Nocturnal Enuresis In Children Research Articles

Prescribing for incontinence and nocturnal enuresis

This article provides an overview of the main drugs used for the treatment of incontinence and nocturnal enuresis. There is particular reference to the prescribing issues associated with antimuscarinic drugs in relation to cautions, contraindications and side effects. The clinical guidelines for the treatment of nocturnal enuresis in children and the use of desmopressin are highlighted. The reader has the opportunity to self-check their own knowledge with a pre-reading self-assessment.

German Version of the Pediatric Incontinence Questionnaire for Urinary Incontinence Health Related Quality of Life

We translated and cross-culturally adapted the English version of the Pediatric Incontinence Questionnaire, and tested the reliability and validity of the German version. This cross-sectional study was done at 3 tertiary referral centers for childhood urinary incontinence. The self-reported and proxy English version was translated and cross-culturally adapted. From July 2007 to April 2008 we evaluated the German version in 91 boys and 54 girls with a mean +/- SD age of 9.3 +/- 2.2 years (range 6 to 18) with nonneurogenic urinary incontinence and in their parents. For concurrent criterion related validity, the German questionnaire scales were compared with those of the DCGM-10/-12. On reliability testing of the self-reported and proxy German versions Cronbach's alpha was 0.84 and 0.86, respectively. Interrater convergence between the self-reported and proxy versions showed an ICC of 0.81. Reproducibility was satisfactory for the self-reported and proxy versions (ICC 0.77, 95% CI 0.77-0.90 and 0.85, 95% CI 0.67-0.84, respectively). German version scores correlated with DCGM-10/-12 scores (self-report and proxy r = -0.71 and -0.69, respectively). Mean German version total scores were 23.0 in boys and 23.9 in girls. Except for a slight significant association between age and German version total score in the proxy version (p = 0.01), age, sex and incontinence type or severity (number of wet days/nights per 14 days) were not significantly associated with German version total scores. The German version of the Pediatric Incontinence Questionnaire is a valid and reliable outcome measure to assess health related quality of life in children and adolescents with urinary incontinence.

Lower Urinary Tract Symptoms in Enuretic and Nonenuretic Children

We determined the prevalence of lower urinary tract symptoms in enuretic and nonenuretic children and adolescents in an urban community. We performed a cross-sectional survey including 296 children and adolescents in a small urban community. Trained medical students visited all homes and interviewed the parents or guardians. There were no refusals to participate. Results were analyzed using chi-square and McNemar statistics. The enuresis rate was 10%, including 16.6% and 3.9% in children 5 to 10 years old and adolescents, respectively. The monosymptomatic enuresis rate was only 1.34%. Of those with vs without enuresis lower urinary tract symptoms were present in 86.7% vs 26.8% (p <0.001). In the nonenuretic group lower urinary tract symptoms were associated with nocturia (p = 0.008). The most common daytime urinary symptoms were urgency in 38.2% of cases, holding maneuvers in 30.4% and daytime incontinence in 27.5%. The prevalence rate decreased with age in the nonenuretic group (p = 0.013). The prevalence of lower urinary tract symptoms was high. Nonmonosymptomatic enuresis was common and monosymptomatic enuresis was rare in this population based survey. In nonenuretic cases daytime symptoms were associated with nocturia, suggesting decreased bladder capacity with a mature arousal reaction.

Orthodontic maxillary expansion and its effect on nocturnal enuresis.

A previous retrospective study of 10 children with varying degrees of nocturnal enuresis has shown that one side effect of rapid maxillary expansion (RME) is spontaneous reduction in bed-wetting at night. The aim of this prospective study was to analyze the effect of RME treatment (mean 2 weeks) in cases of chronic, long-standing nocturnal enuresis. Ten children, 8 to 13 years old, who had not responded to conventional medical treatment for bed-wetting, were referred from the pediatric department. Within 1 month of RME of 3 to 5 mm, 4 children were completely dry and 3 showed notable improvement. The results are encouraging, especially given the spontaneous recovery rate of about 15% per year. A reduction in nocturnal enuresis in children has also been reported after tonsillectomy. However, in this pilot study, no significant associations could be found between improvement in nocturnal enuresis and improvement in the nasal airway, age, amount of expansion, or nasopharyngeal dimension (measured on cephalograms).

