Current and Future Perspectives on Managing Primary Nocturnal Enuresis

NOCTURNAL ENURESIS: AN INTERNATIONAL EVIDENCE BASED MANAGEMENT STRATEGY

Assessment of serum level of corticotropin-releasing factor in primary nocturnal enuresis

Effect of nocturnal enuresis on school-age children and their families in Thailand: A cross-sectional study.

Introduction Nocturnal enuresis (NE) is a common pediatric condition. Previous studies have shown the association between OSA and NE. The underlying mechanism may be related to disruptions of sleep and increased sympathetic activation which may impair arousal from sleep. However, it is unclear whether primary or secondary NE is more likely to be associated with OSA. Therefore, this study aimed to investigate this issue. Methods We conducted a retrospective study of pediatric patients with NE who were referred to our sleep center and underwent diagnostic study at Cincinnati Children’s Hospital from January 2005 to September 2024. Patients were divided by NE type and age group (< 12 and ≥12 years old). Exclusion criteria included tracheostomy, ventilator dependence, and neurogenic bladder. OSA was defined by obstructive AHI >1.5/hr. Statistical comparisons between primary and secondary NE were performed by Chi-square for categorical variables and by Mann-Whitney test for continuous variables. Results 138 patients, aged 4-20 years old, met criteria for entry into analysis; 64.1% had primary NE, 35.9% had secondary NE. There was no difference in the age between primary[P] and secondary[S] NE (10.4±3.7 yo [P] vs 9.5±3.6 yo [S]; P=NS). For prevalence of OSA, there were no differences in the prevalence of OSA (61.9%[P] vs 60.0%[S]; P=NS) and percentage of mild, moderate and severe OSA between the two groups. For PSG parameters, there were no differences in the sleep efficiency, percentage of sleep stages (N1, N2, N3, REM), AHI or obstructive AHI (6.5±19.2/hr[P] vs 4.6±8.7/hr[S]; P=NS) between primary and secondary NE. Sub-group analysis of children (< 12) and adolescents (≥12) revealed no significant differences in the prevalence of OSA and PSG parameters in either age group. Conclusion Our study shows a high prevalence of OSA in our cohort of patients with NE who were referred to pediatric sleep clinics. Interestingly, there were no significant differences in the prevalence and severity of OSA between primary and secondary NE in both children and adolescents. These findings emphasize the need for comprehensive screening of OSA in both primary and secondary NE. Further studies are needed to assess the impact of OSA treatment on outcomes in children with NE. Support (if any)

PREVALENCE OF DIURNAL VOIDING SYMPTOMS AND DIFFICULT AROUSAL FROM SLEEP IN CHILDREN WITH NOCTURNAL ENURESIS

To determine the differences or similarities in the clinical presentation between patients with primary and secondary nocturnal enuresis. A total of 170 patients with nocturnal enuresis were assessed at a busy tertiary care pediatric voiding dysfunction clinic at the University of Oklahoma Health Sciences Center. Patients with primary nocturnal enuresis (PNE) were compared with patients with secondary nocturnal enuresis (SNE) for a variety of clinical features, including gender, age when first voiding on their own, age on presentation, infrequent voiding, frequent voiding, urgency, daytime wetting, nocturia, urinary tract infection, constipation, vesicoureteral reflux, attention-deficit/hyperactivity disorder, uroflow results, and ultrasound evidence of a postvoid residual. The only significant difference between the patients with PNE and those with SNE was in the prevalence of constipation. Constipation was significantly associated with PNE (74.59% vs 57.54%; odds ratio: 2.17; 95% confidence interval: 1.07-4.41). When adjusted for a history of constipation, the age at which a child began to void on his or her own became statistically significant. Patients with SNE started to void on their own at 2.13 years (SD: 0.61), an average of 0.22 years earlier than those with PNE, who started to void on their own at 2.35 years. PNE and SNE likely share a common pathogenesis. Symptoms of daytime voiding dysfunction are common in patients with PNE and SNE. Daytime voiding habits might influence how the central nervous system responds at night to a full or contracting bladder.

