The effectiveness of parasacral transcutaneous electrical nerve stimulation in the treatment of monosymptomatic enuresis in children and adolescents: a systematic review

ABSTRACT Background: Parasacral Transcutaneous Electrical Nerve Stimulation (PTENS) is a treatment used in enuresis refractory to first-line treatment. This review aimed to evaluate the effectiveness of PTENS in treating monosymptomatic enuresis (MNE) in children and adolescents. Methods: The study followed the Preferred Reporting Items for Systematic (PRISMA) guidelines. The search was carried out in the following databases: MEDLINE (via PubMed), Web of Science, SCOPUS, Central Cochrane Library and Physiotherapy Evidence Database (PEDro). The selected studies were randomized clinical trials (RCTs). The "Risk of Bias tool for randomized trials" and the "Risk of Bias VISualization" were used to analyze the risk of bias. Results: Of the 624 studies selected, four RCTs were eligible. Three included 146 children and adolescents aged between six and 16.3 years and used similar PTENS protocols with a frequency of 10 Hz, pulse duration of 700 µs and 20 minutes three times/week. One study enrolled 52 patients aged seven to 14 years used PTENS at home, with a pulse duration of 200 µs and 20 to 60 minutes twice/day. Risk of bias was observed in three studies due to results' randomization and measurement. Two studies showed a partial response with a reduction in wet nights, one a complete response in 27% of patients, and one showed no improvement. Conclusion: PTENS reduces wet nights' frequency but does not cure them, except in 27% of patients in one study. Limited RCTs and data heterogeneity are limitations.

Translation, cross-cultural adaptation and validation of the Short Screening Instrument for Psychological Problems in Enuresis for use in Brazil (SSIPPE-Br)

Abstract Objective: Enuresis is associated with attentional and emotional comorbidities in 20 to 30 % of cases. The Short Screening Instrument for Psychological Problems in Enuresis (SSIPPE) is a questionnaire that allows the initial screening of these comorbidities. This study aimed to translate, culturally adapt, and validate the SSIPPE for Brazilian children and adolescents (SSIPPE-Br). Methods: Six steps were performed for translation and cross-cultural adaptation: translation, synthesis of translations, back-translation, preparation of the pre-final version of the translated instrument, test of comprehensibility of the pre-final version of the tool, and elaboration of the instrument cross-culturally adapted for Brazil, named 13-itens version SSIPPE-Br. To validate the SSIPPE-Br, a cross-sectional study was carried out, in which the validated Brazilian version of the Child and Adolescent Behavior Inventory (CABI) was used. Results: Validation was performed on 127 children and adolescents with a mean age of 9.7 ± 2.8 years, 48 % male. The reliability was estimated using Cronbach's alpha, ranging from 0.86 to 0.89, indicating good internal consistency. The factorial analysis had a good agreement adjustment (KMO 0.755, Bartlett's test < 0.001) and explained 70.5 % of the data variability. In the reproducibility analysis, the Kappa coefficient ranged from 0.94 to 1, which can be considered almost perfect. A highly significant (p-value < 0.001) and direct correlation existed between the three SSIPPE-Br domains and all evaluated CABI domains. Conclusion: The SSIPPE-Br is a valid and reliable tool for emotional problems screening and ADHD symptoms in children and adolescents with enuresis whose first language is Brazilian Portuguese.

The effectiveness of parasacral transcutaneous electrical nerve stimulation in the treatment of monosymptomatic enuresis in children and adolescents: a systematic review.