Prevalence of Urinary Incontinence among Women and Its Impact on Quality of Life in a Semirural Area of Western Turkey

Background/Aims: Urinary incontinence (UI) is a very common and bothersome condition among women, affecting up to 50% of women during their lifetime. Older women are disproportionately affected and often view UI as a normal part of aging, thus precluding contact with medical professionals. The aim of this study was to determine the frequency and risk factors of UI in women aged 20 years or older, as well as to examine its effects on women’s quality of life (QOL). Methods: The study was conducted on 1,585 women aged 20 years and over between January and March 2007. Data were obtained by a face-to-face interview, using a questionnaire consisting of questions pertaining to the women’s demographic characteristics, medical and obstetric history and UI. The Short Form-36 (SF-36) scale was used to assess the QOL of the women. Results: The prevalence of UI in this group of women was 49.5%. UI was significantly associated with advanced age (p < 0.05), lower education level (p ≤ 0.001), recurrent urinary tract infection (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), diabetes mellitus (p ≤ 0.001), a history of nocturnal enuresis in childhood (p < 0.001), taking diuretics (p < 0.05) and body mass index (p < 0.001). When the QOL of the women with and without UI were evaluated, the scores for women without UI were higher than those with mild, moderate or severe UI (p < 0.001 for each). Women with UI of varying severity had lower mean domain scores on the SF-36 than women without UI (p < 0.001 for each). As the severity of UI increased, it was seen that the mean domain scores according to the scale showed a decrease (p < 0.001). Conclusion: It is concluded that UI is a common disorder among women in this region of Turkey and that it also negatively affects these women’s QOL, suggesting the need for more social and medical study in this area.

Risk factors and comorbid conditions associated with lower urinary tract symptoms: EpiLUTS

To explore the risk factors and comorbid conditions associated with subgroups of lower urinary tract symptoms (LUTS) in men and women aged > or =40 years in three countries, using data from the EpiLUTS study, as LUTS are common amongst men and women and increase in prevalence with age. This cross-sectional, population-representative survey was conducted via the Internet in the USA, the UK and Sweden. Participants were asked to rate how often they experienced individual LUTS during the past 4 weeks on a 5-point Likert scale. Eight LUTS subgroups were created. Descriptive statistics and logistic regressions within each LUTS subgroup were used to assess the data. The survey response rate was 59%. The final sample was 30,000 (men and women). The voiding + storage + postmicturition (VSPM) group reported the highest rates of comorbid conditions for both men and women, and the fewest were reported in the no/minimal LUTS and the postmicturition-only groups. Increasing age was associated with increasing LUTS in men, but not in women. Comorbid conditions significantly associated with the VSPM group were arthritis, asthma, chronic anxiety, depression, diabetes (men only), heart disease, irritable bowel syndrome, neurological conditions, recurrent urinary tract infection, and sleep disorders. Risk factors, such as body mass index, exercise level and smoking, played less of a role, except for childhood nocturnal enuresis, which was significantly associated with most LUTS subgroups. In this large population study, many comorbid conditions and risk factors were significantly associated with LUTS among both men and women. Further longitudinal investigations of the associations noted here would help physicians to understand the pathophysiology of LUTS and comorbid conditions, and provide clinical guidelines for patient management of comorbid conditions sharing common pathophysiological pathways.

Management of Nocturnal Enuresis in Children

Management of Nocturnal Enuresis in Children

Nocturnal enuresis in childhood

Nocturnal enuresis is a common childhood problem that has the potential to have a negative impact on the social and emotional well being of the child. The multifactoral aspects of the condition are now better understood and successful treatment involves interventions that simultaneously address each contributory factor. This article gives an overview of those factors and discusses the treatment options.

