Enuresis as a premorbid developmental marker of schizophrenia.

There is comparatively little information about premorbid maturational brain abnormalities in schizophrenia (SCZ). We investigated whether a history of childhood enuresis, a well-established marker of neurodevelopmental delay, is associated with SCZ and with measures of brain abnormalities also associated with SCZ. A Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) based history of enuresis, volumetric brain MRI scans and neuropsychological testing were obtained in patients with SCZ, their non-psychotic siblings (SIB) and non-psychiatric controls (NC). The subjects were 211 patients (79.6% male), 234 of their SIB (43.2% male) and 355 controls (39.2% male). Frequency of enuresis was compared across groups and correlated with cognitive measures. Total and regional brain volumes were determined using voxel-based morphometry on matched subsets of probands (n = 82) with or without enuresis (n = 16, n = 66, respectively) and controls (n = 102) with or without enuresis (n = 11, n = 91, respectively). Patients with SCZ had higher rates of childhood enuresis (21%) compared with SIB (11%; chi(2) = 6.42, P = 0.01) or controls (7%; chi(2) = 23.65, P < 0.0001) and relative risk for enuresis was increased in SIB (lambda(S) = 2.62). Patients with enuresis performed worse on two frontal lobe cognitive tests [Letter Fluency (t = 1.97, P = 0.05, df = 200) and Category Fluency (t = 2.15, P = 0.03, df = 200)] as compared with non-enuretic patients. Voxel-based morphometry analysis revealed grey matter volume reductions in several frontal regions (right BA 9, right BA 10 and bilateral BA 45) and right superior parietal cortex (BA 7) in patients with a history of enuresis as compared with non-enuretic patients (all t > 3.57, all P < 0.001). The high frequency of childhood enuresis associated with SCZ and abnormalities in prefrontal function and structure in patients with a childhood history of enuresis suggest that childhood enuresis may be a premorbid marker for neurodevelopmental abnormalities related to SCZ. These findings add to the evidence implicating prefrontal dysmaturation in this disorder, potentially related to genetic risk factors.

Etiology and pathology of enuresis among primary school children in Isfahan, Iran.

OBJECTIVE: To determine the etiology and pathogenesis of enuresis among primary school children by using a special ultrasound (US) protocol for the assessment of bladder dysfunction and to compare excretion of urinary sodium and calcium in enuretic children. METHODS: We conducted this cross sectional study on 66 enuretic children aged 6-12 years from September 2005 to January 2006 in Isfahan University of Medical Sciences, Iran. Ultrasound (US) was designed for the evaluation of bladder parameters using bladder volume and wall thickness index (BVWI%), and expected percentage bladder volume index for kidney volume. RESULTS: Sixty children (90.9%) had nocturnal enuresis, 5 (7.5%) had diurnal enuresis and one child (1.6%) had nocturnal and diurnal enuresis. Urinary infection was detected in one child (1.5%). The incidence of urinary system abnormalities was 10.6% in all enuretic children. Hypercalciuria was seen in 9.2% and natriuresis in 20.3%. Normal bladder function (BVWI 70% to <130%) was seen in 67%, small bladder with a thick wall (BVWI <70%) in 27% and large bladder capacity with a thin wall (BVWI >130%) was seen in 6% of children with primary nocturnal enuresis (PNE). There was a significant difference in BVWI between children with PNE and secondary nocturnal enuresis (p=0.01). CONCLUSION: Enuresis is a common problem among school children and associated urinary abnormalities are not uncommon. Our results show that US measured bladder parameters can provide useful clues for the underlying bladder dysfunction and may help to guide clinical management.

Refractory monosymptomatic nocturnal enuresis: a combined stepwise approach in childhood and follow-up into adolescence, with attention to the clinical value of normalizing bladder capacity.

