Nocturnal enuresis��theoretic background and practical guidelines

Nocturnal polyuria, nocturnal detrusor overactivity and high arousal thresholds are central in the pathogenesis of enuresis. An underlying mechanism on the brainstem level is probably common to these mechanisms. Enuretic children have an increased risk for psychosocial comorbidity. The primary evaluation of the enuretic child is usually straightforward, with no radiology or invasive procedures required, and can be carried out by any adequately educated nurse or physician. The first-line treatment, once the few cases with underlying disorders, such as diabetes, kidney disease or urogenital malformations, have been ruled out, is the enuresis alarm, which has a definite curative potential but requires much work and motivation. For families not able to comply with the alarm, desmopressin should be the treatment of choice. In therapy-resistant cases, occult constipation needs to be ruled out, and then anticholinergic treatment—often combined with desmopressin—can be tried. In situations when all other treatments have failed, imipramine treatment is warranted, provided the cardiac risks are taken into account.     

Coincidental adrenal ganglioneuroma – a case presenting with enuresis nocturna

A 9-year-old boy presenting with primary enuresis nocturna was discovered to harbour a large left adrenal mass which produced no hormonal abnormalities. He was undergone an exploration and the mass was removed completely. It was found to be an adrenal ganglioneuroma weighing 240 g. Though no cause-and-effect relationship is established, the case no long suffered from enuresis soon after surgery and free of recurrence after 5 years.     

Nortriptyline for treating enuresis in ADHD—a randomized double-blind controlled clinical trial

Background

Treating enuresis in children with attention deficit hyperactivity disorder (ADHD) has not been previously reported. This study aims to investigate the efficacy, tolerability, and adverse effects of nortriptyline for treating enuresis in children with ADHD.

Methods

Forty-three children aged from 5 to 14?years old were randomized into two groups. The treatment group received methylphenidate plus nortriptyline, while the placebo group received methylphenidate plus placebo. Nortriptyline and placebo were administered for 30?days and methylphenidate was administered for 45?days. The major outcome measure was parent-reported frequency of enuresis for 2?weeks prior to the intervention, during the intervention, and for 2?weeks after stopping the adjuvant therapy. Adverse effects were also checked.

Results

While nortriptyline statistically decreased the incidence of nocturnal enuresis during the intervention, the number of enuresis events did not significantly change in the placebo group. In addition, enuresis was not different from the baseline frequency of enuresis after stopping nortriptyline or placebo administration. Both nortriptyline and placebo were tolerated well.

Conclusions

Administration of nortriptyline for treating enuresis in ADHD has not been investigated before. Nortriptyline is statistically superior to placebo. However, enuresis will relapse after stopping nortriptyline in children with ADHD who continue taking methylphenidate.     

Is nocturia of young adulthood a remnant of childhood nocturnal enuresis?

Introduction and hypothesis

Nocturia and nocturnal enuresis (NE) share similar aetiopathological factors, and may represent two different situations involving the same underlying issue. In this study, we tried to evaluate the relation between NE of childhood and nocturia of young adulthood.

Methods

A total of 577 female university students aged 17–24 years were included in the survey. A face-to-face questionnaire was administered concerning present nocturia and past NE history. A non-validated questionnaire, created by the authors, was used to evaluate the presence and the frequency of childhood NE and present nocturia. All participant data were checked by telephone contact with their parents.

Results

The overall prevalence rates of nocturia and history of nocturnal enuresis in the study population were 8.6 % and 15 % respectively. Sixteen per cent of nocturics and 15 % of non-nocturics had a history of childhood NE (p?=?0.837). The childhood NE was graded as severe or infrequent. The presence of nocturia was compared between participants with severe NE and infrequent NE, and no significant difference was observed (11.1 % vs 7.8 %, p?=?0.713). Nocturia frequency was compared with the history of childhood NE and we found that as the nocturia frequency increased, the rate of childhood NE also increased.

Conclusions

There was no relation between young adulthood nocturia and childhood NE in our study population, but as the severity of nocturia increased, the relation between nocturia and NE became more relevant.     

Psychological correlates of enuresis: a case�Ccontrol 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.     

Renal bladder ultrasound evaluation in monosymptomatic primary nocturnal enuresis: is it really necessary?

Background

Published guidelines regarding radiographic imaging in the evaluation of monosymptomatic primary nocturnal enuresis (MPNE) are not followed. We aimed to evaluate the prevalence of urological abnormalities on renal/bladder ultrasound (RBUS) in children with MPNE and to compare the RBUS findings in children with and without MPNE.

Methods

Retrospective data collection in all children aged 5–17 years seen for the initial evaluation of MPNE. Control group consisted of age- and sex-matched children who had abdominal ultrasound for other than bladder-/kidney-related causes. RBUS findings were analyzed with regard to the need for intervention and/or follow-up.

Results

While abnormalities on RBUS were seen in 12.54 % of enuretic children and in 5.38 % of controls (p?=?0.004), the majority of these findings were clinically insignificant. Of those with abnormalities, only 4 enuretic children (1.43 %) required intervention and 8 (2.87 %) needed follow-up studies. These rates were not significantly different from the controls. However, enuretic children with RBUS abnormalities appear to be more resistant to treatment than enuretic children with normal RBUS (p?=?0.002).