A Randomized, Placebo-Controlled, Exploratory Trial of Ibuprofen and Pseudoephedrine in the Treatment of Primary Nocturnal Enuresis in Children

This exploratory randomized, double-blind, double-dummy, placebo-controlled trial of 14 days duration conducted in 22 primary care practices in the United States was used to compare the efficacy of ibuprofen and pseudoephedrine, administered alone or in combination, to placebo for the treatment of primary nocturnal enuresis (PNE) in children aged 6 to 11 years. Ibuprofen (IBU) and pseudoephedrine (PSE) are not approved for the treatment of PNE. Three hundred eighteen children with PNE were enrolled. Eligible children had >or= 8 wet nights during a 14-day baseline. Each child was randomly assigned to 1 of 4 treatment groups: IBU 12.5 mg/kg and PSE HCl 15 or 30 mg (depending on weight) (n = 82), IBU 12.5 mg/kg (n = 78), PSE HCl 15 or 30 mg (n = 76), or placebo (n = 82). Treatment was administered orally at bedtime for 14 days. Caregivers recorded whether the child was wet or dry each night in a daily diary. Children in the IBU alone and IBU and PSE combined groups had greater mean reductions from baseline in the number of wet nights (primary end point) compared to children receiving placebo (-2.9, -2.9, and -1.4, respectively, P < .005); PSE alone (-1.8) was not significantly different from placebo. Children in these groups also had greater mean percentage reductions in the number of wet nights compared to placebo-treated children (26%, 28%, and 12%, respectively). Although not always statistically significant, secondary end points improved in the IBU alone and IBU and PSE combined treatment groups, which included decreases in mean number of wet nights and decreases in the number and percentage of children with >or= 50%, 40%, 30%, or 25% reductions in number of wet nights. Children responding to treatment had larger mean bladder capacities and larger mean percentage of predicted bladder capacities than children who did not respond in each treatment group. No significant differences in adverse events were found among treatment groups. In conclusion, in this exploratory study in children aged 6 through 11 years, IBU provided a beneficial effect in the treatment of PNE compared to placebo, whereas PSE did not. The addition of PSE to IBU did not enhance or diminish the efficacy of IBU. All treatments were well tolerated.

The pathogenesis and therapy of nocturnal enuresis in children

小儿遗尿症是儿科最常见的疾病之一,其病因和发病机制至今尚不明确,可能是由多种病因引起的疾病.长期遗尿可严重损害患儿的自尊心与自信心,导致心理和行为异常.若经久不愈,延至成年,将严重影响患儿的精神和生活,最终导致人格障碍.临床治疗遗尿症主要采取培养良好的排尿习惯、心理治疗及中西医结合治疗等方法。

Nocturnal Enuresis in Children: A Review of the Literature

Nocturnal enuresis (NE) is a very common clinical disorder. According to DSM-IV, NE is defined as repeated voiding, accidental or on purpose, into clothing or into the bed, at least twice a week, for 3 consecutive months, in children older than 5 years, age in which the sfincterial control is acquired. The pathophysiology of NE is not fully understood. It has been suggested that NE is the result of a combination of osmoregulatory or urodynamic disturbances, disorders of arousal and genetic factors. The evaluation of a child with minctional disorders begins with a good history and a physical examination. Then laboratory analysis and instrumental investigations can be used. There are pharmacological and non-pharmacological treatments for NE. The role of drugs is a short-term possibility that allows the child to recover confidence, or a temporary measure to tide him/her over nights spent away from home. For too long, NE has not been recognised as a severe condition, because there was no specific education at medical school and a poor involvement by the practitioners. Keywords: Nocturnal enuresis, bedwetting, sfincterial control, detrusor hyperactivity, nocturnal polyuria

