep apnea, diabetes mellitus, diabetes insipidus, chronic kidney disease, and psychiatric disorders, are associated with enuresis. If identified, these conditions should be evaluated and treated. Treatment of primary monosymptomatic enuresis (i.e., the only symptom is nocturnal bed-wetting in a child who has never been dry) begins with counseling the child and parents on effective behavioral modifications. First-line treatments for enuresis include bed alarm therapy and desmopressin. The choice of therapy is based on the child's age and nighttime voiding patterns, and the desires of the child and family. Referral to a pediatric urologist is indicated for children with primary enuresis refractory to standard and combination therapies, and for children with some secondary causes of enuresis, including urinary tract malformations, recurrent urinary tract infections, or neurologic disorders.

[Etiology primary, monosymptomatic nocturnal enuresis in children. Own research]

INTRODUCTION

Primary monosymptomatic nocturnal enuresis is the most frequent (85%) type of enuresis in children. Establishing its causes enables the choice of effective therapy.

AIM

To establish the causes of primary, monosymptomatic nocturnal enuresis in children on the basis of own investigations.

MATERIAL AND METHODS

The study concerned 47 children (36 boys and 21 girls) with primary, monosymptomatic nocturnal enuresis aged from 5 years 5 months to 15.5 years. The patients were under the care of Nephrological Outpatient Clinic at the Institute of Mother and Child in the years 2009-2013. The detailed medical history, physical examination as well as laboratory investigations of blood and urine and radiological investigations of the urinary tract, were carried out.

RESULTS

The most frequent causes of nocturnal enuresis in the studied groups was destructor over-activity (55,3%). Other causes were: nocturnal polyuria (21,3%) and destructor overactivity together with polyuria (12,8%). In a lower percentile (10,6%) the causes of nocturnal enuresis were incorrect habits concerning drinking, time and amount of fluids taken before sleep and the lack of habits to pass urine before sleep.

CONCLUSIONS

1. Primary monosymptomatic nocturnal enuresis is a significant underestimated problem. 2. Etiology of nocturnal enuresis in the developmental period has heterogenous origin and requires individual diagnostic and therapeutic approach. 3. Obtained results of investigations conclude that primary monosymtomatic nocturnal enuresis is conditioned by concrete organic and not mental causes as is quite often suggested, and in this way stigmatizing the population in which this disorder is found.

Differentiation of subgroups of monosymptomatic enuresis according to prepulse inhibition of the startle reflex

AIM

Monosymptomatic enuresis (ME) is a common disorder in children with serious social and psychological consequences. Treatment is usually initiated with desamino-arginine vasopressin (dDAVP) and/or alarm therapy as first-line treatment and imipramine as second-line. All treatments have proven efficacy, but are not successful with all patients. Therefore, a differentiation into subgroups according to treatment efficacy would be beneficial.

METHODS

A group of patients resistant to first-line treatment was treated with imipramine and compared with matched controls successfully treated with dDAVP and/or alarm therapy. Prepulse inhibition (PPI) to acoustic startle reflexes was measured in all patients.

RESULTS

In a group of 23 nonresponders, the median PPI was 72% (range 43-94%) compared with the matched dDAVP/alarm - responders with a median PPI of 26% (range 0-61%) (p < 0.0001). The response rate to imipramine was 87%.

CONCLUSION

The presented data provide evidence that PPI allows to identify two subgroups of ME. The results offer further insight into (at least) two different pathomechanisms involved in ME: (i) a maturational delay of reflex inhibition with reduced PPI and (ii) a normal PPI, possibly with abnormal sleep patterns, that can be influenced by imipramine.

Sickle cell Nephropathy in children seen in an African Hospital - Case Report

AIMS AND OBJECTIVES

To determine and report the occurrence of overt renal presentations in children with sickle cell disease seen over the last 14 years (1995-2009) at the Emergency Paediatric Unit and Paediatric Ward and followed up at the Paediatric Nephrology clinic of University of Ilorin Teaching Hospital, Ilorin (UITH).

