Epidemiology of enuresis: a large number of children at risk of low regard.

AIM: To describe the epidemiological aspects of nocturnal enuresis (NE). In this study we identify the prevalence and the familial conditions in a large, representative sample of children with monosymptomatic NE (MNE) and nonmonosyptomatic NE (NMNE). MATERIAL AND METHODS: In this descriptive-analytic study the Italian Society of Pediatrics (SIP) promoted a prevalence study of NE using a questionnaire involved 320 primary care Pediatricians from Northern, Central and Southern Italy, from January 2019 to July 2019, with a total of 130,000 children analyzed by questionnaire related to epidemiology and type of NE, familiarity, quality of sleep, eating and drinking habits, pharmacological and psychological/behavioural interventions and family involvement. RESULTS: 270/320 (84.4%) Paediatrician replied to our questionnaire. We enrolled a total of 9307/130,000 (7.2%) children with NE, aged between 5 and 14 years: 2141 diagnosed with MNE and 7176 qualified as NMNE. Poor quality of sleep were reported in 7064 patients; 90% of children did not consider a dietary and drinking recommendation. Pediatrician reported a total of 54.1% of parents who declared to have a negative reaction to their children because of the bedwetting. A percentage of 71.4% of parents declared to use or to have used alternative therapies and not to prefer, at first, a pharmacological intervention. CONCLUSION: The choice of treatment should include psychological/behavioural interventions in all cases to improve the therapeutic outcome. All primary care Pediatricians should be aware of the all aspects of NE to choose the best way to treat every patient.

A case study: Effects of foot reflexotherapy on ADHD symptoms and enuresis nocturia in a child with ADHD and enuresis nocturia.

BACKGROUND AND PURPOSE: Symptoms of Attention-Deficit Hyperactivity Disorder (ADHD) can occur in association with enuresis nocturia. Alternative therapies may be effective in addressing the maladies of children with ADHD comorbidities. The purpose of this study was to investigate the effects of foot reflexotherapy in a child with ADHD and enuresis nocturia. MATERIALS AND METHODS: The patient was an 8-year-old child with ADHD and enuresis nocturia. Pre- and post-tests for ADHD were completed using Vanderbilt ADHD Diagnostic Teacher Rating Scale. The subject was treated with foot reflexotherapy for 20-min per session twice per week for a period of 8 weeks. RESULTS: The child showed improvement in ADHD symptoms and his enuresis nocturia disappeared completely after foot reflexotherapy. CONCLUSION: Foot reflexotherapy was effective in improving inattention, hyperactivity in the child with ADHD. The results of this novel study suggest that foot reflexotherapy can be effective in treating ADHD child with enuresis nocturia.

Clinical management of nocturnal enuresis.

Nocturnal enuresis (NE) is a common health problem. Approximately 10% of 7-year-old children wet the bed regularly during sleep. Enuresis can be categorized into monosymptomatic (MEN) and nonmonosymptomatic (NMEN) forms. MEN occurs without any other symptoms of bladder dysfunction. NMEN is associated with dysfunction of the lower urinary tract with or without daytime incontinence. The rate of comorbid gastrointestinal, behavioral, and emotional disorders is elevated depending upon the subtype of NE. A careful clinical history is fundamental to the evaluation of enuresis. Diagnostic procedures include medical history and psychological screening with questionnaires, bladder and bowel diary, physical examination, urinalysis, ultrasound, and examination of residual urine. The mainstay of treatment is urotherapy with information and psychoeducation about normal lower urinary tract function, the underlying cause of MEN, disturbed bladder dysfunction in the child with NMEN and instructions about therapeutic strategies. Alarm therapy and the use of desmopressin have been shown to be effective in randomized trials. Children with NMEN first need treatment of the underlying daytime functional bladder problem before treatment of nocturnal enuresis. In patients with findings of overactive bladder, besides urotherapy, anticholinergic drugs may be useful.

Psychosocial and respiratory disease related to severe bladder dysfunction and non-monosymptomatic enuresis.