Rapid Maxillary Expansion Effects on Nocturnal Enuresis in Children

To assess the effects of 10-14 days of rapid maxillary expansion (RME) on nocturnal enuresis (NE) in children who have long-standing resistance to medical therapy and to evaluate the long-term success rate after 10 years. Twenty-three children with NE, aged 6-15 years old (mean age = 10), who wet their bed almost every night and had never been dry were referred from pediatric specialists. Mean RME was 6.5 mm (range = 5-8), but only 7 of the 23 patients had lateral crossbites. Rhinomanometric measurements were taken before and after RME, and patients were interviewed 10 years after treatment. Positive effects of RME were observed in nearly 50% of the patients within 1 month of treatment: six were completely dry and five had notable improvements. Relapse in the overexpanded arches to a normal transversal occlusion was noted within 1 year. No correlation was found between success and improved airways, familial heritage, school performance, or other social factors. Younger children responded better to the treatment. Results were stable at the 10-year follow-up, and no adverse reactions were reported. Orthodontic RME is a new option for treating children with NE who are resistant to medical therapy; the treatment has no adverse side effects.

Diagnosis and treatment of nocturnal enuresis in children

Nocturnal enuresis is a heterogeneous disorder with various underlying pathophysiological mechanisms and causes a mismatch between the nocturnal bladder capacity and the amount of urine produced during sleep at night. It is associated with a simultaneous failure of conscious arousal in response to the sensation of bladder fullness. Generally, a complete history and physical examination, with a specific focus on the genitourinary, gastrointestinal, and neurologic systems, is sufficient to evaluate a patient with enuresis. The therapeutic focus is directed toward a differential approach based on the underlying mechanism and toward combination therapies such as alarm devices and desmopressin as well as anticholinergic agents and desmopressin. Children with increased nocturnal urine production usually have a good response to desmopressin therapy. Patients with a small bladder generally show a poor response to desmopressin treatment, but they would benefit more from combination therapy with enuretic alarm, urotherapy, and antimuscarinic agents in addition to desmopressin. Different types of bladder dysfunction, which result in a small nocturnal bladder capacity, probably contribute significantly to the pathogenesis of nocturnal enuresis, particularly in those with treatment failure and refractory symptoms. Because different clinical subgroups may show different responses to treatment, it is necessary to distinguish these subgroups before a decision on the specific treatment protocol can be made.

The prevalence of infrequent bedwetting and nocturnal enuresis in childhood

Although epidemiological surveys generally indicate declining rates of bedwetting with age, recent studies show that children with severe nocturnal enuresis have lower prevalence rates, which persist into adolescence. This study reports prevalence rates of both infrequent bedwetting (IB) and nocturnal enuresis (NE) at five time points during childhood with a large cohort of children. The Avon Longitudinal Study of Parents and Children provided a cohort of 13,973 singleton/twin infants alive at 12 months. These were followed up at 54, 65, 78, 91 and 115 months with a questionnaire relating to frequency of bedwetting and other variables. The prevalences of IB and NE were derived from these measures with missing data imputation being used to correct for possible loss-to-follow-up bias. The overall prevalence rate of bedwetting declined from 30% (54 months) to 9.5% (115 months), being most pronounced between 54 and 65 months. Children with NE (wet at least twice a week) had lower prevalence rates at all ages but were more likely to persist with the problem over time and to have the non-monosymptomatic type of bedwetting compared to children with IB. Children with the severest form of bedwetting are likely to persist with the problem and to have the more complex form (non-monosymptomatic). The results are discussed in relation to the clinical importance of early identification.