PATIENTS AND METHODS

The five cases with overt renal presentations seen during the period were reported and analyzed for age, sex, and renal manifestations.

RESULTS

The age range of the children was 9-15years with a mean of 11years. Four of the five patients were females, with one male. Three of the four females presented with features suggestive of nephrotic syndrome (NS) while the other one had gross haematuria which resolved within 24 hours. The only male had enuresis. The NS in one of the patients progressed to end stage renal disease requiring renal replacement therapy.

CONCLUSION

Children with sickle cell disease should be screened for renal complications especially from the late first decade of life. This will help in the early detection of renal disorder that could lead to chronic kidney disease. It is also suspected that the severe forms of SCN such as NS may have a predilection for the female gender. A more extensive study is needed to test the veracity of this observation.

Psychological correlates of enuresis: a case-control study on an Italian sample

The psychological correlates of enuresis are receiving growing attention, coherently with a multi-factorial approach to this problem, but to date the empirical findings are still inconsistent and incomplete. The aim of this study is to contribute to the understanding of the socio-affective functioning of enuretic children by exploring four central dimensions: attachment, self-esteem, self-control, and temperament. Twenty-two enuretic children with their mothers were enrolled in the study and matched, based on gender and age, to a control group of continent healthy children. Measures were collected through mothers' reports and individual administrations to all children. Controlling for socio-demographic variables, we found a significantly lower incidence of secure attachment, lower self-esteem, and higher rates of behavioral problems among the enuretic group, compared with the control group. No differences in the temperamental dimensions were found. These preliminary findings support the view of enuresis as a bio-behavioral problem and, from a practical standpoint, underline the urgency for physicians not to underestimate this disturbance, but, indeed, to treat the problem through medical strategies and to devote attention to the psychological difficulties of these patients.

Urinary incontinence in children

BACKGROUND

Urinary incontinence (bedwetting, enuresis) is the commonest urinary symptom in children and adolescents and can lead to major distress for the affected children and their parents. Physiological and non-physiological types of urinary incontinence are sometimes hard to tell apart in this age group.

METHODS

This article is based on selected literature retrieved by a PubMed search and on an interdisciplinary expert consensus.

RESULTS AND CONCLUSION

Nocturnal enuresis has a variety of causes. The main causative factors in monosymptomatic enuresis nocturna (MEN) are an impaired ability to wake up when the bladder is full, due to impaired or absent perception of fullness during sleep, and an imbalance between bladder capacity and nocturnal urine production. On the other hand, non-monosymptomatic enuresis nocturna (non-MEN) is usually traceable to bladder dysfunction, which is also the main cause of diurnal incontinence. A basic battery of non-invasive diagnostic tests usually suffices to determine which type of incontinence is present. Further and more specific testing is indicated if an organic cause is suspected or if the treatment fails. The mainstay of treatment is urotherapy (all non-surgical and non-pharmacological therapeutic modalities). Some patients, however, will need supportive medication in addition. Urinary incontinence has different causes in children and adults and must therefore be diagnosed and treated differently as well. All physicians who treat the affected children (not just pediatricians and family doctors, but also pediatric nephrologists, urologists, pediatric surgeons, and child psychiatrists) must be aware of the specific features of urinary incontinence in childhood.

Nocturnal enuresis in adolescents with anorexia nervosa: prevalence, potential causes, and pathophysiology

OBJECTIVE

The aim of this study was to determine the prevalence and potential causes of secondary nocturnal enuresis (NE) in adolescents with anorexia nervosa (AN).

METHOD

Adolescents with AN completed the Incontinence Symptom Index-Pediatric (ISI-P), a self-report urinary incontinence survey. Those who had NE associated with the onset of AN on the ISI-P completed a comprehensive clinical and laboratory evaluation, including urinary flow measurements.

