Primary Nocturnal Enuresis Research Articles

A prospective longitudinal study to estimate the prevalence of obesity in Egyptian children with nocturnal enuresis and the association between body mass index and response to therapy

PurposeNocturnal enuresis is defined as the involuntary voiding of urine in bed beyond the age at which bladder control is normally obtained. Previous studies have suggested a high rate of obesity in children with nocturnal enuresis. We evaluated this hypothesis and investigated the correlation between body mass index and the efficacy of treatment. Subjects and methodsThis was a prospective–longitudinal study done on 180 children with primary mono symptomatic nocturnal enuresis. Urinary diary data and body mass index percentile were determined. Response to the treatment was evaluated statistically and correlated with body mass index percentile. Response to different modalities of the treatment were also statistically evaluated separately and correlated with the BMI. The statistical test used was ANOVA F-test. Results22.7% of our patients with nocturnal enuresis were either overweight or obese (13.9% and 7.8% respectively) according to the Egyptian national growth charts. Therefore, the prevalence of overweight and obesity is not higher in children with nocturnal enuresis as compared to the overall prevalence in normal Egyptian children (14%). But when we adjusted these values according to the social class of our patients, the prevalence of obesity was higher than normal for children of low socioeconomic status.There was no significant correlation between response to standard pediatric urological interventions (behavioral therapy, alarm therapy, imipramine, desmopressin, oxybutynin and tolterodine) and the BMI of our patients. Also, there was no significant difference in the response or relapse rates to the different modalities of therapies in the groups of patients with different BMI. ConclusionsObesity correlates with high BMI in lower socioeconomic classes, but does not correlate with efficacy of the treatment in children with nocturnal enuresis.

Abnormal circadian blood pressure regulation in children with nocturnal enuresis

Introduction: To investigate autonomic nervous system function in enuretic children by performing ambulatory blood pressure monitor (ABPM) for 24 h. Methods: Twenty-eight children ranging in age from 6 to 15 years with primary nocturnal enuresis and 27 age-matched healthy controls were enrolled and they get 24 h ABPM. Hypertension was defined as standard deviation score (SDS) > 1.64 (i.e., >95th percentile) adjusted for gender and height. Urinalysis, urine electrolyte levels, urinary culture, and urinary system ultrasound were carried out in all children. They have also requested to have a diary about daily fluid intake and urine volume. Results: Although the mean 24-h and daytime diastolic blood pressure (BP) did not differ between the groups, systolic BP (SBP) was significantly higher in enuretic children (p < 0.05). The mean night-time SBP, DBP values, SDS and BP loads were found to be significantly higher than those in the controls (p < 0.01). A lack of nocturnal decrease was more prevalent in the enuretic children compared with the control subjects, the difference was statistically significant for DBP but not for SBP. Patients with elevated night-time BP load was found to have higher frequency of urinary incontinence per week as well as per night when compared with enuretic children with normal night-time BP load (r = 0.72, r = 0.69, p < 0.01, respectively). Conclusion: Subtle abnormalities of circadian BP regulation in enuretic children indicated by a selective elevation of nocturnal SBP, DBP, and MAP, and attenuated nocturnal dipping may reflect sympathetic hyper activation and its possible role in pathogenesis of enuresis.

Primary Monosymptomatic Nocturnal Enuresis: Monotherapy vs Combination Therapy

To evaluate the clinical results of monotherapy with combination therapy in treatment of primary monosymptomatic nocturnal enuresis (PMNE) in children. Between December 2008 and May 2013, we reviewed the records of 176 children with PMNE. The monotherapy group received 120 micrograms of desmopressin melt whereas the combination therapy group received 120 micrograms of desmopressin melt plus 1-2 mg oral tablet of tolterodine. The degree of response was evaluated at 1-3 months during the treatment and 6 months after complete cessation of treatment protocol. Between 176 children, 84 and 92 patients received monotherapy and combination therapy, respectively. There were no statistical differences in gender, age, or baseline monthly frequency of PMNE between the two groups. At baseline, patients had an overall mean of 23.6 ± 5.6 wet nights per month, which decreased to 10.8 ± 5.6 and 7.3 ± 5.3 in monotherapy group and 8.9 ± 9.5 and 3.3 ± 4.9 in combination therapy group at 1 and 3 months after treatment. The rates of Complete plus Partial Response to treatment at 1 and 3 months for monotherapy and combination therapy group were 63.1% and 73.9% vs 72.5% and 93.47% (P value .12 vs .006). The relapse of PMNE 6 months after complete cessation of treatment was 16.39% and 9.09% for monotherapy vs combination therapy group. This study supports the efficacy of combination therapy with desmopressin melt plus oral tolterodine over monotherapy with desmopressin melt in the first-line treatment of PMNE in children.