OBJECTIVE: Complicated bladder dysfunctions (BD) (associated with infections/urological complications or irresponsive to treatment) are a small proportion of all cases, but are highly morbid, clinically and psychosocially. Our aim is to describe a cohort of complicated pediatric BD, using subgroup analysis to compare presentations and responses to treatment among genders, age groups, and patients with or without non-monosymptomatic enuresis (NME). We also relate severe BD to other health conditions or to social/behavioral problems and report treatment results. METHOD: Thirty-five cases of complicated BD were reviewed. Neurogenic bladders and anatomical urological problems were excluded. Justifications for referral, comorbidities, and social aspects/familial dynamics were studied. Overactive bladders were primarily treated with oxybutynin. Transcutaneous parasacral neuromodulation was used in case of insufficient response or unbearable side effects. For infrequent voiders, timed voiding and transcutaneous neuromodulation were counseled. RESULTS: Incontinence/enuresis were the motives for referral in only a third of the cases. UTI (42.9%) was the main reason for referral. Hydronephrosis was observed in 8.6% of the children. Respiratory/ENT problems, obesity, and precocious puberty were highly prevalent. Schooling problems and neuropsychiatric disease were common. Social problems were common. Five patients presented urological problems secondary to BD (hydroureteronephrosis, VUR, trabeculated bladder). Twenty percent of cases required high anticholinergic doses and 37.1% transcutaneous electrostimulation. Eight (22.9%) patients abandoned but later resumed therapy, and 14.6% did not follow treatment. Boys tended to be older than girls and presented NME, respiratory, and behavioral problems more often, with a significant difference for asthma and anxiety/depression. Associated health problems and neuropsychiatric treatment tended to be more frequent among those presenting NME. Non-enuretic children tended to show better results from treatment (see Table). CONCLUSION: The social characteristics of our population (severe cases, socially deprived, very poor, not well educated, and with limited access to health care) determine a very specific sampling. Our research demonstrated that even severe cases of BD affecting socially deprived children may be treated, with adhesion to treatment and results comparable with other cohorts of BD, although the children need multidisciplinary attention and close follow-up. Boys, older children, and NME are more difficult to treat and often have other associated health and behavioral problems. Stress-related conditions were common in severe BD. A relatively high occurrence of precocious puberty was an unexpected finding in our research.

Traditional Japanese medicine, Yokukansan, for the treatment of nocturnal enuresis in children.

BACKGROUND: The major pathogenic factors involved in nocturnal enuresis are nocturnal polyuria, small bladder capacity and/or detrusor overactivity, and a high arousal threshold. Desmopressin is the first-line therapy for the patients with diuresis-dependent nocturnal enuresis. Yokukansan, a traditional Japanese medicine, has been used in Japan to treat patients with nervousness, insomnia, and children with night terrors and temper tantrums. We experienced the positive effect of Yokukansan in some of the patients who did not respond well to desmopressin therapy. METHODS: In total, 32 children with monosymptomatic nocturnal enuresis with nocturnal polyuria were treated with oral desmopressin melt tablets, which were approved for clinical use in Japan on 29 May 2012. This treatment was effective for 14 of them. For the rest (n = 18), Yokukansan was introduced in combination with desmopressin. RESULTS: Yokukansan was effective for 12 out of the 18 cases. CONCLUSIONS: Yokukansan should be a candidate for the medication of nocturnal enuresis.

Effects of percutaneous tibial nerve stimulation on adult patients with overactive bladder syndrome: a systematic review.

AIMS: To assess the effectiveness of percutaneous tibial nerve stimulation (PTNS) on adult patients with overactive bladder syndrome, using a systematic review of randomized controlled trials (RCTs), clinical controlled trials (CCTs), and prospective observational cohort studies. METHODS: A computer-aided literature search was performed in: PubMed, EMBASE and CENTRAL (2000 to November 15, 2011) to identify RCTs, CCTs, and prospective observational cohort studies. The study had to investigate the effect of PTNS on overactive bladder syndrome. The methodological quality of each study was assessed and a qualitative analysis was performed to establish the levels of evidence. RESULTS: Four RCTs and six prospective observational cohort studies were identified. There is strong evidence for the efficacy of PTNS versus a sham treatment. There is limited evidence that the use of PTNS and tolterodine ER is equally effective. No additional effect of a combination of Stoller afferent nerve stimulation (SANS) and anticholinergic medication compared to SANS alone. Most cohort studies suggested decreased frequency and improvement of incontinence and nocturia. However, the level of evidence was insufficient to make any firm conclusions. Because the total duration of all included trials varied between 6 and 12 weeks, so far there is little information on treatment periods. CONCLUSIONS: PTNS is efficacious for frequency and urgency urinary incontinence. More high quality studies are needed to improve the level of evidence concerning the efficacy of PTNS with regard to urgency and nocturia, to specify patient selection criteria, optimal treatment modalities and long-term effects as well as the effectiveness in more pragmatic trials.