RESULTS

The prevalence of NE in adolescents with AN was 17.0% (10 of 59). The overall frequency of day- and night-time urinary incontinence symptoms in adolescents with AN was 62.7%; urgency incontinence, 57.6%; stress incontinence, 32.2%; and insensate incontinence, 17.0%. Nine of the 10 adolescents with NE had secondary NE and confirmed that bedwetting ceased after weight restoration.

DISCUSSION

Decreased functional bladder capacity and detrusor instability may contribute to the NE observed in this population. The high prevalence of NE in adolescents with AN warrants further study to determine the potential causative pathways. Clinicians who work with adolescents with AN should assess for this problem.

Epidemiology of nocturnal enuresis in basic schoolchildren in Aden Governorate, Yemen

Nocturnal enuresis is a common problem among children and adolescents. Data regarding this problem in schoolchildren in Yemen are scarce. This study was aimed to determine the prevalence of nocturnal incontinence in Aden school going children, describe its severity and identify the relation between nocturnal enuresis with personal and family characteristics. The study was a cross-sectional survey conducted on the public basic schoolchildren in Aden, Yemen, in the period November 2007-April 2009. A random, multistage sample of 890 students was taken from four districts in eight schools and divided into two strata: males and females. Data were obtained by using pre-recorded questionnaire, which was completed by parents. The response rate was 73.7% (656 students); 113 (17.2%) cases of nocturnal enuresis were encountered. Nocturnal enuresis decreased by age from 31.5% at 6-8 years to 8.7% at 15+ years (P < 0.05). Primary nocturnal enuresis affected 76.1%, of which the majority of children were bedwetting every night. Positive family history of nocturnal enuresis, deeper sleep, daytime enuresis, tea drinking, being non working father or with less education showed significant association with the occurrence of enuresis in the students. Stressful events in the previous 6 months of the study were twice more frequently noted. The study concluded that the prevalence of nocturnal enuresis in Aden public school children and its associated factors are almost comparable with that reported in epidemiological studies from various countries. Health education will encourage the parents to be aware, cope with this problem and seek appropriate medical advice.

An alarming solution: Bedwetting, medicine, and behavioral conditioning in mid-twentieth-century America

This article explores the history of the bedwetting alarm, invented in 1938 by two psychologists to cure enuresis, or bedwetting, using the principles of classical conditioning. Infused with the optimism of behaviorism, the bedwetting alarm unexpectedly proved difficult to implement in practice, bearing a multitude of unanticipated complications that hindered its widespread acceptance. Introduced as a medical and psychological technology, in practice the alarm was also a child-rearing device, encouraging the kind of behavioristic attitudes that had prompted its initial development, while simultaneously promoting the child-centered approach that would become dominant in the early 1950s. The life story of the bedwetting alarm muddies the traditional account of how childrearing theories progressed in tidy succession, suggesting both that behavioristic approaches did not die out in the 1930s and that elements of permissive child-rearing were being considered earlier than we traditionally assume.

[Comparative study on sensory integration function in children with primary nocturnal enuresis]

OBJECTIVE

To study the sensory integration function in children with primary nocturnal enuresis (PNE).

METHODS

The sensory integration function was assessed by the Childhood Sensory Integration Ability Development Checklist in 70 children with PNE and was compared with that in 74 normal children(control group).

RESULTS

The incidence of sensory integration dysfunction (76%) in the PNE group were significantly higher than that in the control group (35%; P<0.01). Severe sensory integration dysfunction occurred in more children in the PNE group compared with the control group (39% vs 18%; P<0.01). The scores of all sensory integration indexes revealed by sensory integration function testing in the PNE group were significantly lower than those in the control group (P<0.01).

CONCLUSIONS

The majority of children with PNE have sensory integrative dysfunction which presents in various aspects. It is necessary to assess the sensory integration function in children with PNE.

