Clinical profile and risk factors of enuresis in children

Background: Enuresis is a common problem in children and its incidence is multifactorial in nature. The aim of this study is to assess the etiological risk-factors in enuresis in the study population and also to compare the risk factors in enuresis subgroups.Methods: A total of 51 patients with enuresis presenting to the department of paediatrics, Institute of Social Paediatrics, Govt. Stanley Hospital, Chennai were included in the study. All children were sub classified as primary/secondary and the primary enuretics were sub classified into monosymptomatic/non monosymptomatic depending on the symptoms. The data was analyzed and the results presented.Results: Enuresis was common in boys. Statistically significant difference in the incidence of disorder between primary and secondary enuretic children was seen in relation to presence of storage symptoms (p=0.04), cystitis (p=0.013) sleep disordered breathing (p=0.0001) and low-income status (p=0.04). No statistically significant difference between into monosymptomatic nocturnal enuresis (MNE) and non-monosymptomatic nocturnal enuresis (NMNE) children was observed in terms of gender, difficulty in arousal, specific gravity, spina bifida, low bladder capacity and family history (p>0.05).Conclusions: The findings of the study reported that risk factors related to the incidence is similar in both primary and secondary enuresis. MNE and NMNE have no differences in the presentation and probably represent the spectrum of a same disorder.

Study of the profile of behavioral problems and quality of life indexes in a pediatric cohort of monosymptomatic enuresis / Estudo do perfil dos problemas de comportamento e dos índices de qualidade de vida numa coorte pediátrica de enurese monossintomática

Abstract Objective: To evaluate and correlate, before and after the therapeutic intervention, the behavioral problem scores evaluated by the CBCL/6-18 questionnaire and the quality of life indexes evaluated by the PedsQL™ 4.0 in patients with monosymptomatic nocturnal enuresis. Method: After the initial evaluation and completion of the CBCL/6-18 questionnaire, a multidisciplinary evaluation and completion of the PedsQL™ 4.0 questionnaire was performed. Of the initially evaluated 140 children and adolescents aged 6-16 years, 58 were excluded due to non-monosymptomatic enuresis or associated comorbidities. Of the initially included 82 patients, who were randomized to three treatment groups, 59 completed the CBCL/6-18 and PedsQL™ 4.0 questionnaires at the end of the treatment and were included in this study. The α error was set at 5% for ruling out the null hypothesis. Results: Of the total of 59 participants, 45.8% responded with total success, 23.7% were partially successful, 23.7% did not reach the improvement criteria, and 6.8% gave up the treatment. There was a significant increase in quality of life indexes and a reduction of post-intervention behavioral problem scores, in the three proposed modalities, in patients who had a total or partial response to treatment. There was no correlation between higher scores of pre-treatment behavior problems and therapeutic failure. Conclusions: Only the participants who successfully responded to interventions showed improvement in quality of life and behavioral problems, which indicates that enuresis is a primary problem that has a negative impact on these parameters. The authors suggest that it is possible to achieve success in the treatment of monosymptomatic enuresis, even in patients with high pre-intervention behavioral problem scores.

Resumo Objetivo: Avaliar e relacionar, pré e pós-intervenção terapêutica, em pacientes com enurese noturna monossintomática, os escores de problemas de comportamento, avaliados pelo questionário CBCL/6-18, e os índices de qualidade de vida, avaliados pelo PedsQL™ 4.0. Método: Após avaliação inicial e preenchimento CBCL6/18, procedeu-se avaliação multidisciplinar e preenchimento do PedsQL™ 4.0. Das 140 crianças e adolescentes de 6 a 16 anos inicialmente avaliados, 58 foram excluídos por enurese não monossintomática ou comorbidades associadas. Dos 82 pacientes inicialmente incluídos e randomizados em três grupos de tratamento, 59 preencheram o CBCL/6-18 e PedsQL™ 4.0 no fim do tratamento e puderam ser incluídos neste trabalho. O erro alfa foi estabelecido em 5% para descarte da hipótese de nulidade. Resultados: Dos 59 participantes 45,8% responderam com sucesso total, 23,7% tiveram sucesso parcial, 23,7% não atingiram critério de melhoria e 6,8% desistiram do tratamento. Verificou-se aumento significativo dos índices de qualidade de vida e redução dos escores de problemas de comportamento pós-intervenção, nas três modalidades propostas, nos pacientes que obtiveram resposta total ou parcial ao tratamento. Não se demonstrou correlação entre maiores escores de problemas de comportamento pré-tratamento e insucesso terapêutico. Conclusões: Apenas os participantes que responderam com sucesso às intervenções melhoraram em sua qualidade de vida e problemas comportamentais, o que indica que a enurese é um problema primário que impacta negativamente esses parâmetros. Sugere-se que é viável obter sucesso no tratamento da enurese monossintomática, mesmo em pacientes com altos escores de problemas de comportamento pré-intervenção.

