Efficacy of sacral transcutaneous electrical nerve stimulation in patients with overactive bladder refractory to anticholinergic treatment: a prospective multi-center study. / Eficacia de la electroestimulación transcutánea sacra en pacientes con vejiga hiperactiva refractarios a fármacos anticolinérgicos. Estudio prospectivo y multicéntrico.

OBJECTIVE: To determine whether sacral transcutaneous electrical nerve stimulation (S-TENS) is an effective treatment in patients refractory to anticholinergic drugs (Achs). MATERIALS AND METHODS: A prospective multi-center study of patients with overactive bladder (OB) refractory to Achs treated with S-TENS from 2018 to 2021 was carried out. S-TENS was applied over 3 months. Symptom progression was assessed using the voiding calendar and the Pediatric Lower Urinary Tract Symptoms Score (PLUTSS), excluding questions 3 and 4 -referring to enuresis- so that progression of daytime symptoms only (LUTS variable) was analyzed. RESULTS: 66 patients -50% of whom were female- were included, with a mean age of 9.5 years (range: 5-15). S-TENS significantly lowered PLUTSS (19.1 baseline vs. 9.5 final, p< 0.001) and LUTS (13.1 baseline vs. 4.8 final, p< 0.001). It also reduced the number of mictions (8.5 baseline vs. 6.4 final, p< 0.001), while increasing urine volume in the voiding records (214 ml baseline vs. 258 ml final, p< 0.001). Enuresis was the only variable refractory to S-TENS. Complication rate was 3% (2 patients with dermatitis in the S-TENS application area). CONCLUSIONS: S-TENS is effective and safe in the short-term in patients with OB refractory to Achs. Further studies assessing long-term efficacy and potential relapses are required.

OBJETIVOS: Determinar si la electroterapia nerviosa transcutánea a nivel sacro (TENS-S) es un tratamiento efectivo en pacientes refractarios a fármacos anticolinérgicos (Ach). MATERIAL Y METODOS: Estudio prospectivo y multicéntrico: pacientes con VH refractaria a Ach tratados con TENS-S entre 2018-2021. El TENS-S se aplicó durante 3 meses. La evolución sintomática fue evaluada utilizando el calendario miccional y el cuestionario PLUTSS (Pediatric Lower Urinary Tract Symptoms Score), pero excluyendo sus preguntas 3 y 4 (referidas a la enuresis) para analizar solamente la evolución de la sintomatología diurna (variable LUTS). RESULTADOS: Fueron incluidos 66 pacientes (50% niñas), con una edad media de 9,5 años (rango: 5-15). El TENS-S disminuyó significativamente el PLUTSS (19,1 inicial vs 9,5 final, p< 0,001) y el LUTS (13,1 inicial vs 4,8 final, p< 0,001). Además, redujo el número de micciones (8,5 inicial vs 6,4 final, p< 0,001) y aumentó el volumen de orina en los registros miccionales (214 ml inicial vs 258 ml final, p< 0,001). La enuresis fue la única variable refractaria al TENS-S. La tasa de complicaciones fue del 3% (2 pacientes, dermatitis en el área de aplicación del TENS-S). CONCLUSIONES: El TENS-S es efectivo y seguro a corto plazo en pacientes con VH refractarios a los Ach. Deben realizarse estudios para evaluar la eficacia a largo plazo y posibles recaídas.

Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment.