[Comparison of therapeutic effects in severe nocturia: gradual versus immediate drug withdrawal]

OBJECTIVE

To investigate possible differences in the prognosis in children with severe nocturia who received different drug withdrawal schedules.

METHODS

Ninety-seven children with severe nocturia were randomly assigned to two groups: control (n=47) and observed (n=50). The control group accepted drug withdrawal immediately, while the observed group accepted dose tapering gradually after a 12-week treatment course. The frequency of enuresis was observed three months after complete drug withdrawal.

RESULTS

During the treatment, the frequency of enuresis in all of children from both the control and the observed groups was reduced by over 90%. Forty-six children (92%) from the observed group showed the frequency of enuresis was reduced by over 90%, but 28 children (60%) from the control group (p<0.01) three months after the complete drug withdrawal. There were no significant differences in the adverse effect and the medication compliance between the two groups.

CONCLUSIONS

The different schedules of drug withdrawal may lead to different prognosis, and the schedule of gradual drug withdrawal may be superior to the immediate one in children with nocturnal enuresis.

[Optimization of enuresis therapy in children using transcranial magnetotherapy]

A total of 58 children (age from 6 to 14 years) suffering from nocturnal enuresis (NE) were divided into two groups. The study group received basic therapy (driptan dose was reduced to 2.5 mg twice a day) in combination with transcranial bitemporal magnetotherapy (TcMT). The control group received placebo TcMT and basic therapy. It is shown that addition of TcMT to reduced basic therapy lowered the score of imperative voiding symptoms 1.3-fold, number of enuresis patients 1.7-fold, volume of the bladder 6.8 months after the treatment 1.9-fold, corrected vegetative status and activity of the subcortical nervous center in 24% children according to cardiointervalography versus the controls. Thus, TcMT improves clinical effect in NE patients in 2-fold reduction of pharmacological burden.

Enuresis in hyperthyroidism: a temporary lack of central control mechanism leads to nocturnal enuresis

We report on a 9-year-old boy who suffered from hyperthyroidism and a new appearance of enuresis. Bedwetting ceased and prepulse inhibition (PPI) - measured as a parameter of central control - increased during the course of therapy.

CONCLUSION

The increase in PPI is an indication that enuresis in hyperthyroidism could be as a result of a temporary loss of central control on brainstem reflexes. The case conveys new insights into the correlation between thyroid hormones and micturition patterns and the aetiology of enuresis.

[Hinman syndrome--an uncommon cause of recurrent urinary tract infections since childhood]

A 20-year-old female presented with a history of recurrent urinary tract infections, diurnal incontinence, nocturnal enuresis, and voiding difficulty. Imaging studies revealed a thick trabeculated bladder and high post-void residual urine volumes. Urodynamic evaluation demonstrated involuntary bladder contractions and no evidence of bladder outlet obstruction. A full neurological and urological workup were both unremarkable. A thorough history revealed her symptoms were initiated after prolonged and stressful potty training with multiple failed attempts. She developed a dysfunctional voiding pattern consistent with a non-neurogenic neurogenic bladder, also known as the "Hinman syndrome". Successful therapy relies primarily on behavior modification maneuvers combined with medical therapy to reduce unstable bladder contractions and alleviate bladder outlet obstruction.

[Alteration of bladder function in response to surgical reduction in bladder capacity: conventional-fill cystometry in awake rabbit model]

OBJECTIVE

To investigate alteration of bladder function in response to surgically reduced bladder capacity by using an awake rabbit model.

METHODS

Forty rabbits were divided into two groups, one was experimental group in which the rabbits underwent semi-cystectomy to reduce 50% bladder capacity (n=20), another was control group in which the rabbits received sham operation (n=20). A conventional-fill cystometric investigation was performed as the animal under awake condition at the times of 4 weeks and 8 weeks after operation.

