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.

Effect of biofeedback treatment on spinning top urethra in children with voiding dysfunction.

OBJECTIVES: Spinning top urethra (STU) deformity arises secondary to detrusor instability, leading to an increase in the intravesical pressure against a closed sphincter. We retrospectively analyzed the effect of biofeedback treatment on STU in children with dysfunctional voiding. METHODS: A total of 121 patients with STU and voiding dysfunction were enrolled in this study. The patients divided into two groups. Group 1 (n = 49) were treated with simple bladder retraining with timed voiding, and group 2 (n = 72) were treated with biofeedback therapy. Voiding cystourethrography was performed 6 and 12 month later to determine the status of the STU after both therapies. RESULTS: The patient age range was 5 to 13 years (mean 8.1 +/- 1.9) in group 1 and 5 to 13 years (mean 8.2 +/- 1.7) in group 2. Group 1 consisted of 41 girls and 8 boys; group 2 consisted of 63 girls and 9 boys. Voiding cystourethrography revealed vesicoureteral reflux in 39 and 59 children in groups 1 and 2, respectively. The improvement rates of the biofeedback therapy in children with STU and vesicoureteral reflux were significantly greater than the children treated with timed voiding at 6 months and 1-year of follow-up. CONCLUSIONS: For children admitted to urology clinics with urinary infection or complaints thought to be an unstable urinary bladder, proximal urethral dilation called STU is detected at a high frequency. It should be remembered that this situation can be related to vesicoureteral reflux and urinary bladder instability. Biofeedback training is a simple, effective, and well-tolerated treatment modality for these children.

Diagnosis and management of dysfunctional voiding.

PURPOSE OF REVIEW: This review will focus on the diagnosis and management of voiding dysfunction in neurologically and anatomically normal children. The discussion will highlight recent developments and research in the clinical approach as well as the etiology and classification of these disorders. RECENT FINDINGS: Voiding dysfunction in children encompasses a wide spectrum of clinical entities, recently classified collectively as dysfunctional elimination syndromes. Voiding dysfunction typically presents after toilet training and may originate from behavioral issues that arise around this time in childhood development. The spectrum of disorders includes urge syndrome, dysfunctional voiding with an uncoordination between the detrusor and urinary sphincter, and enuresis. Clinical symptoms may vary from mild incontinence to severe disorders with endpoints of irreversible bladder dysfunction with vesicoureteral reflux, urinary tract infection and resulting nephropathy. Diagnosis relies heavily on a good history and physical examination, but also includes radiologic and urodynamic evaluation. Treatment generally consists of medical therapy, primarily with anticholinergics as well as behavioral therapy to modify learned voiding patterns that contribute to the voiding dysfunction. SUMMARY: This overview of voiding dysfunction in children outlines the established approaches to its diagnosis and treatment and highlights the most recent developments in the field.

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.

Primary nocturnal enuresis: omega-3 fatty acids may be of therapeutic value.

Primary nocturnal enuresis (PNE), or bed-wetting, is a distressing urinary condition which can persist through childhood and beyond. Altered prostaglandin and nitric oxide production have been observed in children with PNE, and prostaglandin inhibitors are known to be of therapeutic value. Omega-3 fatty acids have the potential to influence the symptoms of PNE by inhibition of prostaglandin and renal nitric oxide production. In addition, children with PNE have an inappropriate startle response and an apparent maturational delay of the central nervous system. Research clearly shows that omega-3 fatty acids play a critical role in the development and function of the central nervous system. It is our contention that inadequate omega-3 intake may play a role in the lack of inhibitory input to the startle and micturition centers in PNE.

[Biofeedback for urinary bladder dysfunctions in childhood. Indications, practice and the results of therapy]. / Biofeedback bei kindlichen Blasenfunktionsstörungen. Indikationen, praktische Durchführung und Therapieergebnisse.

In children, abnormal behavior during micturition, i.e. detrusor/sphincter dyscoordination, causes persistent voiding problems, urinary incontinence and/or recurrent urinary tract infections in up to 15% of cases. Contractions of the external urethral sphincter during micturition lead to functional subvesical obstruction. Nowadays, biofeedback training is the most suitable therapy. Biofeedback training for children is based on the assumption that relaxation and contraction of the urinary external sphincter is a habitual phenomenon and can be restored. With specially developed, computer-assisted biofeedback programs, sphincter contraction and relaxation can be transformed into acoustic or visual signals. Acoustic or optical feedback indicates relaxation and contraction control to the patient. The residual urine volume should subsequently be assessed. The results should be reviewed after each micturition. Poor compliance sometimes makes biofeedback training impossible. Further biofeedback training at home is a reasonable suggestion. Good results-a response rate of up to 90%-demonstrates that biofeedback training is successful in the treatment of detrusor-sphincter dyscoordination. After effective therapy, associated urinary tract infections and vesicoureterorenal reflux may disappear.

Topographic abnormalities in event-related potentials in children with monosymptomatic nocturnal enuresis.