CONTEXT: Enuresis is a common and possibly underestimated condition. While 5-10% of school-aged children suffer from the condition, a lack of background knowledge may impede timely child-adapted and successful therapy. OBJECTIVE: To provide a comprehensive overview of the pathophysiology, diagnosis, and treatment of enuresis. EVIDENCE ACQUISITION: Guideline and position papers from the European Society of Pediatric Urology, the European Association of Urology, and the International Children's Continence Society were acquired. PubMed was searched for literature on enuresis, and all papers published in the last 5 yr were considered. The most relevant information from the papers with the highest level of evidence was extracted and incorporated into the review. EVIDENCE SYNTHESIS: An altered antidiuretic hormone profile, arousal failure, and delayed bladder maturation are the main pathophysiological factors in primary enuresis. Coexisting constipation, obstructive airway disease, attention deficit hyperactivity disorder, obesity, and genetic preconditions influence its prevalence. Diagnosis relies on history-taking and simple noninvasive examinations to differentiate monosymptomatic enuresis and patients with daytime symptoms. It is essential to exclude daytime voiding symptoms, overactive bladder, dysfunctional voiding, and urinary tract infections. Further imaging is indicated in complex cases with a suspicion of underlying congenital malformations or systemic or endocrine diseases and in children refractory to initial therapy. In secondary enuresis, psychological causes should also be taken into consideration. While desmopressin melt tablets and alarm systems constitute the mainstays of treatment in monosymptomatic enuresis, anticholinergics and urotherapy play an additional role in nonmonosymptomatic enuresis. For therapy-refractory cases, after a thorough re-investigation to identify any missed comorbidities and anatomical or functional causes of enuresis, combination therapy and stationary urotherapy might be promising options. CONCLUSIONS: While enuresis seems to be an often underestimated condition in terms of the suffering that children and their families, there are efficacious therapy options once a correct and full diagnosis is made. PATIENT SUMMARY: This article reviews primary and secondary nocturnal enuresis, which is the medical term for the condition whereby children wet their beds regularly after their first birthday. We describe the background of enuresis,including its complex underlying mechanisms, as well as diagnosis and treatment in the light of current scientific publications. We conclude that while enuresis seems to be an often underestimated condition in terms of the suffering that children and their families may undergo, there are efficacious therapy options once a correct and full diagnosis is made.

Prepulse inhibition of acoustic startle and the influence of methylphenidate in children with ADHD.

OBJECTIVE: ADHD is common among children with comorbidity of enuresis. Findings concerning prepulse inhibition (PPI) of startle reflexes are controversial. Although PPI is improved through desamino-arginine vasopressin (dDAVP) in enuresis, some patients also improve concomitant ADHD through dDAVP. This study aims to evaluate whether methylphenidate (MPH) also improves PPI in ADHD. METHOD: Nineteen ADHD patients were investigated in a prospective, double-blind, crossover study with MPH versus placebo. PPI was measured as a reduction of acoustic startle reflexes. Subgroups of gender, ADHD subtype, and baseline PPI were analyzed. RESULTS: Median baseline PPI of ADHD patients (51.7%) was below the value of age-matched normal controls (73%, p = .090). MPH showed no improvement in the whole group, or the subgroups gender or subtype. Reduced baseline PPI was significantly improved (22.5%-39.3%, p = .039). CONCLUSION: Heterogeneity of ADHD is confirmed with a wide range of baseline PPI. The improvement of reduced baseline PPI through MPH suggests impaired sensorimotor gating in this subgroup.

Enuresis and more.

We describe Pervasive Refusal Syndrome, an important but rare, debilitating condition that may present to paediatric services. Although previous reports have described improvement seen with care delivered in the mental health setting, we have demonstrated treatment predominately delivered in a paediatric ward environment associated with successful recovery.

Clinical and urodynamic effect of methylphenidate for the treatment of giggle incontinence (enuresis risoria).

AIMS: We retrospectively investigated the efficacy of methylphenidate (MPH) in giggle incontinence (GI), and the relationship between GI and urodynamic parameters. METHODS: Nine (n = 9) female GI patients underwent 1 year of treatment with 5 mg MPH. Three questionnaires, voiding diaries, and UDS were conducted before and after treatment. The severity of GI was classified into mild, moderate, and severe. Clinical success was characterized as: full response, response, partial response, and non-response. RESULTS: The mean age of all patients was 16.2 ± 2.3 years. Five patients had mild, one had moderate, and three had severe grade incontinent. All patients reported complete cessation of wetting after MPH treatment. The mean duration of asymptomatic period was 7 ± 3.2 months. There were no statistically significant score changes in all three questionnaires: Urgency Perception Scale (UPS), Overactive Bladder Symptom Score (OABSS) and Primary Overactive Symptom Questionnaire (POSQ), and voiding diaries (P > 0.05). In UDS, there were no statistically significant altered parameters, except maximum urethral closure pressure (MUCP) and maximum urethral pressure (MUP). After treatment, the mean MUCP was increased from 52.2 ± 6.8 to 73.0 ± 5.4 cmH(2) O (P < 0.05), and the mean MUP was increased from 48.6 ± 7.3 to 70.2 ± 5.0 cmH(2) O (P < 0.05). CONCLUSIONS: MPH can be a viable option for the primary treatment of GI, and it may be related to increasing urethral closure pressure. It was not possible to establish if a relationship between GI and detrusor overactivity exists.