Nocturnal enuresis (NE) is one of the most frequent paediatric pathologies. The prevalence of primary nocturnal enuresis (PNE) is around 9% in children between 5 and 10 years of age and about 40% of them have one or more episodes per week. Still for too long, PNE has not been recognised as a pathological condition, particularly by the medical community; as a consequence, there was no specific education at medical school, and a poor involvement by the practitioners. Enuretic children have a sense of social difference and isolation; some of them do express a low self-esteem. Also, self-esteem is improved by the management NE even if this management fails to cure the condition. Primary monosymptomatic nocturnal enuresis (PMNE) is an heterogeneous condition for which various causative factors have been identified such as: nocturnal polyuria, sleep disturbances, reduced bladder capacity or bladder dysfunction, upper airway obstruction. The positive diagnosis of PMNE is based on a complete questionnaire and a careful physical examination. A drinking and voiding chart is an essential non-invasive tool: first, to collect information about the initial drinking and voiding habits of the child, then to reassess the accuracy of the diagnosis. Only motivated patients should receive a specific treatment for their NE and the treatment should be proposed based on the type of PMNE. PMNE associated with nocturnal polyuria should be treated with desmopressin, which reduces nighttime urine production. For PMNE with a reduced bladder capacity alarms should be the first-line treatment. Oxybutinin, a drug with anticholinergic properties, is not theoretically indicated for the treatment of PMNE except for a very small subgroup of patients who have an overactive bladder only during sleep. In cases refractory to monotherapy, NE is probably the result of an association of different physiopathological factors (e.g. both a nocturnal polyuria together with a small bladder capacity) some of them are still unknown. In these patients, a combination of treatments may be more effective than monotherapy. Various combination therapies can be proposed to improve the cure rates.

EXAMINATION OF THE STRUCTURED WITHDRAWAL PROGRAM TO PREVENT RELAPSE OF NOCTURNAL ENURESIS

Role of Posterior Tibial Nerve Stimulation in the Treatment of Refractory Monosymptomatic Nocturnal Enuresis: A Pilot Study

THE EFFICACY AND SAFETY OF ORAL DESMOPRESSIN IN CHILDREN WITH PRIMARY NOCTURNAL ENURESIS

An 8-year-old boy presented with primary nocturnal enuresis as the first clinical sign of ureterocele in the absence of dysuria, urinary incontinence or urinary tract infections. A prolonged history of bedwetting prompted subsequent clinical and laboratory evaluations, leading to the correct diagnosis of ureterocele. Primary and persistent nocturnal enuresis as an initial manifestation of ureterocele has not been reported previously. The present patient showed a feature not previously described in children with ureterocele. Although rare, ureterocele should be considered in the differential diagnosis of children presenting with primary nocturnal enuresis. Keywords: Primary nocturnal enuresis; Simple orthotopic ureterocele; Single-system ureter.

Background Nocturnal enuresis (NE) is one of the most common pediatric sleep-related problems. Data on sleep patterns in children with NE are conflicting. Objective We aimed at studying the sleep architecture, associated breathing problems, and its relation to antidiuretic hormone (ADH) in children with primary NE. Patients and methods This study included 31 children aged 6-18 years with primary monosymptomatic NE and 16 healthy matched controls. They were subjected to a single overnight polysomnography and assessment of ADH levels at 9-11 a.m. and 9-11 p.m. Results Enuretic children had significantly prolonged sleep latency and higher stage N1 percentage, less total sleep time, lower sleep efficiency, and lower rapid eye movement sleep percentage compared with the control group. Ten (32.2%) NE children had nocturnal arrhythmia, whereas six (19.35%) had a respiratory distress index more than 5. Reversed ADH secretion pattern was present in 82% of the NE children. Children with reversed ADH secretion had lower stage N1 and respiratory distress index, and higher sleep efficiency, compared with NE children with normal ADH rhythm. Conclusion Primary NE is associated with disturbed sleep architecture. NE could be a presenting symptom for hidden sleep disordered breathing. The association of NE with cardiac arrhythmia is an interesting finding that requires further research. Most NE children have a reversed pattern of ADH secretion.