540 Mental and psychological characteristics of young adult males with primary nocturnal enuresis: A case-control observational study

540 Mental and psychological characteristics of young adult males with primary nocturnal enuresis: A case-control observational study

Association between Asthma and Primary Nocturnal Enuresis in Children

Enuresis, sleep respiratory disorders and asthma compromise the quality of sleep in children and may occur in association with each other. An association between sleep respiratory disorders and enuresis has already been demonstrated. According to united airways disease abnormalities of the upper and lower airways may coexist. A child who wheezes has a greater chance of snoring and having obstructive sleep apnea. Since asthma and sleep respiratory disorders may be associated, and sleep respiratory disorders are associated with enuresis, we determined the possibility of an association between asthma and enuresis. Between August 20 and March 2015 parents/guardians of children 6 to 14 years old from 16 elementary schools in our area were randomly chosen for study. Children with nonmonosymptomatic enuresis and urological or neurological disease were excluded. The Tucson and ISAAC (International Study of Asthma and Allergies in Childhood) questionnaires wereused to assess sleep respiratory disorders and asthma, respectively. A total of 523 children (283 males and 240 females) with a mean ± SD age of 9.42 ± 2.46 years were included in analysis. The overall prevalence of enuresis was 15.87% (95% CI 12.98-19.26). Asthmatic children with wheezing in the last 12 months were 2.33 times more likely to have had enuresis at some point in life (OR 2.33, 95% CI 1.37-3.95, p = 0.0017). If enuresis was present, the chance increased to 2.78 (95% CI 1.38-5.61, p = 0.0041). Enuretic children were 5.34 times more prone to have apnea reported by parents (95% CI 2.19-13.03, p= 0.0002). These findings demonstrate that asthma as well as sleep respiratory disorders is associated with primary nocturnal enuresis.

Chiropractic Care of an 8-Year-Old Girl With Nonorganic, Primary Nocturnal Enuresis: A Case Report

ObjectiveThe purpose of this case report is to describe the chiropractic management of an 8-year-old girl with nonorganic, primary nocturnal enuresis. Clinical FeaturesAn 8-year-old female patient presented to a chiropractic clinic with persistent nighttime bedwetting. The patient experienced enuresis, on average, 7 nights per week. The patient presented with no other comorbidities or complaints, such as low back or pelvic pain. Intervention and OutcomesChiropractic treatment included high-velocity, low-amplitude manipulation of the left sacroiliac joint over 3 visits. Follow-up at 3 months revealed only 3 subsequent episodes of nocturnal enuresis. ConclusionThis patient reported the resolution of nonorganic, primary nocturnal enuresis after receiving a series of side-posture chiropractic manipulations of the left sacroiliac joint.

Assessment of Blood Pressure in Primary Monosymptomatic Nocturnal Enuresis

Introduction: Enuresis is defined as the repeated voiding of urine into bed at least twice a week for at least 3 consecutive months in a child who is at least 5 years of age. Primary enuresis occurs in children who have never been consistently dry through the night. Monosymptomatic enuresis has no associated daytime symptoms. Increased nocturnal urine production in primary nocturnal enuretic patients could possibly be associated with autonomic nervous system dysfunction. The aim of this study was to investigate autonomic nervous system function in enuretic children. Materials and Methods : In this study, children with monosymptomatic primary nocturnal enuresis (MPNE) and healthy children without MPNE were enrolled and their blood pressure was measured twice a day (in the morning and afternoon). Urinalysis, urine electrolyte levels, urinary culture, and urinary system ultrasound were performed in all the children. They were also requested to have a diary about daily fluid intake and the volume of daily urine. Results: The MPNE group comprised 100 children (M/F: 58/42) and the control group included 100 healthy children (M/F: 51/49). The mean age of the children was 8.1±2.3 and (8.9±2.53 years in MPNE and control groups, respectively. The mean diastolic blood pressure (DBP) during the nighttime and daytime did not differ between the groups (p-value>0.05); however, the mean systolic blood pressure (SBP) was significantly higher in the nighttime in the MPNE group (p-value 0.05). Conclusions: Nighttime SBP was significantly higher in children with MPNE. These subtle abnormalities of the circadian blood pressure regulation may reflect autonomic nervous system dysfunction and contribute to the pathogenesis of MPNE. Keywords : Child; Enuresis; Blood pressure; Autonomic dysfunction

