This Month in Pediatric Urology

Abstract

You have accessJournal of UrologyThis Month in Pediatric Urology1 Nov 2022This Month in Pediatric Urology Julian Wan Julian WanJulian Wan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002979AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Fluoxetine for Treatment of Refractory Primary Monosymptomatic Nocturnal Enuresis in Children Pediatric urologists often are asked to explain what it is that we do by the public, acquaintances, friends, family, and a surprising number of medical practitioners since we do not remove cancerous prostates, treat impotence, or relieve stress incontinence. Usually, we take great pains to explain that we are surgeons and physicians. We perform orchiopexies, pyeloplasties, hypospadias repairs, anti–vesicoureteral reflux operations, and many other procedures. We deal with symptomatic urinary stones and reconstruct neurogenic bladders and handle many complicated congenital anomalies. And yes, we do circumcisions, and cope with the sequalae such as residual foreskin, penile skin bridges, adhesions, and meatal stenosis. Usually, the 1 diagnosis which is universally understood to be in our domain of expertise is nocturnal enuresis (NE). While many specialists may treat NE, it often falls to the pediatric urologist the more difficult so-called recalcitrant or refractory patients. In many cases, the solution can be simple—better compliance with fluid and food restrictions before bed, better daytime voiding and bowel habits, and better compliance with the medication or alarm. But in some cases, we are faced with patients who seem to have exhausted our treatment options. Hussiny et al (page 1126) from Egypt address this issue with their randomized placebo-controlled trial using the selective serotonin re-uptake inhibitor, fluoxetine.1 They enrolled 110 patients who had severe primary monosymptomatic NE that had been unresponsive to the usual treatments such as wetting alarms, desmopressin, and anticholinergics. The patients were split between the fluoxetine and placebo arms. At 12 weeks, the fluoxetine arm had a 7.1% complete and 66.1% partial response rate. The placebo arm had 0% and 16.7%, respectively. While the results are impressive, before anyone suggests supplanting our mainline therapies, fluoxetine is a serious medication, and we should all be careful to truly exhaust existing options. Yet, we should not ignore the reality for many of the older patients who have never experienced a dry night. It can have profound long-term effects. When desmopressin was first released into general use over 3 decades ago, there was an interesting paper from an adult enuretic.2 It detailed the 40-year–long history of a chemical engineer who was first treated at age 5. After no benefit he would spend the next 40 years trying for a cure. He was able to get married despite a wet bed, have 2 children, got rejected from national service, and underwent naturopathic, alarm therapy, magnetic therapy, diuretics, amphetamines, psychological conditioning with cold showers, homeopathy, impramine with serious side effects, sand-pit crawling, hypnosis, and acupuncture—all without any benefit. He finally was prescribed desmopressin by a urologist and that left him 100% dry at night at age 41 years. For this individual, the development of a new therapy was miraculous and altered his life. He noted “Over the years, the intrinsic difficulties of nocturnal enuresis have been compounded by the effects of the unsuccessful treatments. Psychiatric treatment changed my behavior but improvement of my self-image had to await treatment with DDAVP.” Will fluoxetine be a new last line of therapy? More work will be needed to help establish that, but the search for an effective treatment for these patients should not be dismissed.