A network meta-analysis of desmopressin, alarm, and combination of both in the treatment of monosymptomatic nocturnal enuresis in children / 临床儿科杂志

Objective To systematically explore the efficacy of four intervention regiments including desmopressin, alarm, desmopressin combined with alarm, and desmopressin combined with anticholinergic drugs in the treatment of monosymptomatic nocturnal enuresis in children by network meta-analysis. Methods The databases of PubMed, Cochrance Library, EMBase and Web of Science were systematically searched and retrieved upto August 1, 2017. Included were the randomized controlled trials (RCTs) which had any two or more of four intervention regiments (desmopressin, alarm, desmopressin combined with alarm, and desmopressin combined with anticholinergic drugs) for treatment of monosymptomatic nocturnal enuresis in children. The literature was screened according to the established inclusion and exclusion criteria, and the data extraction and quality evaluation were performed for the final inclusion of RCT. Software R 3.3.2 and STATA 14.0 were used for data analysis. Results Fifteen RCTs were included with a total of 1505 children. Network meta-analysis showed that the complete response rate and success rate of desmopressin combined with anticholinergic drugs were higher than those of desmopressin (complete reaction rate: OR=2.8, 95％ CI :1.5～5.4; success rate: OR=3.5, 95％ CI :1.7～7.5) and alarm (complete response rate: OR=2.7, 95％ CI :1.1～6.6; success rate: OR=3.8, 95％ CI: 1.6～9.0. The success rate of desmopressin combined with alarm was higher than that of alarm (OR=1.9, 95％CI: 1.1～3.4) . The recurrence rate of alarm after treatment was significantly lower than that of desmopressin (OR=0.15, 95％CI: 0.03～0.53) . The ranking results showed that the complete response rate and success rate of desmopressin combined with anticholinergic drugs were the best. The desmopressin combined with alarm can minimize the number of bed-wetting episodes per week and the recurrence rate of alarm was the lowest among the four regiments. Conclusion The effect of desmopressin combined with anticholinergic drugs is significantly better than that of alarm or desmopressin alone. The combination of desmopressin and alarm has a slight advantage or similar effect to that of single alarm or desmopressin treatment. The effect of desmopressin is similar to that of alarm. Alarm treatment has the lowest recurrence rate.

Enuresis alarm therapy for preschool children with primary monosymptomatic nocturnal enuresis: A report of 95 cases / 中国实用儿科杂志