A case of imipramine induced toxicity with Brugada electrocardiographic pattern in a toddler

Imipramine, a tricyclic antidepressant (TCA), is used for the treatment of non-polar depression and nocturnal enuresis in children in whom an organic pathology has been excluded, anxiety disorders, and neuropathic pain. Clinical toxicity following the treatment of TCAs, including imipramine, is well known. The anticholinergic effects initially present include a dry mouth, ileus, dilated pupils, urinary retention, and mild sinus tachycardia. The central nervous system toxicity includes delirium, agitation, restlessness, hallucinations, convulsions, and CNS depression or coma. However, the most life-threatening toxicity remains the development of cardiac dysrhythmias. Conduction delays such as QRS and corrected QT prolongation, wide QRS complex tachycardia, and the Brugada electrocardiographic pattern have been reported. Sodium bicarbonate decreases QRS widening and suppresses dysrhythmias by providing excess sodium to reverse the TCA-induced sodium-channel blockade and possibly by binding directly to the myocardium. There are no pediatric case reports on imipramine or other TCA associated toxicity in Korea. Here, we describe a patient who presented with convulsions, tachycardia with a wide QRS complex, a Brugada electrocardiographic pattern, and anuresis associated with an accidental overdose of imipramine and the outcome of treatment with sodium bicarbonate.

Genetic and environmental influences on sleeptalking, half-sleeping, night terrors, and nocturnal enuresis in childhood

The purpose of this study was to clarify genetic contributions to the childhood behavioral phenomena of sleeptalking, half-sleeping, night terrors, and nocturnal enuresis using the two largest databases of Japanese twins. The subjects were children of members of several maternal associations for multiples, including 765 pairs ranged in age from 3 to 15 years with a mean age of 7.0 years, as well as school applicants, including 1,140 twin pairs 11-12 years of age. All data were gathered by questionnaire. Structural equation modeling showed that the proportion of total phenotypic variance attributable to genetic influences was 88-96% regarding sleeptalking, 62-91% regarding half-sleeping, and 70-91% regarding night terrors, which were higher in the school applicants group than in the maternal associations group. Age and gender difference was suggested to impact nocturnal enuresis. Moreover, co-occurrence of sleeptalking, half-sleeping, and night terrors were attributed partly to common genetic or environmental factors for these three traits.

The Prevalence of Attention Deficit-Hyperactivity Disorder in Children With Nonmonosymptomatic Nocturnal Enuresis: A 4-Year Followup Study

The prevalence of attention deficit-hyperactivity disorder was increased in a predominantly nonmonosymptomatic nocturnal enuresis population reported on previously. At 2 years after onset of treatment for enuresis attention deficit-hyperactivity disorder seemed to be a risk factor for continuing enuresis. In the current 4-year followup study we sought to determine whether the original attention deficit-hyperactivity disorder diagnosis could be reconfirmed, thereby reflecting the presence of a psychiatric syndrome rather than a coping behavior to deal with the negative consequences of enuresis. An additional study goal was to investigate the evolution in enuresis status in children with and without attention deficit-hyperactivity disorder. A total of 79 children diagnosed with enuresis in the baseline study took part in a 3rd screening for attention deficit-hyperactivity disorder. A diagnostic interview (Diagnostic Interview Schedule for Children-Parent Edition) was administered to the parents, questionnaires (Child Behavior Checklist/Teacher Report Form, Disruptive Behavior Disorder Rating Scale) were completed by the parents and teachers, and medical files were consulted. Of the baseline attention deficit-hyperactivity disorder diagnoses 64% could be reconfirmed at 4-year followup, compared to 73% at 2-year followup. The prevalence of enuresis also decreased by 23%, to 42%. The distribution of enuresis at 4-year followup did not significantly differ between children with and without a baseline or final diagnosis of attention deficit-hyperactivity disorder. No significant predictors of bedwetting episodes could be found in sociodemographic, attention deficit-hyperactivity disorder or organic characteristics. At 4-year followup a substantial number of children still met the criteria for attention deficit-hyperactivity disorder, even after becoming dry. The prevalence rate of enuresis decreased much faster than that of attention deficit-hyperactivity disorder, suggesting the presence of a psychiatric syndrome rather than a coping behavior. Contrary to intermediate findings, current enuresis status could no longer be predicted by attention deficit-hyperactivity disorder symptoms.