BACKGROUND: Parasacral Transcutaneous Electrical Nerve Stimulation (PTENS) is a treatment used in enuresis refractory to first-line treatment. This review aimed to evaluate the effectiveness of PTENS in treating monosymptomatic enuresis (MNE) in children and adolescents. METHODS: The study followed the Preferred Reporting Items for Systematic (PRISMA) guidelines. The search was carried out in the following databases: MEDLINE (via PubMed), Web of Science, SCOPUS, Central Cochrane Library and Physiotherapy Evidence Database (PEDro). The selected studies were randomized clinical trials (RCTs). The "Risk of Bias tool for randomized trials" and the "Risk of Bias VISualization" were used to analyze the risk of bias. RESULTS: Of the 624 studies selected, four RCTs were eligible. Three included 146 children and adolescents aged between six and 16.3 years and used similar PTENS protocols with a frequency of 10 Hz, pulse duration of 700 µs and 20 minutes three times/week. One study enrolled 52 patients aged seven to 14 years used PTENS at home, with a pulse duration of 200 µs and 20 to 60 minutes twice/day. Risk of bias was observed in three studies due to results' randomization and measurement. Two studies showed a partial response with a reduction in wet nights, one a complete response in 27% of patients, and one showed no improvement. CONCLUSION: PTENS reduces wet nights' frequency but does not cure them, except in 27% of patients in one study. Limited RCTs and data heterogeneity are limitations.

Validación de constructo de un algoritmo hipnoterapéutico para niños con enuresis nocturna monosintomática

Introducción: La enuresis nocturna es un motivo frecuente de consulta en pediatría, psiquiatría infantil, psicología y medicina familiar, con mayor porcentaje en los niños de 5 años de edad, seguidos por los de 7 y 9, en ese orden. Objetivo: Determinar la validez de constructo del algoritmo hipnoterapéutico para pacientes con enuresis nocturna monosintomática. Métodos: Se realizó una investigación compleja de 97 pacientes, atendidos en la Clínica de Hipnosis Terapéutica de la Universidad de Ciencias Médicas de Santiago de Cuba, desde febrero del 2021 hasta julio del 2022, la cual estuvo estructurada en 3 etapas metodológicas de validación de constructo para dar continuidad a la etapa IV de la validación de contenido del algoritmo hipnoterapéutico, sobre la base de 2 cuasi-experimentos sin grupo de control y un estudio cuasiexperimental con grupo de control no equivalente de la segunda etapa de dicha investigación. Resultados: El análisis factorial sobre el estudio de componentes principales fue factible, pues los factores 1, 2 y 3 debían mantenerse, lo cual se expresó en el gráfico de sedimentación y en la varianza total explicada, a través de los porcentajes acumulados en los autovalores iniciales y la suma de las saturaciones al cuadrado de la extracción y la rotación con 64,24 %. Conclusiones: La validación de constructo del algoritmo diseñado mostró pertinencia, dada por la idoneidad del análisis factorial y la prueba de esfericidad de Bartlett.

Introduction: Bedwetting is a frequent reason to visit pediatric, infant psychiatry, psychology and family medicine services, with more percentage in 5 years children, followed by 7 and 9 years children, in that order. Objective: To determine the construct validity of the hypnotherapeutic algorithm for patients with monosymptomatic bedwetting. Methods: A complex investigation of 97 patients was carried out, who were assisted in the Therapeutic Hypnosis Clinic of the University of Medical Sciences in Santiago de Cuba, from February, 2021, to July, 2022 which was structured in 3 methodological phases of construct validation to continue the phase IV of hypnotherapeutic algorithm content validation, on the base of 2 quasi-experiments without control group and a quasi-experiment with non equivalent control group of the second phase of this investigation. Results: The factorial analysis on the study of main components was possible, because the factors 1, 2 and 3 should stay, which was expressed in the sedimentation graph and in the explained total variance, through the percentages accumulated in the initial auto values and the sum of saturations to the square of extraction and rotation with 64.24%. Conclusions: The construct validation of the designed algorithm showed relevancy, given by the suitability of the factorial analysis and the Bartlett test of spherical form.

Translation, cross-cultural adaptation and validation of the Short Screening Instrument for Psychological Problems in Enuresis for use in Brazil (SSIPPE-Br).