Objective To assess the working memory and explore the activation of brain areas for children with primary nocturnal enuresis (PNE) with fMRI scan. Methods Twenty three right-handed children with PNE and 20 age-matched right-handed healthy children as the controls were recruited.Intelligence tests were performed by means of Wechsler Young Children Scales of Intelligence (C-WISC) in children with PNE and normal controls. The full intelligence quotient (FIQ), verbal IQ (VIQ),performances IQ (PIQ) and the memory/caution (M/C) factor of PNE children and the controls were measured. After Intelligence tests, an enent-related fMRI scan was performed using the categorial N-Back working memory task. Percent of correct responses (PCR) and mean reaction time to correct response (mRT) were recorded and analyzed by the student t test. The fMRI data were analyzed using Statistical Parametric Mapping 2 (SPM2), the differences in activation were compared between two groups. Results The data of 15 PNE children and 15 healthy children were evaluated. The FIQ, VIQ and PIQ in PNE group were in a normal range and no statistical significance with the control group ( P ＞ 0. 05). M/C factor in the PNE group(90.4 ±10.2)was significantly lower than that in the control group (99. 6 ± 11.9) (t =2. 260,P ＜ 0. 05). In the N-Back test, PNE children had significantly less PCR [(72.7±6.3 ) % vs. ( 86. 3 ±6. 7) %, t = 5. 727,P ＜ 0. 01] and longer mRT [ (625. 8 ± 72.5) ms vs. (534. 8 ± 63. 3 ) ms, t = 3. 684,P ＜ 0.01] than the healthy controls. The activation regions of PNE patients and healthy children were mainly in the dorsal right frontal lobe, right parietal lobe, left temporal lobe gyrus fusiformis and bilateral cerebellum posterior lobe. The activation level in left posterior cerebellar lobe in PNE children was significant lower than that in healthy controls (P＜0.01). Conclusion The children with PNE have deficits in working memory which might be associated with the dysfunction of the left cerebellum. Key words: Nocturnal enuresis; Magnetic resonance imaging; Memory disorders

Objective: Enuresis nocturna is an important social and psychological problem in children. Uroflowmetry (UF) is a noninvasive urodynamic test that is performed in daily clinical practice to evaluate urinary function. In UF evaluation, urine amount, urination time, latency time, maximum urine flow rate access time, maximum urine flow rate, and mean urine flow rate are evaluated. The objective of the study was to evaluate the UF results of children with primary nocturnal enuresis (PNE). Materials and Methods: The UF findings of healthy and visualized children without any urinary symptoms and who were prospectively admitted to the urology and pediatric surgery outpatient clinic with the complaint of PNE were compared. Information and UF results of PNE and healthy children included in the study were recorded. In this research, we compared the clinical characteristics and features of bladder assessment: UF, postvoid residuals, and bladder wall thickness between boys and girls with PNE and the clinical characteristics and bladder assessment between children with primary and secondary PNE. Results: A total of 183 children, comprised 103 potty-trained children with PNE and 80 potty-trained healthy children were included in the study. There were 60 children in the PNE group and 62 children in the control group. There was no statistically significant difference between the groups in terms of age. When the UF findings of both groups were compared, it was found that only maximum flow was higher in the children with PNE. In other parameters, there was no difference between the two groups. The Qmax in the group with PNE and the control group was found to be 20.48 ± 6.57 ml/s and 17.22 ± 6.17 ml/s, respectively (P = 0.001). Conclusions: The present study reveals that there is no difference between patients with enuresis nocturna and healthy individuals in terms of UF. Therefore, UF is not recommended for use in differential PNE diagnosis.

Objective To explore the prevalence of different subtypes of primary nocturnal enuresis (PNE) of children aged 5-12 years in Henan Province. Methods From October 2016 to May 2017, a cross-sectional survey of primary enuresis prevalence was performed by randomly selecting 9650 children aged 5-12 years from 18 primary schools and 12 middle schools in Henan Province. An anonymous questionnaire was employed for surveying the epidemiology of primary enuresis and its different subtypes. Results A total of 9650 questionnaires were distributed and 8978 questionnaires recovered. There were 8517 valid questionnaires with an effective questionnaire recovery rate of 88.3%. The overall prevalence of PNE was 6.4%(545/8517), the overall prevalence of monosymptomatic enuresis (MNE) 4.6%(395/8517) and the overall prevalence of non-monosymptomatic enuresis (NMNE) 1.8%(150/8517) while accounted for 27.5% of PNE. With advancing age, the prevalence of PNE decreased (χtrend2=143.06, P 0.05). The overall incidence of frequent nocturnal enuresis in children with PNE was 70.1% (382/545) and the incidence of frequent nocturnal enuresis with MNE and NMNE was compared [69.1%(273/395) vs. 72.7%(109/150)]. The difference was not statistically significant (χ2=0.66, P>0.05). Conclusions Around 10% of children aged 5-6 years suffer from PNE. It is one of the major diseases affecting children's quality-of-life. And 1/3 of PNE children are associated with daytime symptoms and the frequency of nocturnal enuresis has remains high. Clinicians and parents should pay great attention. Key words: Diurnal enuresis; Epidemiology; Children