Role of posterior tibial nerve stimulation in the treatment of refractory monosymptomatic nocturnal enuresis: a pilot study.

PURPOSE: We evaluated the early clinical and urodynamic results of posterior tibial nerve stimulation in patients with refractory monosymptomatic nocturnal enuresis. MATERIALS AND METHODS: We randomly assigned 28 patients with refractory monosymptomatic nocturnal enuresis to 2 equal groups. Group 1 received a weekly session of posterior tibial nerve stimulation for 12 weeks and group 2 was the placebo group. Evaluation was performed in each group at baseline and after posterior tibial nerve stimulation to compare clinical and urodynamic findings. Another clinical assessment was done 3 months after the first followup. RESULTS: The 2 groups were comparable in baseline clinical and urodynamic data. Overall, 13 patients (46.4%) had detrusor overactivity and 14 (50%) had decreased bladder capacity. After treatment 11 group 1 patients (78.6%) had a partial or full response to posterior tibial nerve stimulation but only 2 (14.3%) in group 2 had a partial response (p = 0.002). Also, the average number of wet nights in group 1 was significantly lower than at baseline (p = 0.002). All urodynamic parameters significantly improved in group 1. In contrast, the number of wet nights and urodynamic parameters did not change significantly in group 2. At 3-month followup the number of patients with a partial or full response in group 1 had decreased from 11 (78.6%) to 6 (42.9%). No change was evident in group 2. CONCLUSIONS: Posterior tibial nerve stimulation can be a viable treatment option in some patients with refractory monosymptomatic nocturnal enuresis. However, deterioration in some responders with time suggests the need for maintenance protocols.

Evaluation and treatment of nonmonosymptomatic nocturnal enuresis: a standardization document from the International Children's Continence Society.

PURPOSE: This document represents the consensus guidelines recommended by the ICCS on how to evaluate and treat children with nonmonosymptomatic nocturnal enuresis (NMNE). The document is intended to be clinically useful in primary, secondary and tertiary care. MATERIALS AND METHODS: Discussions were held by the board of the ICCS and a committee was appointed to draft this document. The document was then made available to the members of the society on the web site. The comments were vetted and amendments were made as necessary to the document. RESULTS: The main scope of the document is the treatment of NMNE with drugs other than desmopressin-based therapy. Guidelines on the assessment, and nonpharmacologic and pharmacologic management of children with NMNE are presented. CONCLUSIONS: The text should be regarded as an expert statement, not a formal systematic review of evidence-based medicine. It so happens that the evidence behind much of what we do in the care of enuretic children is quite weak. We do, however, intend to present what evidence there is, and to give preference to this rather than to experience-based medicine, whenever possible.

[Optimization of enuresis therapy in children using transcranial magnetotherapy].

A total of 58 children (age from 6 to 14 years) suffering from nocturnal enuresis (NE) were divided into two groups. The study group received basic therapy (driptan dose was reduced to 2.5 mg twice a day) in combination with transcranial bitemporal magnetotherapy (TcMT). The control group received placebo TcMT and basic therapy. It is shown that addition of TcMT to reduced basic therapy lowered the score of imperative voiding symptoms 1.3-fold, number of enuresis patients 1.7-fold, volume of the bladder 6.8 months after the treatment 1.9-fold, corrected vegetative status and activity of the subcortical nervous center in 24% children according to cardiointervalography versus the controls. Thus, TcMT improves clinical effect in NE patients in 2-fold reduction of pharmacological burden.

[Isolated primary nocturnal enuresis: international evidence based management. Consensus recommendations by French expert group]. / Enurésie nocturne primaire isolée: diagnostic et prise en charge. Recommandations par consensus formalisé d'experts.