OBJECTIVE: Enuresis is associated with attentional and emotional comorbidities in 20 to 30 % of cases. The Short Screening Instrument for Psychological Problems in Enuresis (SSIPPE) is a questionnaire that allows the initial screening of these comorbidities. This study aimed to translate, culturally adapt, and validate the SSIPPE for Brazilian children and adolescents (SSIPPE-Br). METHODS: Six steps were performed for translation and cross-cultural adaptation: translation, synthesis of translations, back-translation, preparation of the pre-final version of the translated instrument, test of comprehensibility of the pre-final version of the tool, and elaboration of the instrument cross-culturally adapted for Brazil, named 13-itens version SSIPPE-Br. To validate the SSIPPE-Br, a cross-sectional study was carried out, in which the validated Brazilian version of the Child and Adolescent Behavior Inventory (CABI) was used. RESULTS: Validation was performed on 127 children and adolescents with a mean age of 9.7 ± 2.8 years, 48 % male. The reliability was estimated using Cronbach's alpha, ranging from 0.86 to 0.89, indicating good internal consistency. The factorial analysis had a good agreement adjustment (KMO 0.755, Bartlett's test < 0.001) and explained 70.5 % of the data variability. In the reproducibility analysis, the Kappa coefficient ranged from 0.94 to 1, which can be considered almost perfect. A highly significant (p-value < 0.001) and direct correlation existed between the three SSIPPE-Br domains and all evaluated CABI domains. CONCLUSION: The SSIPPE-Br is a valid and reliable tool for emotional problems screening and ADHD symptoms in children and adolescents with enuresis whose first language is Brazilian Portuguese.

Constipação oculta e semi-oculta em crianças com enurese monossintomática ou não monossintomática / Occult and semi-occult constipation in children with monosymptomatic or non monosymptomatic enuresis

ABSTRACT Background: Functional constipation and enuresis frequently coexist. Constipation treatment often results in resolution or improvement of the enuresis. However, besides the classical presentation, patients can present with occult constipation (OC) diagnosed in complementary evaluation; in addition, semi-occult constipation (SOC) can be detected by means of a detailed questionnaire. Objective: To quantify OC and SOC frequency in children with monosymptomatic or non monosymptomatic enuresis (MNE or NMNE). Methods: Otherwise healthy children/adolescents, with enuresis refractory to behavioral therapy and denying constipation after simple questions, answered a structured bowel habit questionnaire and were submitted to a plain abdominal radiological exam. Constipation was classified considering the Boston diagnostic criteria (to allow diagnosis at initial stages), and fecal loading in the X-ray quantified ≥10 by the Barr score. Children with constipation received a standardized treatment (except 26 "pilot" children). Results: Out of 81 children, 80 aged 9.34±2.07 years, 52.5% male, were diagnosed with constipation: 30 OC, 50 SOC; 63.75% had MNE, 36.25% NMNE (six NMNE without behavioral therapy). Demographic data and the Barr score were similar for OC and SOC, but SOC children experienced significantly more constipation complications (retentive fecal incontinence and/or recurrent abdominal pain). Not showing the Bristol Stool Scale (BSS) to 24 "pilot" children, or absence of constipation symptoms accompanying BSS predominantly type 3, in 13 children, did not significantly impact the detection of constipation by the Barr score. Children identifying BSS 3 or ≤2 had similar results. Twenty-eight children, with adequate follow-up after treatment, improved or recovered from constipation at 44 of their 52 follow-up visits. Conclusion: In patients with MNE or NMNE refractory to behavioral therapy, and who initially denied constipation after simple questions, a detailed questionnaire based on the Boston diagnostic criteria detected SOC in 61.7%, and the radiological Barr score revealed fecal loading (OC) in 37.0% of them.