AIMS: A functional maturational delay in the central nervous system is dwelled upon in the pathogenesis of monosymptomatic nocturnal enuresis (MNE). In this study we studied whether according to controls N200 and P300, components of the event-related potential (ERP), which is related to aspects of cognitive processing, showed any difference in its topographic distribution in children within the age group 10-13 with monosymptomatic nocturnal enuresis and discussed its relation to the pathogenesis of MNE. METHODS: We performed P300 in 18 patients with MNE and in 16 age-matched healthy subjects. P300 were evoked by an auditory oddball paradigm consisting of 150 tone bursts (80% 1 kHz; 20% 2 kHz). The latencies of the N200 and the P300 waves and the amplitude of the P300 wave were measured. RESULTS: There was no statistical difference between the enuretic group and the controls in N200 and P300 latency and amplitude in the midline frontal (Fz), central (Cz), and parietal (Pz) recording site of the 10-20 International System. In the enuretic group while P300 amplitude in the Fz site was significantly less than the P300 amplitude in the Cz site, there was no statistical difference between the Fz and Pz P300 amplitude values. CONCLUSIONS: When different levels of maturational delay are considered in MNE, it may be claimed that maturational delay in children whose enuresis lasts until older ages will be different from those whose enuresis ends at an early age. The determination of P300 amplitude in parietal records being less in enuretics when compared to the controls may show that there are regional differences in stimuli processing rate/quality.

[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.

Sleep arousal function in enuretic males.

Enuretic children are described as difficult to arouse from sleep. This paper reports on the clinical implications of auditory sleep arousal thresholds in 15 enuretic and 18 control subjects (7-12-year-old males). All children were studied in a sleep laboratory for four consecutive nights using standard polysomnographic recording techniques. Sleep was undisturbed for the first two nights and waking thresholds were measured on the following two nights. Enuretic children were found to wet most frequently in the first two-thirds of the night. Arousal attempts were successful in 39.7% of controls and 9.3% attempts were successful in enuretics. The results of this study suggest that enuretic males were more difficult to arouse than age-matched controls. The elevated arousal thresholds may have been the result of delayed maturation. Therefore, treatment programs that rely on awakening should be cognizant of these features.

Prepulse inhibition of startle and the neurobiology of primary nocturnal enuresis.

BACKGROUND: Children with primary nocturnal enuresis (PNE) wet the bed during all stages of sleep and irrespective of state of arousal, suggesting that during sleep, when voluntary, i.e., cortical control, is not available, the signal from the distended bladder is not registered in the subcortical centers inhibiting micturition. Deficient prepulse inhibition (PPI) of startle has been reported in PNE. This study evaluates the association of this PPI deficit in PNE with comorbidity with attention-deficit hyperactivity disorder (ADHD) and with intelligence. METHODS: Prepulse modulation of startle was studied in 96 boys with PNE and 105 nonenuretic boys using intervals of 60, 120, and 4000 msec between the onset of a 75-dB 1000-Hz tone and a 104-dB noise burst. Thirty-one percent of the enuretic and 36% of the nonenuretic boys were diagnosed with ADHD. RESULTS: After adjustment for presence or absence of ADHD, lower or higher IQ, age, and unmodulated startle amplitude, there was a significant association between PNE and deficient PPI of startle following the 120-msec prepulse interval. Those enuretic boys who also were ADHD or had higher performance IQs (> or = 110) showed the greatest PPI deficit. CONCLUSIONS: A common deficiency of inhibitory signal processing in the brain stem may underlie both deficient PPI and the inability to inhibit micturition in PNE. Strong familiarity for PNE, ADHD, and intelligence suggests a possible genetic mediation of these effects.

Sleep spindles and arousal: the effects of age and sensory stimulation.

This study assessed a proposed sleep-preserving role for sleep spindles by evaluating variations in this activity as a function of factors, both naturally occurring and experimentally induced, known to affect and effect arousal from sleep. These factors included age, auditory stimulation, and experimentally induced arousal from sleep. Analyses were based on data from 84 males (5-49 yrs. old) from normal and clinical (hyperactive, enuretic, and chronic pain) populations who had participated in sleep auditory arousal threshold studies involving adaptation and 1-2 experimental nights. Spindles on experimental nights were visually analyzed and incidence determined for the two minutes preceding and throughout all Stage 2 arousal attempts. Prestimulation spindle occurrence in 39 preadolescent subjects with two experimental nights did not vary significantly from night-to-night, and prestimulation period comparisons between clinical groups and their respective controls were also non-significant. Anticipated relationships between spindle activity and indices of arousal-either inverse with respect to known variations in arousal threshold, i.e., decreases with age and across the night, or direct with respect to stimulus intensity particularly on trials when arousal did not occur-were not observed. Instead, all age groups showed significant decreases in spindle density as an increasing negative function of stimulus intensity. These findings suggest that to the extent to which sleep spindles can be considered to play a role in sleep preservation by inhibiting or attenuating potentially arousing stimuli, these effects appear to be restricted to endogenously generated stimuli and are passive rather than reactive in nature.

Spot urine osmolality, age and bladder capacity as predictors of response to desmopressin in nocturnal enuresis.