Assessment of Blood Pressure in Primary Monosymptomatic Nocturnal Enuresis

Introduction: Enuresis is defined as the repeated voiding of urine into bed at least twice a week for at least 3 consecutive months in a child who is at least 5 years of age. Primary enuresis occurs in children who have never been consistently dry through the night. Monosymptomatic enuresis has no associated daytime symptoms. Increased nocturnal urine production in primary nocturnal enuretic patients could possibly be associated with autonomic nervous system dysfunction. The aim of this study was to investigate autonomic nervous system function in enuretic children.Materials and Methods: In this study, children with monosymptomatic primary nocturnal enuresis (MPNE) and healthy children without MPNE were enrolled and their blood pressure was measured twice a day (in the morning and afternoon). Urinalysis, urine electrolyte levels, urinary culture, and urinary system ultrasound were performed in all the children. They were also requested to have a diary about daily fluid intake and the volume of daily urine.Results: The MPNE group comprised 100 children (M/F: 58/42) and the control group included 100 healthy children (M/F: 51/49). The mean age of the children was 8.1±2.3 and (8.9±2.53 years in MPNE and control groups, respectively. The mean diastolic blood pressure (DBP) during the nighttime and daytime did not differ between the groups (p-value&gt;0.05); however, the mean systolic blood pressure (SBP) was significantly higher in the nighttime in the MPNE group (p-value&lt;0.05) but did not differ between the groups during the daytime (p-value&gt;0.05).Conclusions: Nighttime SBP was significantly higher in children with MPNE. These subtle abnormalities of the circadian blood pressure regulation may reflect autonomic nervous system dysfunction and contribute to the pathogenesis of MPNE.Keywords: Child; Enuresis; Blood pressure; Autonomic dysfunction

Advances in the management of primary monosymptomatic nocturnal enuresis in children

Advances in the management of primary monosymptomatic nocturnal enuresis in children

The influence of the sleep-wake cycle on primary monosymptomatic nocturnal enuresis: a non-randomized comparative study

Backround: Enuresis implies severe stress in affected children, and impairs quality of life and sleep. Children with enuresis experience difficulties in their arousal from sleep, possibly associated with disturbances of the circadian rhythm. In this study, we aimed to evaluate the sleep–wake cycle and sleep disturbances in children with monosymptomatic enuresis nocturna (MEN). Method: The study comprised 70 children with MEN who were admitted to the pediatrics and urology outpatients department and 94 age-matched healthy controls. Parents completed “Strengths and Difficulties Questionnaire,” Children’s Sleep Habits Questionnaire (CSHQ), Children’s Chronotype Questionnaire scale. Results: Children with enuresis had significantly more sleep and psychological problem. Enuresis group reported higher bedtime resistance, parasomnias, breathing-related problems, and daytime sleepiness in CHSQ (p < 0.05). Although circadian preference did not differ statistically between the groups (p > 0.05), sleep duration on school days and awakening and mid-sleep points, both on scheduled and free days, were found to be significantly different in the enuretic group (p < 0.05). In logistic regression analysis, age, sleep period on scheduled days, sleep inertia on scheduled and free days were significant predictor for enuresis. Discussion: Children with enuresis were more likely to experience problematic sleep. This may reflect that enuretic children have impaired sleep–wake cycles, leading to dysregulation of daily functional changes of bladder capacity and related hormones such as ADH. These findings might imply a sleep–wake disturbance in enuresis.