RESULTS

Compared with control subjects, the maximum cystometric capacity in experimental group was remarkably decreased at week 4 [(35.3 +/- 8.2) mL vs. (71.6 +/-12.9) mL, P < 0.05), and week 8 [(46.2 +/- 12.1) mL vs. (82.7 +/- 20.1) mL, P < 0.05] respectively; while the maximum voiding detrusor pressure was significantly enhanced at week 4 [(24.4 +/- 7.0) vs. (16.5 +/- 7.2) cm H2O, P < 0.05) and week 8[(27.7 +/- 8.0) vs. (16.8 +/- 7.5) cm H2O, P < 0.05) respectively.

CONCLUSION

Alteration of bladder function, which mainly presented as the increase of maximum voiding detrusor pressure, was elicited at four to eight weeks after surgical reduction of bladder capacity in rabbit.

Pupillometric assessment of autonomic nervous system in children with functional enuresis

Functional enuresis is defined as repeated voiding of urine into bed or clothes in children after 5 years of age following the exclusion of major somatic diseases. Autonomic nervous system dysregulation has been proposed as a pathophysiologic mechanism in the etiopathogenesis. The objective of this study was to evaluate autonomic nervous system functions with pupil diameter measurement in enuretic children. The study group consisted of 17 children with functional enuresis (ten boys, seven girls), and the control group consisted of 34 healthy children (20 boys, 14 girls). Pupil diameter measurements were performed under photopic and mesopic lighting conditions by using a pupillometer. Mean photopic pupil diameter was found to be larger in the enuretic children than in the healthy controls (4.47 +/- 0.52 mm vs. 4.03 +/- 0.75 mm; P = 0.03). Autonomic nervous system imbalance of the ocular system is considered to be part of the autonomic nervous system dysregulation in functional enuretic children.

[Sensory integration function in children with primary nocturnal enuresis]

OBJECTIVE

To assess the sensory integration function of children with primary nocturnal enuresis (PNE) and explore the role of sensory integration dysfunction in the pathogenesis of PNE.

METHODS

Sensory integration function was assessed by the Childhood Sensory Integration Ability Development Checklist in 46 children with PNE and 46 normal children (control).

RESULTS

The incidence of sensory integration dysfunction in the PNE group (82.6%) was significantly higher than that in the control group (43.5%)(P<0.01). Seventeen patients (36.9%) presented with severe sensory integration dysfunction in the PNE group but only 1 (2.1%) in the control group (P<0.01). The scores of all nine sensory integration indexes revealed by sensory integration function testing in the PNE group were significantly lower than those in the control group (P<0.01).

CONCLUSIONS

Children with PNE have sensory integration dysfunction. Sensory integration dysfunction may be associated with the pathogenesis of PNE.

Enuretic sleep: deep, disturbed or just wet?

Enuretic children sleep "deeply" in the sense that they are difficult to arouse from sleep, but not in the sense that their sleep is necessarily polysomnographically different from other children. The enuretic children's arousal difficulties may be due to a disturbance at the brainstem level and/or to frequent arousal stimuli from the bladder. It may be hypothesised that the sleep disturbance of enuretic children may lead not only to the wetting of the sheets but to disturbances of daytime psychological functioning as well.

Sustainability of remission of pediatric primary nocturnal enuresis--comparison of remission using Try for Dry vs. non-Try for Dry treatment plans

This study examined the sustainability of remission of primary nocturnal enuresis (PNE) using an algorithm-based multimodal treatment plan, Try for Dry. Remission of PNE using the Try for Dry treatment method was retained longer and more often than using a non-Try for Dry plan.

Obstructive upper airway problems and primary enuresis nocturna relationship in pediatric patients: reciprocal study

OBJECTIVE

To determine the relationship between primary enuresis nocturna (PEN) and obstructive upper airway problems (OUAPs).

DESIGN

Prospective, descriptive study.

SETTING

Tertiary care academic medical centre.