Reboxetine in therapy-resistant enuresis: results and pathogenetic implications.

OBJECTIVE: To investigate whether the norepinephrine reuptake inhibitor reboxetine is effective as a non-cardiotoxic alternative to imipramine in the treatment of therapy-resistant enuresis. MATERIAL AND METHODS: Twenty-two children with severely socially handicapping enuresis resistant to urotherapy, the enuresis alarm, desmopressin and anticholinergics (all children had tried all these treatments) were given reboxetine, 4-8 mg at bed-time, for compassionate reasons. RESULTS: Thirteen of the children (59%) achieved complete dryness with reboxetine, either as monotherapy or combined with desmopressin. Side-effects were minor and did not lead to discontinuation of treatment. CONCLUSIONS: Although the results of this study need to be confirmed in randomized, placebo-controlled trials, reboxetine may prove to be a useful treatment for therapy-resistant nocturnal enuresis.

[Laser acupuncture as third-line therapy for primary nocturnal enuresis. First results of a prospective study]. / Laser-Akupunktur als Third-line-Therapie bei primärer Enuresis nocturna. Erste Ergebnisse einer prospektiven Studie.

Laser acupuncture is a painless, non-invasive, and cost effective treatment for children with therapy resistant monosymptomatic nocturnal enuresis. This kind of acupuncture is an alternative treatment with positive results. Currently, we are treating 24 children (22 males, 2 females) out of a planned 200 children aged between 5 and 12 years. These patients have had a classic monosymptomatic nocturnal enuresis. Up to now, school medicine therapy has been unsuccessful. Over 3 months, we treated the children once a week with acupuncture, inserting at the following points: medial Ren 3, bilateral Ma 36, bilateral Mi 6, bilateral Bl 33, medial Ren 6, medial Ex B5.A better enuresis frequency was achieved in 21 out of the 24 children (87.5%). Before the end of the 12th treatment, six of the 24 children (25%) were completely dry and 16 (66.6%) had an enuresis frequency reduced by more than half after the 12th treatment.

[A suggested treatment algorithm in nocturnal enuresis with emphasis on partial responders]. / Therapiealgorithmus bei Enuresis nocturna.

Monotherapeutic strategies often have only partial success in primary nocturnal enuresis (PNE). This analysis evaluated whether adjuvant treatment strategies improve outcomes. PNE children were submitted to a distinct therapeutic strategy including urotherapy (behavioral modifications), a first-line and, if necessary, a second-line treatment period. Outcome was the relief of bedwetting, the follow-up was 3-79 months. Urotherapy was applied. Nonresponders were assigned to desmopressin as first-line treatment. For complete responders a structured withdrawal program was applied. Partial responders were assigned to adjuvant second-line treatment according to their individual symptomatology, masked at basic investigations, incorporating either anticholinergics (propiverine hydrochloride), biofeedback, alpha-blocker (alfuzosin), alarm or psychotherapy, in addition to desmopressin. Nonresponders were referred to specialized management. The study included 259 children suffering from PNE (92 girls, 167 boys, aged 5-18 years): 42 children were relieved from bedwetting after urotherapy and 136 children had a complete response to desmopressin. Three nonresponders were assigned to specialized management, 61 partial responders had adjuvant treatments, and 17 partial responders had no further treatment. The suggested treatment algorithm resulted in 227 complete responders, 29 partial responders, and 3 nonresponders. The need for preliminary urotherapy is evident. The proposed desmopressin monotherapeutic strategy, incorporating a structured withdrawal program, is more effective than the standard desmopressin treatment module. Applying adjuvant treatment modules improves the complete response rate up to 88%. In partial responders overall efficacy rates are improved further. Nonresponders (1.2%) will be referred to specialized management, but many partial responders will gain improvement sufficient to refrain from invasive procedures.