Socio-Demographic Characteristics and Predictors of Childhood Primary Nocturnal Enuresis in Benin City, Nigeria

Socio-Demographic Characteristics and Predictors of Childhood Primary Nocturnal Enuresis in Benin City, Nigeria

Advances in the management of primary monosymptomatic nocturnal enuresis in children

Intermittent incontinence of urine in a sleeping child who has previously been dry for less than 6 months without any other lower urinary tract symptoms is considered to be primary monosymptomatic nocturnal enuresis (PMNE). Although, most children outgrow PMNE with age, the psychological impact on the child warrants parental education and patient motivation and treatment. Motivational therapy, alarm therapy and drug therapy are the mainstay of treatment. Motivational and alarm therapy have better success rates than drug therapy alone. Desmopressin is the commonly used first-line drug and is best for short-term relief. Other drugs such as anti-cholinergics, imipramine and sertraline are used in resistant cases. This review focuses on the assessment and treatment of PMNE.

Efficacy of alarm intervention in primary monosymptomatic nocturnal enuresis in children

Background: Enuresis affects about 15 to 20% of five year old children, and even up to 2% of young adults. The various treatment modalities used are behavioural therapy, alarm intervention and pharmacological therapy. Current evidences suggest that alarm intervention is preferable to other modalities of treatment. So a study was done to assess the efficacy of alarm interventions in primary monosymptomatic nocturnal enuresis in children. Methods: A prospective study was done on children aged between 5-18 years with primary monosymptomatic nocturnal enuresis on a total of 62 children. An enuresis diary was maintained by parents. All children received alarm intervention for 12 weeks. A child remaining dry for two consecutive weeks was taken as a success. The subjects were followed up for 12 weeks, two or more wet night in 2 weeks period were taken as relapse. If child failed to become dry after 12 weeks of alarm intervention, intervention was continued for maximum of 6 months or till he became dry. Results: Out of 62 children, majority were males and in the age group of 5-7 years. Family history of enuresis was present in 30.65% of children. A total of 74.19 % of subjects achieved dryness while failures were 25.8% and relapse was seen in 23.91 % during follow up. Significant improvement was noticed as early as 2 months after alarm intervention (p 0.00499) but maximum improvement was seen after 5 months (20 week). On follow up 23.91 % children had relapsed but the frequency of wet nights among these also was significantly low (mean wet nights 0.08/week). Even among failures there was a significant decrease in mean number of wet nights (from 4.24 wet nights/week to 1.85 wet nights/week). Conclusions: Alarm treatment was an effective intervention for management of primary monosymptomatic nocturnal enuresis with high success and low relapse rate.

Attention deficit hyperactivity disorder in children with primary monosymptomatic nocturnal enuresis: A case-control study.

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood neurological disorders. The aim of this study was to investigate ADHD in children with primary monosymptomatic nocturnal enuresis (PMNE) and compare it with healthy children. A total of 100 five to 16-year-old children with PMNE and 100 healthy children without NE were included in this case-control study as the cases and control groups, respectively. Subjects were selected from children who were referred to the pediatric clinic of the Amir Kabir Hospital of Arak, Iran, based on inclusion and exclusion criteria. ADHD was diagnosed by Conner's Parent Rating Scale-48 and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria and was confirmed by consultation with a psychiatrist. Data were analyzed by binomial test using SPSS18. ADHD inattentive type was observed in 16 cases (16%) with PMNE and five controls (5%) (P=0.01). Despite these significant differences in the case and control groups, 25 (25%) and 16 (16%) children were affected by ADHD hyperactive-impulsive type (P=0.08) and 15 (15%) and 16 (16%) children were affected by ADHD mixed type (P=0.84), respectively. ADHD inattentive type in children with PMNE was significantly more common than that in healthy children. The observed correlation between ADHD inattentive type and PMNE makes psychological counseling mandatory in children with PMNE.