METHODS

Two groups of patients were included in the study. Newly diagnosed pediatric PEN patients between August 2004 and June 2005 were evaluated for OUAPs in the Department of Otorhinolaryngology of our institution and constituted the first group of patients. During the same period, patients who were on the surgery list for upper airway problems were examined for PEN in the Department of Pediatric Psychiatry as the second group. Obtained data were analyzed with regard to patient demographics and the relationship between PEN and OUAPs, and follow-up results are reported.

MAIN OUTCOME MEASURES

There were 32 patients in each group. In the first group, 5 patients (15.6%) had totally obstructing severe septal deviation, 8 patients (25.0%) had moderate septal deviation, 10 patients (31.3%) had allergic rhinitis and inferior turbinate hypertrophy, 3 patients had adenotonsillar hypertrophy (9.4%), and 1 patient (3.1%) had septal perforation. The frequency of OUAP in PEN patients was 65.6%. In the second group, 10 patients (31.3%) had a PEN diagnosis. After at least 3 months (mean 6.3 months) of follow-up, four patients (40%) were free of PEN and two patients (20%) experienced improvement in PEN. Another four patients did not have any change in the severity of PEN.

CONCLUSIONS

According to our results, OUAPs are very common in PEN patients and PEN is a common symptom of OUAPs.

[The evaluation of urinary tract dysfunction in children with monosymptomatic primary nocturnal enuresis]

The reason for our search was various investigations about urinary tract dysfunctions in enuretic children.

AIM

The aim of our study was estimation of lover urinary tract function in children with monosymptomatic primary nocturnal enuresis without positive reaction for a long non pharmacological therapy.

MATERIAL AND METHODS

54 children after 9-12 months behavioral therapy and short pharmacological treatment (desmopresin) was undergoing urodynamic investigation (uroflowmetry and cystometry).

RESULTS

Urodynamic disorders was found in 44/54 of estimated children. In 34 of children it was overactive bladder, in 6 patients we found detrusor-sphincter discoordination. Five children had decreased bladder capacity. Next to non pharmacological treatment we used anticholinergic or Baclofen depending on the results of urodynamic tests. The response to the treatment (non bedwetting at all) we observed in 34 children (in 9 of them after 3 months of therapy, in 16 after 6 months of therapy and in 12 after 12 months of therapy). The rest of children had decreased number of wet night per month.

CONCLUSION

The pharmacological treatment of urodynamic disorders helps to children with monosymptomatic primary nocturnal enuresis to lost this symptom.

The use of desmopressin in the management of nocturnal enuresis in patients with spinal cord injury

AIM

The aim of this study is to evaluate the use of desmopressin acetate (DDAVP) in the management of nocturnal enuresis in patients with spinal cord injury (SCI), as well as arginine vasopressin (AVP) daily production, urine output, urine osmolarity and clean intermittent catheterization (CIC) before and after the use of desmopressin.

METHODS

We studied 11 patients with SCI (7 men 4 women). All patients attended a rehabilitation program and used a wheelchair for locomotion. To improve bladder function and achieve socially acceptable continence all patients were placed on a regimen of anticholinergic drugs (oxybutynin 5 mg, 1x3 daily), evening antibiotic prophylaxis and CIC. The subjects were also on night CIC in order to avoid nocturnal incontinence. DDAVP was given intranasally (20 mg before bedtime) in association with other standard therapy. Urine samples were collected under sterile conditions from all patients at 6:00 a.m. and 6:00 p.m. Urine volume was measured and the amount of urine per hour was calculated. Blood samples were also taken to measure serum AVP, urea, creatinine and serum electrolyte.

RESULTS

Our data suggest that nocturnal polyuria in SCI patients occurs due to a lack of diurnal variation of antidiuretic hormone (ADH) secretion. The use of desmopressin produced a statistically significant increase in urine production rate during the day (56.2 vs 81.2 mL/h, P<0.001) and a decrease in nocturnal urine production (59.2 vs 27.7 mL/h, P<0.001). Desmopressin treatment reflects also on urine osmolarity, which did not change during the day (496 vs 489 mOsm/mL, P>0.5) but showed a significant increase during the night (385 vs 862 mOsm/mL, P<0.001). There was a significant decrease in night CIC. No serious adverse effects were observed.