RESUMO Contexto: Constipação funcional e enurese frequentemente coexistem. Tratamento da constipação geralmente resulta em cura ou melhora da enurese. Entretanto, além da apresentação clássica, pode ocorrer constipação oculta (CO), diagnosticada por exame subsidiário; ademais, ao aplicar questionário detalhado, pode-se detectar constipação semioculta (CSO). Objetivo: Obter as frequências de CO e CSO em crianças com enurese mono- ou não monossintomática (EMN ou ENMN). Métodos: Crianças/adolescentes saudáveis, exceto por enurese refratária à terapia comportamental, e que negavam constipação após perguntas simples, respondiam a questionário estruturado sobre hábito intestinal, e realizavam radiografia simples de abdômen. A constipação foi classificada considerando os critérios diagnósticos de Boston (que permitem diagnóstico em fases iniciais) e retenção fecal na radiografia quantificada ≥10 pelo escore de Barr. As crianças com constipação receberam tratamento padronizado (exceto 26 crianças "piloto"). Resultados: Das 81 crianças, 80 com idade 9,34±2,07 anos, 52,5% masculinas, foram diagnosticadas com constipação: 30 CO, 50 CSO; 63.75% tinham EMN, 36.25% ENMN (6 ENMN sem terapia comportamental). Os dados demográficos e o escore de Barr foram semelhantes para CO e CSO, mas as crianças com CSO apresentaram significativamente mais complicações de constipação (incontinência fecal retentiva e/ou dor abdominal recorrente). A não apresentação da Escala Fecal de Bristol (EFB) para 24 crianças "piloto", ou ausência de sintomas de constipação acompanhando EFB predominantemente do tipo 3, em 13 crianças, não teve impacto significativo na detecção de constipação pelo escore de Barr. Crianças que identificaram EFB 3 ou ≤2 tiveram resultados semelhantes. Vinte e oito crianças, com acompanhamento adequado após o tratamento, melhoraram ou se recuperaram da constipação em 44 de seus 52 retornos. Conclusão: Em pacientes com EMN ou ENMN refratária à terapia comportamental, e que inicialmente negavam constipação após perguntas simples, questionário baseado nos critérios diagnósticos de Boston detectou CSO em 61.7%, e o escore radiológico de Barr revelou retenção fecal (CO) em 37% deles.

Treating asthma in patients with enuresis: repercussions on urinary symptoms

ABSTRACT Background: Children presenting enuresis are more likely to be asthmatics. The association between enuresis and sleep-disordered breathing has already been demonstrated and several studies have shown at least partial improvement of two thirds or more of the cases of enuresis adenoidectomy. Studies have already described associations between enuresis and allergies but do not assess the repercussions of allergy treatment in enuretics. Objective: This study aims to evaluated whether asthma treatment alters the course of enuresis and whether there is any predictive factor associated with this improvement. Materials and Methods: Twenty patients (5 - 12 years old) with uncontrolled enuresis and asthma, received treatment for asthma. Children were also assessed for the presence of rhinitis and other allergies. The control of asthma was confirmed by a validated questionnaire and primary enuresis by clinical history and wet night diaries. Patients received only asthma treatment. Results: At least partial improvement of enuresis was observed in 55% of the patients with an increase in 64.4% in the number of dry nights at the end of the study (p=0.01). The "presence of other allergies" and "obstruction seen in nasal endoscopy" positively influenced the improvement of urinary symptoms (OR = 3.350; CI 0.844-13.306) and (OR=1.272; CI 0.480-3.370), respectively. Discussion: Until now, only patients presenting upper airway obstruction were known to benefit from the improvement of urinary symptoms when undergoing treatment for their respiratory problems. In our study, we found at least partial improvement in enuresis in 55% of our patients, with only clinical asthma treatment. Conclusion: Controlling asthma in children with primary enuresis resulted in a significant increase in dry nights.

Treating asthma in patients with enuresis: repercussions on urinary symptoms.

BACKGROUND: Children presenting enuresis are more likely to be asthmatics. The association between enuresis and sleep-disordered breathing has already been demonstrated and several studies have shown at least partial improvement of two thirds or more of the cases of enuresis adenoidectomy. Studies have already described associations between enuresis and allergies but do not assess the repercussions of allergy treatment in enuretics. OBJECTIVE: This study aims to evaluated whether asthma treatment alters the course of enuresis and whether there is any predictive factor associated with this improvement. MATERIALS AND METHODS: Twenty patients (5 - 12 years old) with uncontrolled enuresis and asthma, received treatment for asthma. Children were also assessed for the presence of rhinitis and other allergies. The control of asthma was confirmed by a validated questionnaire and primary enuresis by clinical history and wet night diaries. Patients received only asthma treatment. RESULTS: At least partial improvement of enuresis was observed in 55% of the patients with an increase in 64.4% in the number of dry nights at the end of the study (p=0.01). The "presence of other allergies" and "obstruction seen in nasal endoscopy" positively influenced the improvement of urinary symptoms (OR = 3.350; CI 0.844-13.306) and (OR=1.272; CI 0.480-3.370), respectively. DISCUSSION: Until now, only patients presenting upper airway obstruction were known to benefit from the improvement of urinary symptoms when undergoing treatment for their respiratory problems. In our study, we found at least partial improvement in enuresis in 55% of our patients, with only clinical asthma treatment. CONCLUSION: Controlling asthma in children with primary enuresis resulted in a significant increase in dry nights.