OBJECTIVE: The causes and treatment of isolated primary nocturnal enuresis (PNE) are the subject of ongoing controversy. We are proposing consensus practical recommendations, based on a formalised analysis of the literature and validated by a large panel of experts. METHODOLOGY: A task force of six experts based its work on the guide for literature analysis and recommendations and recommendation grading of the French Haute Autorité de Santé (formalized consensus process methodological guidelines) to evaluate the level of scientific proof (grade of 1 to 4) and the strength of the recommendations (grade A, B, C) of the publications on PNE. As a result of this, 223 articles from 2003 on were identified, of which only 127 (57 %) have an evaluable level of proof. This evaluation was then reviewed by a 19-member rating group. Several recommendations, poorly defined by the literature, had to be proposed by a professional agreement resulting from a consultation between the members of the task force and those of the rating group. For its final validation, the document was submitted to a reading group of 21 members working in a wide range of specialist areas and practices but all involved in PNE. RESULTS: The definition of PNE is very specific: intermittent incontinence during sleep, from the age of 5, with no continuous period of continence longer than 6 months, with no other associated symptom, particularly during the day. Its diagnosis is clinical by the exclusion of all other urinary pathologies. Two factors must be identified during the consultation: nocturnal polyuria promoted by excessive fluid intake, inverse secretion of vasopressin, snoring and sleep apnoea. It is sensitive to desmopressin; small bladder capacity evaluated according to a voiding diary and the ICCS formula. It may be associated with diurnal hyperactivity of the detrusor (30 %). It is resistant to desmopressin. Problems associated with PNE are: abnormal arousal threshold, attention deficit hyperactivity disorder (ADHD) (10 %), low self-esteem. The psychological component is not very significant. CONCLUSION: PNE is not psychological in origin. The management of this condition includes: evaluating the intrafamilial tolerance and the child's motivation, evaluating the rate, the volume of urine and wet nights using a diurnal and nocturnal diary; education (sufficient fluid intake at the start of the day, decrease in hyperosmolar intake in the evening, regular and complete urination); specific treatments: desmopressin for polyuric forms (expected success rate of 60-70 %), alarms for forms involving small bladder capacity (expected success rate of 60-80 %); alternative treatments and/or treatments combined with the preceding ones, for refractory forms: oxybutinin, tricyclic antidepressants (risk). Results obtained with hypnosis, psychotherapy, acupuncture, homoeopathy or chiropractic are not currently validated (insufficient level of proof).

The effect of desmopressin on renal water and solute handling in desmopressin resistant monosymptomatic nocturnal enuresis.

PURPOSE: We sought to evaluate the effect of desmopressin on renal water and solute handling in children with monosymptomatic nocturnal enuresis and desmopressin resistant nocturnal polyuria compared to healthy controls. MATERIALS AND METHODS: A total of 12 patients with enuresis and nocturnal polyuria, normal bladder reservoir function and no response to desmopressin, and 10 age matched controls were enrolled in the study. Children were admitted to the hospital for a 48-hour protocol comprising urine collections and blood sampling. Sodium and water intake was standardized. During the second night children received 40 mug intranasal desmopressin. Parameters characterizing the renal water and solute handling were measured and compared between baseline nights and nights with desmopressin. RESULTS: Desmopressin markedly reduced nocturnal urine output in patients with enuresis, minimizing sodium, urea and overall solute excretion, despite the fact that these children were unresponsive to desmopressin at home. This effect on renal sodium handling was not mediated by atrial natriuretic peptide, angiotensin II, aldosterone or renin. Desmopressin did not influence urinary prostaglandin E(2) excretion. The antinatriuretic effect was seen only in patients with enuresis, and it was directly correlated with the reduction in urine output. CONCLUSIONS: Children with nocturnal enuresis and nocturnal polyuria who do not exhibit adequate response to desmopressin at home seem to respond well to the agent at the clinic. The effect of desmopressin in children with enuresis seems largely dependent on reductions in the amount of sodium excreted. Sodium regulating hormones remained unaffected by desmopressin, indicating a possible direct effect of the agent on renal sodium handling.

Moxibustion, an alternative therapy, ameliorated disturbed circadian rhythm of plasma arginine vasopressin and urine output in multiple system atrophy.

Previously no alternative therapy approach has been made to ameliorate disturbed circadian arginine vasopressin rhythm (C-AVP-R) in multiple system atrophy (MSA). A 65-year-old man with MSA showed loss of C-AVP-R and nocturnal polyuria. We performed moxibustion at specific acupuncture points on the bladder and inside the feet, once a day, 3 times a week, for 6 months. After the treatment, his C-AVP-R appeared to be normal, and the nocturnal urine output decreased to 75% (p<0.01). Together with the previous studies, it seems possible that somatic warm stimulation by moxibustion in specific points might have facilitated AVP secretion in this patient.