CONCLUSION

Our results suggest that desmopressin administration is an beneficial treating option for patients with SCI when fluid restriction and other preventive measures are not able to control abnormal nocturnal polyuria.

The effect of obesity on treatment efficacy in children with nocturnal enuresis and voiding dysfunction

PURPOSE

Obesity continues to be a leading public health concern in the United States. Our previous studies have suggested that there is a high rate of obesity in children with dysfunctional voiding, especially nocturnal enuresis. We investigated the correlation between body mass index and the efficacy of treatment in obese patients.

MATERIALS AND METHODS

We evaluated retrospectively records from patients seen with a diagnosis of nocturnal enuresis or dysfunctional voiding between January 2004 and July 2005. Bladder and bowel symptoms and urinary diary data were evaluated, and body mass index percentile was determined. Response to treatment was evaluated and correlated with body mass index percentile.

RESULTS

We evaluated 250 children, of whom 96 (38%) had nocturnal enuresis and 154 (62%) had dysfunctional voiding. Body mass index was normal in about half of the patients, and half were above the 85th percentile for body mass index. Patients with a body mass index above the 85th percentile had a reduced response to therapy. After treatment patients with a normal body mass index had a lower nocturnal accident frequency than those above the 85th percentile. Similarly, in those with voiding dysfunction the response rate was 65% in association with a normal body mass index vs 35% with a high body mass index. Furthermore, patients with a normal body mass index had a significantly higher rate of completing a urinary diary compared to those with a high body mass index.

CONCLUSIONS

Obesity correlates with a lower voiding diary completion rate and lower efficacy of treatment in children with nocturnal enuresis or dysfunctional voiding.

Sigmoid orthotopic neobladder after radical cystectomy for bladder tumour: an Indian experience

OBJECTIVE

To determine the long-term results of constructing a sigmoid neobladder after radical cystectomy for transitional cell carcinoma (TCC) of the urinary bladder.

PATIENTS AND METHODS

The study included 170 patients with TCC of the bladder and a normal sigmoid colon. After radical cystectomy the neobladder was formed by completely detubularizing an isolated sigmoid colon segment. Subsequently patients were followed by clinical, biochemical, radiological and urodynamic assessments.

RESULTS

Four patients died soon after surgery; the neobladder-related delayed complications were death in three patients, loss of five renal units, and electrolyte imbalance in five patients. Uretero-intestinal anastomotic narrowing was another frequent delayed complication. Most (97%) patients had nocturnal incontinence, and most voided with a good stream with a minimal postvoid residual urine volume.

CONCLUSION

The sigmoid neobladder, despite some limitations, is the best option for diverting urine after radical cystectomy.

Metabolic control and nocturnal enuresis in children with type 1 diabetes

This study examined the relationship between metabolic control and enuresis in youths with type 1 diabetes. Participants were 203 youths with type 1 diabetes at an outpatient pediatric diabetes clinic. Outcome measures included HbA(lc), nocturia, blood glucose, polydipsia, frequency of daytime urination, and diabetic ketoacidosis. The mean fasting blood glucose (FBG) level of children with enuresis (FBG = 192 mg/dl) was significantly higher than that of children without enuresis (FBG = 160 mg/dl, p = .03). Differences in HbA(lc) levels between children with enuresis and those without enuresis approached significance (9.2% vs. 8.6%, p = .07). Findings indicate that metabolic control indices (FBG, HbA(1c), polyuria, and polydipsia) are related to nocturnal enuresis in youths with type 1 diabetes. Further studies should determine the mechanism by which this relationship occurs to initiate appropriate interventions.