Diagnóstico y tratamiento de pacientes con vejiga neurogénica en la Unidad Técnica de Cirugía Pediátrica / Diagnosis and treatment of patients with Neurogenic bladder in the Surgery Technical Unit Pediatric

El presente trabajo toma como base el documento: "Manejo Urológico del Mielomeningocele" de las Guías de Atención Pediátrica, del Hospital De Pediatría "Juan P. Garrahan" de la ciudad de Buenos Aires - Argentina; de los autores: Dra. Carol Burek y Dra. Liliana Campmany. En la Unidad Técnica de Cirugía Pediátrica del Hospital de Especialidades Carlos Andrade Marín, se atienden por mes unos 50 a 70 pacientes afectos de vejiga neurogénica desde el nacimiento hasta la adolescencia. Es una enfermedad crónica que requiere un diagnóstico correcto con estudios de imagen y función de la vía urinaria además de un posterior manejo diario por parte de los padres con la guía del médico especialista.

This work is based on the document: "Urological Management of Myelomeningocele" from the Pediatric Care Guidelines of the Hospital De Pediatría "Juan P. Garrahan" of the city of Buenos Aires - Argentina; by the authors: Dr. Carol Burek and Dr. Liliana Campmany. In the Pediatric Surgery Technical Unit of the Carlos Andrade Marín Specialties Hospital, 50 to 70 patients affected by neurogenic bladder from birth to adolescence are treated every month. It is a chronic disease that requires a correct diagnosis with imaging and urinary tract function studies, as well as subsequent daily management by the parents under the guidance of the specialist.

Parasacral transcutaneous electrical neural stimulation versus urotherapy in primary monosymptomatic enuresis: A prospective randomized clinical trial.

OBJECTIVE: To evaluate the clinical response of parasacral transcutaneous electrical neural stimulation (parasacral TENS) associated with urotherapy in children with primary monosymptomatic nocturnal enuresis (PMNE) compared to urotherapy alone. MATERIAL AND METHODS: This prospective controlled clinical trial enrolled 72 children over 5 years of age with PMNE. Children were randomly divided into two groups, control group (CG), treated with urotherapy and scapular stimulation, and experimental group (EG), treated with urotherapy and parasacral TENS. In both groups, 20 sessions were performed, 3 times weekly, for 20 min each, with 10 Hz frequency, 700 µS pulse width and intesity determinated by the patient threshold. The percentages of dry nights were analyzed for 14 days before treatment (T0), after the 20th session (T1), 15 (T2), 30 (T3), 60 (T4), and 90 (T5) days after the end of the sessions. Patients of both groups were followed with intervals of 2 weeks in the first month and monthly for three consecutive months. RESULTS: Twenty-eight enuretic children, 14 girls (50%) with a mean age of 9.09 ± 2.23 years completed the study. There was no difference in mean age between groups. Mean percentage of dry nights in EG at T0 was 36%, at T1 49%, at T2 54%, at T3 54%, at T4 54%, and 57% at T5; while in CG, these percentages were 28%, 39%, 37%, 35%, 36%, and 36%, respectively. CONCLUSIONS: Parasacral TENS associated with urotherapy improves the percentage of dry nights in children with PMNE, although no patient had complete resolution of symptoms in this study.

Eficácia E Custo-Utilidade De Intervenções Para O Tratamento Da Enurese Em Crianças E Adolescentes Sob A Perspectiva Do Sistema Único De Saúde Brasileiro: Effectiveness and Cost-Utility of Interventions for Enuresis Treatment in Children and Adolescents From the Brazilian Single Health System Perspective.