Prevalence and perception of nocturnal enuresis in children of a rural community in southwestern Nigeria.

Nocturnal enuresis after the fifth year of life is a distressing problem. In Nigeria, there is a dearth of information about the condition. This cross-sectional study was carried out to determine the prevalence and perception of the condition among children in Igbo-Ora, a rural community in southwestern Nigeria. Four hundred parents/guardians were interviewed and information obtained on 644 children aged 6-12 years. Overall enuresis prevalence was 17.6% (19.9% among boys and 14.9% among girls). The reported causes of nocturnal enuresis included urinary tract infection (33.5%), excessive play (27.5%) and deep sleep (25%). A majority (74.5%) of the respondents would use herbs or traditional medicine to treat enuresis, while only 6.8% of the respondents sought orthodox healthcare facilities for its management. Only 18 (25%) of the 71 parents/guardians with enuretic children had ever consulted a health worker. The misconceptions and inappropriate enuresis management methods among the parents/guardians require health education intervention.

Síndrome de Smith Magenis: un caso de abordaje multidisciplinar / Smith Magenis síndrome: a multidisciplinar approached

M.R., niña de 9 años diagnosticada de síndrome de Smith Magenis que es derivada a salud mental infantil por su pediatra porque desde hace varios meses presenta alteraciones heterogéneas del comportamiento, autoagresividad, insomnio global y enuresis primaria nocturna. Describimos la clínica y las exploraciones realizadas. Discutimos el diagnóstico y la orientación terapéutica empleada, destacando la necesidad de realizar un abordaje multidisciplinar que incluya profesores, pediatras y profesionales de la salud mental infantil (AU)

[Electromyographic evidence in conservative treatment of stress enuresis in women]. / Rezul'taty élektromiograficheskikh issledovanii pri konservativnom lechenii stressovogo nederzhaniia mochi u zhenshchin.

Electromyography (EMG) with needle electrodes of urethral and anal sphincters was performed in 32 patients with stress enuresis (SE). All the patients received conservative treatment as pelvic fundus exercise by Kegel (17 patients), use of vaginal cones (4 patients), ESMP-15-1 device electrostimulation (11 patients). In treatment failure, SE was corrected surgically. The response was assessed 8 weeks after the treatment. Satisfactory results were obtained in 23(72%) women. Reinnervation of urethral sphincter and the anus of different severity was found in 13(41%) and 30(97%) patients, respectively. Denervation in urethral and anal sphincter occurred in 4(13%) and 6(19%) patients, respectively. The comparison of the results of treatment and EMG findings has shown that good results were achieved only in patients with moderate reinnervation of the sphincters. Patients with denervation and/or severe reinnervation of the sphincters did not benefit from the conservative therapy or its result was minimal. It is shown that needle EMG is a reliable method of assessing the condition of urethral and anal sphincters and helps to make timely choice of SE treatment in women.

Electro-acupuncture in the treatment of children with monosymptomatic nocturnal enuresis.

OBJECTIVE: The aim of this study was to investigate the effects of a long series of electro-acupuncture (EAP) sessions on bedwetting symptoms. MATERIAL AND METHODS: Twenty-five children (age range 7-16 years) with monosymptomatic nocturnal enuresis and treated earlier without success were included in the study. The median number of wet nights per week was 4.7 before treatment. Bedwetting, voided volume, sleep and nocturia were evaluated 3 weeks, 3 months and 6 months after 20 sessions of EAP lasting 8 weeks. RESULTS: All the children, with the exception of one, tolerated EAP treatment well. At the three follow-up sessions it was found that the number of dry nights had increased gradually from a median of 2.3 in the pre-test to 3.0, 4.3 and 5.0 per week, respectively. Compared to pre-treatment findings there were more dry nights in 65% of the children (p < 0.001) and 5 out of 23 children were responders (> 90% reduction of the numbers of wet nights) at the 6 months' follow-up. According to the parents, the sleep arousal threshold had decreased in about 50% of the children.

The new dental-medical renaissance. Medically efficacious functional jaw orthopedics.