OBJECTIVE: To explore the effectiveness of enuresis alarm therapy on preschool children with primary monosymptomaticnocturnal enuresis(PMNE). METHODS: Totally 95 PMNE preschool children aged 3.5 to 6 years admitted between January 2017 and July 2018 to Department of Nephrology,Affiliated Children's Hospital of Capital Institute of Pediatrics,were randomly divided into two groups:alarm group(53 cases)and control group(42 cases). The alarm group was managed by enuresis alarm therapy,while the control group received basic treatment. Treatment ceased after 12 weeks of training or when the cases achieved 14 consecutive dry nights(meaning successful treatment). The relapse cases were recorded 1 month after stopping treatment. The alarmtherapy was performed again in the relapse cases for another course. RESULTS: Seven cases(13.2%)discontinued intervention in the alarm group. The response of the alarm therapy in the remaining 46 patients was as follows:full response(FR)in 29 cases(63.0%),partial response(PR)in 7 cases(15.2%),no response(NR)in 10 cases(21.7%). A total of 25 patients achieved 14 consecutive dry nights in FR cases. Successful treatment requires a minimum course of treatment for 42 days. Relapse occurred in 11 cases within the first 1 month after stopping treatment,and 8 relapse patients responded to another course of alarm therapy. Three cases(7.1%)lost to follow-up in the control group. The response of the control group in the remaining 39 patients was as follows:FR in 0 case,PR in 17 cases(43.6%)and NR in 22 cases(56.4%). No cases achieved successful treatment in the control group. The full response rate was significantly different between two groups(Fisher's exact test χ~2=55.10,P=0.00). Half(5 cases)of NR patients were less than 4 years old,while in the FR+PR patients,the percentage of children under 4 years old was only 8.3%(3 cases)in alarm therapy group(Pearson chi-square test,χ~2=9.457,P=0.007). No severe adverse events occurred in all cases. CONCLUSION: Enuresis alarm therapy is a safe and effective way to treat PMNE preschool children. The enuresis alarm provided gradual effects and require more than 1 month in achieving successful effect. The appropriate age for alarm treatment is over four years old.

Effectiveness of Intra-anal Biofeedback and Electrical Stimulation in the Treatment of Children With Refractory Monosymptomatic Nocturnal Enuresis: A Comparative Randomized Controlled Trial / 대한배뇨장애요실금학회지

PURPOSE: To compare the effects of intra-anal biofeedback (BF) and intra-anal electrical stimulation (ES) on pelvic floor muscles (PFMs) activity, nocturnal bladder capacity, and frequency of wet night episodes in children with refractory primary monosymptomatic nocturnal enuresis (PMNE). METHODS: Ninety children of both sexes aged 8–12 years with refractory PMNE participated in this study. They were randomly assigned to 3 groups of equal number: control group (CON) that underwent behavioral therapy and PFM training, and 2 study groups (BF and ES) that underwent the same program in addition to intra-anal BF training and intra-anal ES, respectively. PFMs activity was assessed using electromyography, nocturnal bladder capacity was evaluated by measuring the first morning voided volume, and a nocturnal enuresis diary was used for documenting wet night episodes before treatment and after 3 months of treatment. RESULTS: After training, all groups showed statistically significant improvements in all measured outcomes compared to their pretreatment findings. The ES group showed significantly greater improvements in all measured outcomes than the CON and BF groups. CONCLUSIONS: Both intra-anal BF training and ES combined with behavioral therapy and PFMs training were effective in the treatment of PMNE, with intra-anal ES being superior to BF training.

Urinary Calcium Excretion in Children with Primary Monosymptomatic Nocturnal Enuresis

PURPOSE: Hypercalciuria has been suggested to be involved in the pathogenesis of nocturnal enuresis associated with polyuria. We have measured the amount of calcium excretion in the urine from children with monosymptomatic nocturnal enuresis and studied the association with enuresis. METHODS: Thirty-six children (20 males and 16 females, age 5 to 15.6 years) presenting with monosymptomatic nocturnal enuresis were recruited for this study. RESULTS: Among 36 patients, 6 patients had hypercalciuria, providing a 16.7% frequency. The mean Ca/Cr ratio of hypercalciuria group showed 0.23+/-0.10 on daytime, and 0.33+/-0.10 on nighttime showing higher values in nighttime, but it was not statistically significant. Average 24 hour calcium excretion was 8.95 mg/kg. Night/day time urine volume ratio in hypercalciuria group was 0.87+/-0.20, and that in normocalciuria group was 0.81+/-0.33, also showing no difference. Daytime Ca/Cr ratio and nighttime Ca/Cr ratio from all enuresis patients showed a significant correlation (P=0.0001). However, Ca/Cr ratio between daytime and nighttime urine volume had no significant correlation, respectively (daytime P=0.08; nighttime P=0.07). Also, daytime and nighttime Na concentration, urea concentration, and osmolality also had no significant correlation with urine Ca/Cr ratio, respectively. CONCLUSION: Hypercalciuria shown in some of enuresis patients is not directly caused by primary monosymptomatic nocturnal enuresis.