OBJECTIVES: This study aimed to estimate the cost-utility of effective interventions for enuresis treatment in children and adolescents and to calculate the incremental cost-utility ratio from the perspective of the Brazilian Unified Health System in a 1-year time horizon. METHODS: The economic analysis is in 7 stages: (1) survey of evidence of treatments for enuresis, (2) performing the network meta-analysis, (3) estimation of the probability of cure, (4) cost-utility analysis, (5) model sensitivity analysis, (6) analysis of acceptability of interventions by acceptability curve, and (7) monitoring the technological horizon. RESULTS: The association between desmopressin and oxybutynin is the therapeutic strategy with the highest probability of success in the treatment of enuresis in children and adolescents compared with placebo (relative risk [RR] 2.88; 95% confidence interval [CI] 1.65-5.04), followed by the combination therapy between desmopressin and tolterodine (RR 2.13; 95% CI 1.13-4.02), alarm (RR 1.59; 95% CI 1.14-2.23), and neurostimulation (RR 1.43; 95% CI 1.04-1.96). Combination therapy between desmopressin and tolterodine was the only 1 considered not to be cost-effective. Neurostimulation, alarm therapy, and therapy had the respective incremental cost-utility ratio values: R$5931.68, R$7982.92, and R$29 050.56/quality-adjusted life-years. CONCLUSION: Among the therapies that are on the borderline of efficiency, the combined therapy between desmopressin and oxybutynin presents the greatest incremental benefit at an incremental cost that is still feasible, given that it does not exceed the reference value of the cost-effectiveness threshold established in Brazil.

One-day voiding diary in the evaluation of Lower Urinary Tract Symptoms in children

ABSTRACT Introduction: Voiding diary (VD) is an important tool in the evaluation of children with voiding symptoms. Voiding frequency, maximal voided volume (MVV), average voided volume (AVV) and nocturnal volume (NV) can be extracted and are valuable in diagnosing and monitoring these disorders. Recently, ICCS has reduced the period of data recording on VD from 3 to 2 days. We hypothesized that one day voiding diary would be enough for guiding treatment. Materials and Methods: Children with overactive bladder (OAB) and primary monosymptomatic enuresis (PMNE) were oriented to fulfill a 3-day VD. Data obtained from VD were evaluated for the first day (1dVD), the first two days (2dVD), and all 3 days (3dVD) and compared according to the MVV, AVV, frequency, NV and expected bladder capacity (EBC). The Friedman, Student's t test and the Fisher's exact was used. ANOVA was used for multiple comparisons. We also used Pearson correlation test. Results: Ninety-eight children were included, 59 had PMNE and 30 OAB. Frequency, AVV and VN were similar regardless how many days the voiding episodes were recorded. Only MVV was higher by a mean of only 32 mL on 3dVD compared to 1dVD. A 1dVD has a sensitivity of 93,9% and a positive likelihood ratio of 2.2. As for the correlation of MVV and EBC it was observed that in 83% of children, MVV was lower than EBC. MVV corresponds to 67% and 69% of EBC in children with PMNE and OAB, respectively. Conclusion: We believe that 1dVD is sufficient to assess these children. It has a high sensitivity and good correlation to 3dVD in evaluating these children. Bladder capacity in this population, evaluated by maximum voided volume, was close to 68% of that obtained by the EBC.

One-day voiding diary in the evaluation of Lower Urinary Tract Symptoms in children.

INTRODUCTION: Voiding diary (VD) is an important tool in the evaluation of children with voiding symptoms. Voiding frequency, maximal voided volume (MVV), average voided volume (AVV) and nocturnal volume (NV) can be extracted and are valuable in diagnosing and monitoring these disorders. Recently, ICCS has reduced the period of data recording on VD from 3 to 2 days.We hypothesized that one day voiding diary would be enough for guiding treatment. MATERIALS AND METHODS: Children with overactive bladder (OAB) and primary monosymptomatic enuresis (PMNE) were oriented to fulfill a 3-day VD. Data obtained from VD were evaluated for the first day (1dVD), the first two days (2dVD), and all 3 days (3dVD) and compared according to the MVV, AVV, frequency, NV and expected bladder capacity (EBC). The Friedman, Student's t test and the Fisher's exact was used. ANOVA was used for multiple comparisons. We also used Pearson correlation test. RESULTS: Ninety-eight children were included, 59 had PMNE and 30 OAB. Frequency, AVV and VN were similar regardless how many days the voiding episodes were recorded. Only MVV was higher by a mean of only 32 mL on 3dVD compared to 1dVD. A 1dVD has a sensitivity of 93,9% and a positive likelihood ratio of 2.2. As for the correlation of MVV and EBC it was observed that in 83% of children, MVV was lower than EBC. MVV corresponds to 67% and 69% of EBC in children with PMNE and OAB, respectively. CONCLUSION: We believe that 1dVD is sufficient to assess these children. It has a high sensitivity and good correlation to 3dVD in evaluating these children. Bladder capacity in this population, evaluated by maximum voided volume, was close to 68% of that obtained by the EBC.