Conclusions

A small proportion of abnormalities seen on RBUS in children with MPNE require intervention and/or further evaluation. The identification of insignificant RBUS findings could lead to unnecessary additional investigations owing to parental concern. Detailed history and a voiding diary may be sufficient in the initial evaluation of children with MPNE, although RBUS may play an important role in patients who are resistant to treatment.     

Persistent and occasional nocturnal enuresis in orthotopic urinary diversion: is there a urodynamic difference?

OBJECTIVE: To establish urodynamic criteria differentiating between men with a radical cystoprostatectomy and ileal neobladder who are persistently enuretic and those who are occasionally enuretic. PATIENTS AND METHODS: Fifty enuretic men at least 1 year after a radical cystoprostatectomy and ileal neobladder (hemi-Kock or 'W' neobladders) were divided into two groups according to the persistence of their complaint; 17 men were persistently enuretic (nightly) and 33 were occasionally enuretic (<3 episodes/week). Both groups were compared with 50 fully continent men with similar reservoirs. Uroflowmetry, enterocystometry and urethral pressure profilometry were carried out according to International Continence Society standards and terminology. RESULTS: Both enuretic groups had significantly higher residual urine volumes, pressure at mid-capacity and at maximum enterocystometric capacity, amplitude of uninhibited contractions, and lower compliance than continent men. Men with occasional enuresis also had a significantly higher frequency and duration of uninhibited contractions than continent men. Men with persistent enuresis had significantly lower average and maximum urinary flow rates than continent men, and significantly lower functional urethral length and maximum urethral pressure. Uroflowmetric and urethral pressure differences were dissimilar between men with occasional enuresis and controls. CONCLUSION: Enuretic men had significantly higher residual urine volumes and enterocystometric pressure variables than continent men. Men with persistent enuresis had significantly lower flow rates and less urethral resistance. Pharmacological inhibition of reservoir contraction and/or management of residual urine by clean intermittent catheterization before sleep might cure occasional enuresis.     

Is second-line enuretic alarm therapy after unsuccessful pharmacotherapy superior to first-line therapy in the treatment of monosymptomatic nocturnal enuresis?

INTRODUCTION: We aimed at comparing the success rates of primary enuretic alarm therapy with those of secondary alarm therapy after failed pharmacotherapy in the treatment of monosymptomatic nocturnal enuresis (MNE). PATIENTS AND METHODS: We randomly applied enuretic alarm therapy in 35 MNE patients (group 1) and desmopressin therapy in 49 MNE patients (group 2). The success and rebound rates after 3 and 6 months were determined. We also applied enuretic alarm therapy as a secondary treatment in 19 group 2 patients with complete rebound after 6 months (group 3). The success rates of patients who have received primary and secondary enuretic alarm therapy were compared. RESULTS: The success rates for groups 1 and 2 were 82.65 and 81.63%, respectively (p = 0.885), at 3 months and 54.28 and 26.53%, respectively (p = 0.007), at 6 months. The success rates in group 3 were 84.21 and 52.63%, respectively, at 3 and 6 months. When these success rates were compared between groups 1 and 3, no statistically significant difference was found (p = 1.000). CONCLUSION: Prior pharmacotherapy did not increase success rates of alarm therapy in our MNE patients.     

Do holding exercises or antimuscarinics increase maximum voided volume in monosymptomatic nocturnal enuresis? A randomized controlled trial in children

PURPOSE: We assessed prospectively the efficacy of holding exercises and/or antimuscarinics (oxybutynin chloride and placebo) for increasing maximum voided volume in prepubertal children with monosymptomatic nocturnal enuresis. MATERIALS AND METHODS: We randomly allocated 149 children to 5 groups, namely holding exercises with placebo (group A), holding exercises with oxybutynin (group B), placebo alone (group C), oxybutynin alone (group D) and alarm treatment (controls, group E). Maximum voided volume was the greatest voided volume from a 48-hour bladder diary, and holding exercise volume was the greatest volume produced with postponement of voiding after a fluid load, once daily for 4 days. Study medication, holding exercise procedures and alarm treatment were administered for 12 weeks. RESULTS: Holding exercises combined with placebo or oxybutynin significantly increased holding exercise volume and maximum voided volume, by 25% (p <0.001) and 21% (p <0.01), respectively, in group A, and by 43% (p <0.001) and 41% (p <0.001), respectively, in group B. Medication without holding exercises (groups C and D) did not increase holding exercise volume or maximum voided volume, and in these groups oxybutynin was not significantly superior to placebo. A borderline increase in holding exercise volume did not affect maximum voided volume in group E. Monosymptomatic nocturnal enuresis response was significantly lower with all 4 holding exercise volume modulating treatments (7%) compared to alarm therapy (73%). CONCLUSIONS: In the treatment of children with monosymptomatic nocturnal enuresis maximum voided volume can be increased significantly through holding exercises, but not with oxybutynin chloride alone. Compared to controls, increasing maximum voided volume had a minimal effect on monosymptomatic nocturnal enuresis.