Nocturnal Polyuria is Related to Absent Circadian Rhythm of Glomerular Filtration Rate

Monosymptomatic nocturnal enuresis is frequently associated with nocturnal polyuria and low urinary osmolality during the night. Initial studies found decreased vasopressin levels associated with low urinary osmolality overnight. Together with the documented desmopressin response, this was suggestive of a primary role for vasopressin in the pathogenesis of enuresis in the absence of bladder dysfunction. Recent studies no longer confirm this primary role of vasopressin. Other pathogenetic factors such as disordered renal sodium handling, hypercalciuria, increased prostaglandins and/or osmotic excretion might have a role. So far, little attention has been given to abnormalities in the circadian rhythm of glomerular filtration rate. We evaluated the circadian rhythm of glomerular filtration rate and diuresis in children with desmopressin resistant monosymptomatic nocturnal enuresis and nocturnal polyuria. We evaluated 15 children (9 boys) 9 to 14 years old with monosymptomatic nocturnal enuresis and nocturnal polyuria resistant to desmopressin treatment. The control group consisted of 25 children (12 boys) 9 to 16 years old with monosymptomatic nocturnal enuresis without nocturnal polyuria. Compared to the control population, children with nocturnal polyuria lost their circadian rhythm not only for diuresis and sodium excretion but also for glomerular filtration rate. Patients with monosymptomatic nocturnal enuresis and nocturnal polyuria lack a normal circadian rhythm for diuresis and sodium excretion, and the circadian rhythm of glomerular filtration rate is absent. This absence of circadian rhythm of glomerular filtration rate and/or sodium handling cannot be explained by a primary role of vasopressin, but rather by a disorder in circadian rhythm of renal glomerular and/or tubular functions.

Desmopressin Resistant Nocturnal Polyuria May Benefit From Furosemide Therapy Administered in the Morning

There is increasing evidence that a subgroup of patients with monosymptomatic nocturnal enuresis and nocturnal polyuria resistant to desmopressin may have an abnormal circadian rhythm of renal tubular sodium handling. The pathogenesis of this phenomenon remains to be elucidated. If the increased sodium excretion overnight results in desmopressin resistance, decreasing the sodium excretion overnight may result in subsequently better desmopressin response. We conducted a pilot study of the anti-enuretic and antidiuretic effects of desmopressin combined with 0.5 mg/kg furosemide daily in patients with desmopressin resistant nocturnal polyuria despite dietary sodium and protein restriction. Values were plotted against the reference frame of a desmopressin responsive enuresis group. Baseline values revealed significantly lower urinary osmolality and higher diuresis rate overnight compared to the reference population (monosymptomatic nocturnal enuresis desmopressin responders). Introduction of desmopressin resulted in normalization of nocturnal urinary osmolality. However, nocturnal polyuria persisted, despite reaching maximal urinary concentration overnight. Although protein and sodium restriction resulted in a significant decrease in urinary osmolality and diuresis rate, the difference was not clinically important enough to reach normal values or to achieve continence. Furosemide in the morning resulted in a significant increase in diuresis and osmotic and sodium excretion during the day, and decreased nighttime diuresis and osmotic excretion. In 9 of 12 patients the nocturnal antidiuretic effect resulted in an anti-enuretic effect, defined as enuresis less than 1 wet night per month. In 3 patients insufficient anti-enuretic effects were obtained despite significant antidiuresis. This pilot study clearly demonstrates that introduction of early morning furosemide results in a significantly lower nocturnal diuresis rate. Reduced diuresis associated with unchanged urinary osmolality results in decreased nocturnal osmotic excretion in compensation for increased osmotic (sodium) excretion during the daytime.

Primary monosymptomatic nocturnal enuresis in children and adolescents

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.