Functional Jaw Orthopedics (FJO) is medically efficacious, exceptionally unique and unequaled in speed of a cure for a number of very common medical conditions currently only "managed" by modern medicine. This publication combines scientific citations and case presentations to show how and why dentists who advocate and provide early FJO treatment will lead a New Dental-Medical Renaissance into some of the most profound areas of medicine. Nocturnal enuresis (chronic bed-wetting) otitis media (ear infections), cor pulmonare, cognitive thought, vision, hearing, cardio-pulmonary dysfunction, and myocardial infarction have FJO dental-medical relationships. Early FJO treatment fulfills the ADA Code of Ethics which "calls upon dentists to follow high ethical standards which have the benefit of the patient as their primary goal: Do No Harm and Do Good."

Incidental spina bifida occulta in functional enuresis observed during laser reflexo therapy.

The etiology of persistent functional enuresis in children is ill understood. A wide range of therapeutic modalities have been tried. During investigations preceding a trial of laser reflexo therapy in functional enuretic children aged 7 to 10 years spina bifida occulta was observed in 86.6% of subjects. The lesions were predominantly at the L5-6 level. There were no cutaneous stigmata in the form of lipoma, tufts of hair, or dermal sinus at the back. Neurologic examination was unremarkable and there were no associated skeletal malformations. This strong association of spina bifida occulta with functional enuresis is higher than the reported incidence of 16.5% to 34% in normal children. This strong association hitherto unreported, raises an interesting issue in the search for the etiopathogenesis of functional enuresis.

Long-term home studies of water balance in patients with nocturnal enuresis.

A 2-week, home-based study was conducted on 75 children with nocturnal enuresis to monitor the frequency of enuretic episodes and the volume of nocturnal urine production. The objectives of the study were to correlate nocturnal urine production to the occurrence of nocturnal enuresis and response to desmopressin (Minirin, DDAVP) treatment. Furthermore, patient compliance was evaluated. Enuresis episodes and nocturnal urine production was recorded every night during two base-line weeks without treatment and during 2 weeks with 20-40 micrograms desmopressin at bedtime. During both periods fluid intake and micturition volumes were recorded for 2 days. Desmopressin response was defined as > 50% reduction in wet nights during treatment. It was found that patient compliance was acceptable in most patients. Regarding urine output it was found that base-line nocturnal urine production was significantly higher during nights when enuresis occurred than during "dry" nights and significantly higher in desmopressin responders compared with desmopressin non-responders. During treatment with desmopressin, nocturnal urine production in desmopressin responders decreased to levels similar to those of non-responders. The results confirm inpatient circadian studies of urine output and emphasise the importance of nocturnal polyuria in patients with monosymptomatic enuresis. The response to desmopressin was found to correlate with the occurrence of nocturnal polyuria. Home studies were considered to be a useful tool in the characterisation of patients with nocturnal enuresis.

Renal functions of enuretic and nonenuretic children: hypernatriuria and kaliuresis as causes of nocturnal enuresis.

OBJECTIVE: The aim of this study was to investigate the pathophysiologic cause(s) of primary nocturnal enuresis. Therefore, electrolyte concentrations of urine specimens were evaluated in the morning, and alterations compared between enuretics and nonenuretics. METHODS AND PATIENTS: First morning urine specimens of 27 enuretics and 21 nonenuretic subjects fed the same diet were collected, and urinary electrolytes were measured. The urinary Ca/Cr ratio, tubular reabsorption of phosphorus (TRP) and fractional sodium (FE Na%) and potassium excretions (FE K%) were determined for patients and controls. RESULTS: There was no significant difference in the Ca/Cr ratio and TRP between patients and controls, but enuretic patients had significantly higher FE Na% and FE K% values than controls (p < 0.001). There were significant positive correlations between FE Na% and (r = 0.81, p < 0.001) FE K% and the frequency of bedwetting, respectively, among enuretic patients (r = 0.54, p < 0.001). CONCLUSION: Since Na and K excretion of enuretic patients was higher than in nonenuretics, it can be concluded that there may be a benign hereditary and/or postural renal tubular handling disorder of Na and K in enuretic children.