Sleep Pattern in Primary Enuretic Children

Objectives: Nocturnal enuresis is a common problem in children. A disturbance of sleep was suggested as a pathogenetic factor. Our aim is to compare sleep of primary nocturnal enuretic children with a group of matched controls. Subjects and methods: This study was carried out on two groups; Patient group: included 20 patients; 13 males and 7 females with primary monosymptomatic nocturnal enuretic. Age range between 6-15 years and control group: included 20 apparently healthy subjects (10 males and 10 females) without any urological, neurological or other medical diseases. Nocturnal enuresis sheet, sleep questionnaire, Intelligence quotient and overnight polysomnography were applied. Results: Nocturnal enuresis was common in males than females in patient group with no significant difference. Family history of NE was positive in 65% of cases. Excessive somnolence was significantly higher in patients than in control group. Arousal disorders and sleep wake transition disorders were common in patient group than control group with no significant difference between the two groups. There was a significant increase in stage 3 and 4 duration and a highly significant decrease in arousal index in patients in comparison to the control group. There was no statistically significant difference in sleep latency, REM latency and stage 1 & 2 duration in patients in comparison to control group. Enuretic events were distributed across the night and not related to specific sleep stage. Conclusions: It seems that some children with primary nocturnal enuresis are deep sleepers. A high arousal threshold may be one of the pathogenetic factors underlying primary nocturnal enuresis.

Incidence of obsessive-compulsive disorder in children with nonmonosymptomatic primary nocturnal enuresis.

Introduction:Enuresis is defined as the repeated voiding of urine into clothes or bed at least twice a week for at least 3 consecutive months in a child who is at least 5 years of age. The behavior is not due exclusively to the direct physiologic effect of a substance or a general medical condition. Diurnal enuresis defines wetting, whereas awake and nocturnal enuresis refers to voiding during sleep. Primary enuresis occurs in children who have never been consistently dry through the night, whereas secondary enuresis refers the resumption of wetting after at least 6 months of dryness. Monosymptomatic enuresis has no associated daytime symptoms, and nonmonosymptomatic enuresis, which is more common, often has at least one subtle daytime symptom. Monosymptomatic enuresis is rarely associated with significant organic underlying abnormalities. Obsessive–compulsive disorder (OCD) is a chronic disabling illness characterized by repetitive, ritualistic behaviors over which the patients have little or no control. The purpose of this study was to investigate the relationship between OCD and nonmonosymptomatic nocturnal enuresis (NMNE).Materials and Methods:In this case–control study, we evaluated 186 children aged 6–17 years old who were visited in the pediatric clinics of Amir Kabir Hospital, Arak, Iran. The control group included 93 healthy children, and the case group included 93 age- and sex-matched children with stage 1–3 chronic kidney disease (CKD). Then, the children's behavioral status was evaluated using the Children's Yale-Brown Obsessive–Compulsive Scale.Results:The difference in compulsion was significant (P = 0.021), whereas the difference in obsession was significant between the two groups (P = 0.013). The most common symptom in CKD children with compulsion was silent repetition of words.Conclusion:Compulsive and obsessive are more common in NMNE versus healthy children. The observed correlation between compulsive-obsessive and NMNE makes psychological counseling mandatory in children with NMNE.

Meta analysis of the alarm treatment and desmopressin in the treatment of primary nocturnal enuresis in children

Objective To explore the therapy efficacy for children with primary nocturnal enuresis by meta-analysis on the efficiency of alarm treatment versus desmopressin. Methods PubMed, Central, Elesvier, CNKI and some other databases were browsed to obtain all randomized controlled trails(RCT) and to compare the therapy between alarm treatment and desmopressin.Data extraction and quality evaluation were done by methods recommended by Cochrane center.The results of short-term and long-term efficacy and compliance were analyzed by Review Manager 5.0. Results Fifty-four RCT were retrieved and 11 RCT were included in the study.There was no statistical difference between alarm treatment and desmopressin when analyzing by no wetting episode, wetting no more than 1 night per month, wetting nights' decrease over 90% or wetting nights decrease over 50%.By 3-month follow-up after treatment stopped, alarm treatment significantly reduced the wetting nights to over 50% or less than 1 night per month than desmopressin.By 6-month follow-ups after treatment stopped, there was no difference between alarm treatment and desmopressin when analyzed by wetting no more than 1 night.The relapse rate of desmopressin was higher than that of alarm treatment(P=0.007). However, the withdrawal and abandonment rate of alarm treatment was higher than that of desmopressin(P<0.000 01). Severe adverse effects were not found in both of the treatment groups. Conclusions There is no statistical difference between alarm and desmopressin therapy in short-term treatment.The efficiency of alarm device is better than that of desmopressin in long-term treatment.The follow-up of alarm treatment lost more than that of desmopressin.Desmopressin is better than the alarm treatment in compliance but has higher recurrence rate. Key words: Primary nocturnal enuresis; Alarm treatment; Desmopressin; Meta analysis; Child

