儿童原发性遗尿症应用去氨加压素疗效的探讨

目的 研究应用去氨加压素（弥凝）治疗儿童原发性遗尿症（PNE）的临床疗效，并探讨其治疗指征。方法 对2003年4月至2006年8月在上海儿童医学中心发育行为儿科被确诊为PNE的160例患儿给予去氨加压素治疗，观察其近期疗效和远期疗效，以及治疗过程中的变化，并采用多因素分析利于疗效的指征。结果 去氨加压素治疗PNE的近期和远期治愈率分别为40.6% (65/160)和28.1%(45/160)，停止治疗3个月后的复发率高达57.5%。在治疗的第1个月末，患儿平均遗尿次数迅速减少，由每周(6.38±1.82)次降至每周（3.16±0.95）次；第2~4个月末，平均遗尿次数下降不明显，仅由每周（3.16±0.95）次降至每周（2.54±0.69）次。160例患儿中，85例治疗前从不夜间自行起床排尿，治疗后其中有23例出现夜间自行起床排尿。在治疗的第1个月末，患儿遗尿发生时间中位数明显后推，由原来的凌晨2：00～3：00时推后至清晨4：00～5：00时。回归分析显示降低药物治疗效果的危险因素为遗尿次数多，指每周>7次（RR=3.15，95%CI：2.84～4.64）；功能性膀胱容量小，指<5 mL?kg-1（RR=2.92，95%CI：1.86～3.93）；遗尿发生时间早，指早于清晨4：00时（RR=1.65，95%CI：1.16～2.55）。结论 应用去氨加压素治疗儿童PNE起效快，近期疗效较好，但复发率较高，使远期疗效降低；选取功能性膀胱容量大、夜间首次遗尿发生在清晨4时以后、遗尿次数少的患儿选用去氨加压素能极大地提高临床疗效。

Exploring therapeutic index of desmopressin for treating primary nocturnal enuresis in children

Objective Studying the clinical efficacy and therapeutic index of desmopressin for treating primary nocturnal enuresis in Chinese children. Methods The objects of the study were 160 children who were diagnosed as primary nocturnal enuresis(PNE) in department of developmental and behavioral pediatrics of Shanghai children's medical center from April 2003 to August 2006, included 82 boys and 78 girls; The age range was 5 to 16, mean age was （8.26±2.84） years old. PNE diagnosis strictly followed International Classification of Diseases, the 10th edition (ICD-10). Based on Chinese enuretic children's characteristics, the enuresis questionnaire was formed, including general conditions, clinical manifestations, clinical history, birth history, developmental and behavioral history, family history, psychological and social environments, outcomes of psychological tests(including Achenbach children behavioral checklist, Wechsler intelligence scale for children-Revised, Wechsler preschool and primary scale of intelligence), day-time functional bladder capacity, outcomes of laboratory tests(such as urine routine, nocturnal urine specific gravity, x-ray graph of lumbar and sacral vertebrae, ultrasonic graph of urinary system etc), diagnosis, treatment procedure. The variables involved in the questionnaire were 43. All patients were treated with oral desmopressin. Before treatment, the blood pressure was tested. If it was abnormal, desmopressin should not be applied. Desmopressin was taken under the condition of stopping drinking water or any waterful food (like milk, watermelon and so on) after 5 pm. Oral desmopressin was taken with 10~20mL water 30 minutes before bed time. The short-term and long-term efficacy, changes in the period of treatment were observed. Logistic multi-factor analysis was applied to find out the therapeutic index that improved clinical efficacy of desmopressin. Results The short- term and long-term cure rates were 40.6% and 28.1%, respectively; The relapse rate was 57.5% 3 months after stopping desmopressin use. During the first month of treatment, the average frequency of enuretic onsets decreased dramatically from 6.38±1.82 times per week to 3.16±0.95 times per week whereas during the second, third and fourth month of treatment, the average frequency of enuretic onsets decreased mildly from 3.16±0.95 times per week to 2.54±0.69 times per week. Among 160 enuretic children, 85 children never got up to urinate by themselves before treatment, however after treatment there were 23 children who developed the ability to get up to urinate by themselves when the bladder was full during sleep. During the first month of treatment period, the median of enuretic occurrence time postponed apparently from 2～3am to 4～5am. Logistic regression analysis showed the risk factors that decrease efficacy of desmopressin were more than 7 times of bed-wetting onsets(RR=3.15，95%CI：2.84-4.64), less than 5ml/kg of the functional bladder capacity（RR=2.92，95%CI：1.86-3.93）, nocturnally first bed-wetting onset after 4 am(RR=1.65，95%CI：1.16-2.55). Conclusions The short-term efficacy of desmopressin was rapid and good but the relapse rate was high, so the long-term efficacy of desmopressin was decreased. The clinical efficacy of desmopressin would be improved dramatically if selecting patients with bigger functional bladder capacity, fewer bed-wetting onsets, nocturnally first bed-wetting onset after 4 am.