OBJECTIVE: To assess the importance of normalizing bladder capacity to the age-expected capacity in children with refractory monosymptomatic nocturnal enuresis (MNE), and to evaluate the long-term results when these children grow into adolescence. PATIENTS AND METHODS: The study included 34 children with refractory MNE; all were treated > 5 years earlier for their MNE using a combined stepwise approach, consisting of retention control training, oxybutynin and an enuresis alarm. Data were obtained on their enuretic state, night-time voiding behaviour and bladder capacity, from a questionnaire and a voiding chart. RESULTS: Before starting treatment, all patients had a bladder capacity that was too small for their age. After the combined stepwise approach, MNE improved in all patients and 24 (71%) were cured. Although the bladder capacity was increased to the age-expected capacity in 26 (76%), most woke at night to void. Currently, at a mean of 7.7 years after the primary treatment, 28 (82%) of the patients are completely dry at night, of whom 15 (54%) arouse to void for 35% of the nights. Six patients (18%) still have some enuretic episodes. Only those who were dry after primary treatment and remained dry had a normal age-expected increase in bladder capacity. For all others there was a decrease in age-related bladder capacity. CONCLUSIONS: In patients with refractory MNE, a combined stepwise approach improves and may even eliminate enuresis, but normal night-time bladder behaviour in adolescence and adulthood is only achieved in some. Furthermore, about a fifth still have some enuretic episodes.

Enuresis: prevalence, risk factors and urinary pathology among school children in Istanbul, Turkey.

BACKGROUND: Enuresis is a common problem among children and adolescents, and can lead to important social and psychological disturbances. The aim of the present study was to establish the prevalence of enuresis among school children and determine the risk factors associated with this disorder. METHODS: A cross sectional population-based study was conducted in 1576 children. The pupils enrolled in the study were chosen randomly from 14 primary schools located in seven different regions of Istanbul. Data were collected via a questionnaire completed by parents. Enuretic children were invited to the pediatric nephrology outpatient clinic of Cerrahpasa Medical School, Istanbul, Turkey. A detailed history was taken, physical and ultrasonographic examinations, urinalysis and urine culture were performed. The relationship between the prevalence of enuresis and the patients' age, gender, region, the parental educational level and employment status, number of family members, and the family's monthly income were tested by means of chi(2 ) and logistic regression analysis. The comparison between the two enuretic groups (monosymptomatic nocturnal enuresis group vs diurnal enuresis only and diurnal-nocturnal enuresis group) regarding the sociodemographic factors were tested with the chi(2) test and P < 0.05 was accepted as statistically significant. RESULTS: The study group was composed of 1576 school children aged between 6 and 16 years. The overall prevalence of enuresis was 12.4%. When the chi(2) test was used, a significant relationship was found between the prevalence of enuresis and age, educational level of the father, the family's monthly income, and number of family members. However, when logistic regression analysis was applied, there was a statistically significant relationship only between enuresis, and age and number of family members. In the whole group, monosymptomatic enuresis nocturna was found to be more common in boys. When the two enuretic children groups (monosymptomatic nocturnal, diurnal only and nocturnal-diurnal enuretics) were compared with each other regarding gender, parental educational and employment status, and number of family members, statistically significant differences were found. Both maternal and the paternal low educational status were found to be associated with monosymptomatic enuresis nocturna. Likewise, monosymptomatic enuresis nocturna was found to be more common in the children of the unemployed mothers, while diurnal enuresis was more common in the children of unemployed fathers. Nocturnal enuresis was found to be associated with large families. No statistically significant difference was demonstrated between the two groups of enuretics regarding age and family income levels. The rate of urinary abnormalities in the whole group was 7.1%. CONCLUSIONS: Enuresis is a common problem among school children and associated urinary abnormalities are not uncommon. Identification of children at risk is an essential first step before choosing the individualized management for each enuretic child.

The nasal mucosa of children with nocturnal enuresis before and after treatment with 1-deamino 8-D-arginine vasopressin spray.

Intranasal administration of 1-deamino 8-D-arginine vasopressin (DDVAP) used for treatment of nocturnal enuresis (NE), might be expected to have various effects on the nasal mucosa, e.g. altering the clearance by the mucociliary apparatus. We evaluated two samples (brushes) of epithelial surface cells from the nasal mucosa, one from each nostril, of 18 children (ten males and eight females) with a mean age of 7.7 years (range: 5-13 years) who were affected by primary NE. Samples were taken before and 1 and 6 months after administration of DDVAP spray. No qualitative changes in the epithelial surface cells from nasal mucosa were recognized and only non-statistically significant increases in percentages of goblet, ciliated, basal and unciliated cells at 1 and 6 months after therapy were observed. Thus, it appears that DDVAP spray can be used for at least 6 months in children without apparent risk of damage to the epithelial surface cells from the nasal mucosa.