The objective of the current study was to find a cost-effective way of correlating spot urine osmolalities, bladder capacity and age in patients with monosymptomatic nocturnal enuresis with response to treatment with desmopressin (Minirin, DDAVP). A total of 35 children fulfilled the entry criteria and were included in the study. Constipation was eliminated in these children by appropriate enema treatment and diet adjustment prior to enrollment. Urine samples were collected at home at times that would best reflect fluctuations in plasma vasopressin levels (08:00, 16:00 and 22:00) over three consecutive 24-hour periods. Maximal functional bladder capacity was determined from the largest voided volume. A 2-week dose-titration treatment period with intranasal desmopressin was then conducted. With doses of desmopressin being increased by 10 micrograms every 3 days. Response to desmopressin treatment was then assessed and factors that were observed to be markers of a favourable response were noted. Of the 35 children, 27 demonstrated a complete response to desmopressin treatment, at doses of 10-30 micrograms. Spot urine osmolalities were not predictive of the response to desmopressin (P > 0.1). In contrast, there was a significant correlation between a high maximum functional bladder capacity and response to desmopressin (P = 0.006). Age was also predictive of a good response to desmopressin treatment (P = 0.008).

Evaluation and management of primary nocturnal enuresis.

Enuresis can be a source of family crisis, and can contribute to a lack of self-esteem in the affected child. It must be stressed to both parent and child that improvement is gradual and largely a function of maturation in cases where no organic problem is identified. Research shows that many enuretic children seem to have small bladder capacities (Long, 1991), and that the majority have a polyuric factor such as a decreased level of AVP that is amenable to replacement therapy with desmopressin (Bloom, 1993; Hamburger, 1993; Hjälmås & Bengtsson, 1993; Nørgaard & Djurhuus, 1993). Utilizing pharmacologic treatment can accelerate spontaneous cure or act as a substitute until time provides nocturnal continence (Nørgaard & Djurhuus, 1993). Nurse practitioners can use multiple modalities in a holistic approach to reframe this problem and to involve children in solving their own problem. The child who is given a basic understanding of the physiology involved in the healing process will be able to identify inner healing resources and utilize external resources available to him or her. This approach begins with children's imaging the desired outcome of urinary control and ends with achieving increased self-esreem and the sense of competence they deserve.

Treatment of enuresis risoria in children by self-administered electric and imaginary shock.

OBJECTIVE: To treat enuresis risoria (giggle micturition) by a self-administered electric and imaginary shock and to evaluate the outcome after behavioural therapy. PATIENTS AND METHODS: Six boys and three girls with enuresis risoria were evaluated and treated. The mean age at referral was 10.4 years (range 5.7-14.2). All children had episodes of involuntary complete bladder emptying triggered by hearty laughter or giggling. The frequency ranged from four times per day to twice a week. No other voiding problems were noted. Five patients (four boys and one girl, mean age 10.2 years, range 5.7-14.2) received conditioning training which consisted largely of the self-administration of a harmless, painless electric shock to the back of one hand, at the moment when micturition was induced by laughter, leading to inhibition of the voiding reflex. Later, the electric shock was replaced by an imaginary shock. Training was undertaken on an outpatient basis. A mean of eight sessions, each of 45 min duration, was necessary to train the children. The mean follow-up was 26 months (range 12-51). RESULTS: The frequency of wetting was reduced by a mean of 89% in all children 1 year after the successful completion of the training. In three children, followed for 2 years, this result stabilized at that proportion. One of these children, followed for > 3 years, gradually reverted to the original pattern of daily wetting and another patient, with a follow-up of > 4 years, maintained an 86% reduction of wetting incidents. CONCLUSION: Until now, there was no specific treatment for enuresis risoria and not all patients outgrow the problem; this experimental conditioning programme shows promise in diminishing wetting incidents. However, the programme needs further testing in a prospective study.

[Primary enuresis in children. Which treatment today?]. / L'enuresi primaria in età pediatrica. Quale trattamento oggi?

Nowadays enuresis is a problem that pediatric urologists are often called to treat, since it affects 15 to 30% of school-age children. In 85% of affected children bedwetting is monosymptomatic, not accompanied by other voiding disorders or daytime incontinence. Treatment of choice is still highly controversial, as the physiopathology is not yet fully understood and the pathogenesis is multifactorial: genetic and psychological factors, sleep disorders, urinary reservoir abnormalities, urine production disorders can all play a part. Behavioural treatments (psychotherapy, bladder training and biofeedback, electric alarm) and pharmacological therapy (tricyclic antidepressants, anticholinergics, DDAVP) have been used with variable results. In our 1 year experience (54 enuretic children) DDAVP proved to be effective in reducing the number of wet nights per week in 79% of cases. Acupuncture, which we have been using for many years, also gave good results in 55% of treated patients. Long term success of DDAVP and acupuncture was respectively 50 and 40%. We discuss the probable pathophysiology and present our own results and those reported in the literature. It has to be stressed that an accurate diagnostic selection of patients and a better understanding of physiopathology are the basis of effective treatment of enuresis.