Proximal tubule proteins are significantly elevated in bladder urine of patients with ureteropelvic junction obstruction and may represent novel biomarkers: A pilot study

Ureteropelvic junction obstruction (UPJO) is the major cause of hydronephrosis in children and may lead to renal injury and early renal dysfunction. However, diagnosis of the degree of obstruction and severity of renal injury relies on invasive and often inconclusive renal scans. Biomarkers from voided urine that detect early renal injury are highly desirable because of their noninvasive collection and their potential to assist in earlier and more reliable diagnosis of the severity of obstruction. Early in response to UPJO, increased intrarenal pressure directly impacts the proximal tubule brush border. We hypothesize that single-pass, apically expressed proximal tubule brush border proteins will be shed into the urine early and rapidly and will be reliable noninvasive urinary biomarkers, providing the tools for a more reliable stratification of UPJO patients. We performed a prospective cohort study at Connecticut Children's Medical Center. Bladder urine samples from 12 UPJO patients were obtained prior to surgical intervention. Control urine samples were collected from healthy pediatric patients presenting with primary nocturnal enuresis. We determined levels of NGAL, KIM-1 (previously identified biomarkers), CD10, CD13, and CD26 (potentially novel biomarkers) by ELISA in control and experimental urine samples. Urinary creatinine levels were used to normalize the urinary protein levels measured by ELISA. Each of the proximal tubule proteins outperformed the previously published biomarkers. No differences in urinary NGAL and KIM-1 levels were observed between control and obstructed patients (p = 0.932 and p = 0.799, respectively). However, levels of CD10, CD13, and CD26 were significantly higher in the voided urine of obstructed individuals when compared with controls (p = 0.002, p = 0.024, and p = 0.007, respectively) (Figure). Targeted identification of reliable, noninvasive biomarkers of renal injury is critical to aid in diagnosing patients at risk, guiding therapeutic decisions and monitoring treatment efficacy. Proximal tubule brush border proteins are reliably detected in the urine of obstructed patients and may be more effective at predicting UPJO.

Commentary on “No effect of basic bladder advice in enuresis: A randomized controlled trial”

Cederblad et al. [1] are the first to report results of a randomized clinical trial (RCT) assessing whether the recommendation to initially treat all children suffering from nocturnal enuresis (NE) with basic bladder advice (BBA) can be supported by evidence. Forty children aged 6 years and older with primary untreated NE and without daytime incontinence were randomized to receive either first BBA during 1 month and then alarm therapy (AT) for 8 weeks, or only AT. Since BBA did not reduce enuresis frequency or the end results after the AT, the authors concluded that the recommendation to treat all children with BBA first cannot be supported and recommend to start with the AT or desmopressin as first-line treatment [1]. The research question was relevant and interesting. However, we feel that the conclusion cannot be supported because of important methodological flaws.

Efficacy of posterior tibial nerve stimulation in the treatment of children with primary mono-symptomatic nocturnal enuresis

Background/Aims: Primary monosymptomatic nocturnal enuresis is the most frequent (85%) type of enuresis in children. However, there is limited research on the effect of posterior tibial nerve stimulation on monosymptomatic nocturnal enuresis in children. This study investigated the effect of posterior tibial nerve stimulation on primary monosymptomatic nocturnal enuresis in children. Methods: This controlled exposure study was conducted using a pretest–posttest design between March and December 2014. Participants (n=80) were randomly distributed to two study groups (control and intervention) using block randomisation. Participants in the control group were given and instructed on how to use a bedwetting alarm in addition to medical treatment for 12 weeks, whereas participants in the intervention group received posterior tibial nerve stimulation in addition to medical treatment for 12 weeks. The frequency of nocturnal enuresis, maximum voided volume and quality of life were evaluated before and after treatment. Results: Comparative analysis between pre- and post-treatment data revealed significant differences in both groups across all measured variables (p&lt;0.05), with significant improvements in all three outcome measures found in the intervention group. Post-treatment, the intervention group demonstrated decreased frequency of nocturnal enuresis and improved maximum voided volume and quality of life. Conclusions: Posterior tibial nerve stimulation is an effective and safe approach for the treatment of primary monosymptomatic nocturnal enuresis and control of bedwetting in children.