Magnetic resonance imaging in children with voiding dysfunction: is it indicated?

PURPOSE: We evaluated the role of magnetic resonance imaging (MRI) of the lumbosacral spinal cord in children with complicated voiding dysfunction and normal neuro-orthopedic examination. MATERIALS AND METHODS: We reviewed the records of 32 consecutive children with complicated enuresis who were referred for neurosurgical evaluation, including those with a history of refractory voiding dysfunction or incontinence associated with persistent vesicoureteral reflux, encopresis, or associated leg or back pain. Nine patients were excluded from study because of urethral or anorectal anomalies, or failure to meet the inclusion criteria. Eligible for study inclusion were 23 children with a mean age of 8.9 years. Complete neurological and orthopedic examinations were normal in all patients except 1 with mild scoliosis and 1 with congenital facial palsy. RESULTS: Urodynamic studies revealed instability in 14 cases, hypertonia in 7, hyporeflexia in 2 and detrusor-sphincter dyssynergia in 4. Skeletal abnormalities, mostly spina bifida occulta, were detected in 16 of the 23 children (70%). Spinal MRI was normal in 21 patients (91.3%), including 1 with a tethered cord and lipoma associated with a complex skeletal abnormality, and 1 with a nonprogressive, nonsurgical T7 to T9 syrinx. Only the case of lipoma required neurosurgical intervention. CONCLUSIONS: The value of MRI is limited in children with voiding dysfunction and a normal neuro-orthopedic assessment. This study should be reserved for patients with associated neuroorthopedic findings or complex skeletal deformity on plain x-ray.

Urological abnormalities in 1,328 patients with nocturnal enuresis.

OBJECTIVES: Evaluation of the incidence of urological abnormalities as revealed by urological examinations of a large number of patients with enuresis. METHODS: Patients with the chief complaint of nocturnal enuresis were examined urologically. RESULTS: The incidence of urological abnormalities was 1.8% of 940 patients on intravenous pyelography (IVP), 7.1% of 695 patients on voiding cystourethrography (VCG) and 11.5% of 487 patients on cystometry (CM). No abnormal findings were observed in 58 patients on renal ultrasonography (US). 92.1% of reflux cases detected by VCG were low grade and only 8.9% of patients with reflux had pyuria. 20.2% of 446 patients who were submitted to all these examinations had some urological abnormality. Only pollakisuria was statistically more frequent in patients with urological abnormalities than in patients without them. CONCLUSION: These data suggest that the incidence of urological abnormalities was rather low when compared with the past literature. In particular, IVP was though to be unnecessary.

Value of cystourethroscopy in the assessment of children with recurrent urinary tract infections and/or enuresis.

Forty-one children ages 6-14 years consecutively referred for recurrent urinary tract infections (RUTI) and/or enuresis constituted the study group. Cystourethroscopy (CUS) was carried out in 40 children and pathologic findings were revealed in 70% of children with RUTI in the absence of vesico-ureteral reflux (VUR). However, only in 4 patients did CUS influence treatment. Based on these data we conclude that routine CUS is not justified in the evaluation of this group of children unless anatomical infravesical lesions are suspected. VUR was proven in 44% of children with RUTI. In 86% of these ureters abnormal ureteric orifices were demonstrated. We therefore find CUS to be valuable in the assessment of children with both RUTI and VUR, because this examination is helpful in selecting patients who might need operation for severe VUR. CUS was not of therapeutic benefit to children with enuresis. Five patients with macroscopic haematuria during urinary tract infection were not managed differently following CUS.

Histological and urodynamic study of the bladder in enuretic children.

In a study of the bladders of 12 enuretic children by cystoscopy, light microscopy and urodynamics, cystoscopic trabeculation was found in 10 cases. Histologically, the trabeculation resembled adult trabeculation of obstructive aetiology, collagen infiltration being the characteristic hallmark. Using urodynamic measurements, the bladders behaved like those of adult enuretics; 10 out of 12 were unstable and voiding occurred at relatively high pressures. There was no correlation between symptoms and either cystoscopic or histological trabeculation.