Relationship between nocturnal enuresis and sleep in children and adolescents.

BACKGROUND: Nocturnal enuresis (NE) is a multifactorial and complex condition. One less understood factor in its pathophysiology is the enuretic inability to wake up when the bladder is full (impaired arousal). OBJECTIVE: We aimed to investigate the relationship between sleep and NE in children and adolescents. METHODS: A systematic review was performed following the PRISMA guidelines, and the electronic databases MEDLINE (via PubMed) and SCOPUS were searched until March 2022. Eligibility criteria were studies that recruited patients aged five-17 years with a diagnosis of NE according to the International Child Continence Society (ICCS), Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5), or International Classification Criteria of Sleep Disorders-Third edition (ICSD-3) who had their sleep assessed using validated questionnaires and/or polysomnography. The tool used to analyze the risk of bias in the included studies was the risk of bias in non-randomized studies of exposure. RESULTS: Of 1582 citations screened, nine were included, giving 1685 participants, 581 with NE. All studies were observational and half had a low risk of bias. Four studies evaluated sleep by questionnaires only; two used questionnaires and polysomnography; two used only polysomnography, and one used sleep logs and actigraphy. Sleep questionnaires showed that children with enuresis had more sleep problems than controls, especially parasomnias, breathing disorders, and daytime sleepiness. Among the polysomnography parameters, the sleep stage architecture and periodic limb movements during sleep had conflicting data between the two studies. LIMITATIONS: The studies evaluated sleep through heterogeneous tools. They used different questionnaires; even those considered by polysomnography did not record the same channels. CONCLUSION: It seems that enuretic children and adolescents sleep differently from those who are non-enuretic. More studies are needed to clarify the best way to assess sleep and better understand this relationship. The review protocol was registered with PROSPERO, CRD42021266338. There was no funding.

Validación de un algoritmo hipnoterapéutico para niños con enuresis nocturna monosintomática / Validation of a hypnotherapeutic algorithm for children with monosymptomatic nocturnal enuresis i: en

Introducción: La enuresis nocturna monosintomática es la micción involuntaria intermitente durante la noche. Esta se presenta en 15 % de los niños de 5 años, en 5 % de los de 10 años y 12 % de los adultos jóvenes sin defectos congénitos o adquiridos. Objetivo: Validar un algoritmo hipnoterapéutico diseñado para pacientes con enuresis nocturna. Métodos: Se realizó un estudio complejo en la Clínica de Hipnosis Terapéutica de la Universidad de Ciencias Médicas en Santiago de Cuba, de febrero del 2021 a julio del 2022, el cual estuvo estructurado en dos etapas metodológicas; en la primera se diseñó el algoritmo terapéutico y en la segunda se validó el contenido de este. A tal efecto, se aplicaron un cuestionario del tipo Likert, el índice de validez de contenido, el coeficiente de concordancia de Kendall, así como el coeficiente alfa de Cronbach y el análisis de conglomerados. Resultados: La validación del contenido realizada por los expertos mostró una excelente consistencia interna, con un coeficiente alfa de Cronbach de 0,9221, que se interpreta como una altísima fiabilidad del instrumento. Asimismo, el índice de validez del contenido de los ítems fue superior a 0,89, lo que también denotó una validez elevada. Conclusiones: La validación del algoritmo hipnoterapéutico diseñado y sometido al criterio de expertos demostró ser adecuado, con elevada coherencia y concordancia evaluativas.

Introduction: Monosymptomatic nocturnal enuresis is the involuntary urine loss during sleep which affects 15 % of 5-years-old children, 5 % of 10-years-olds and 12 % of young teens without congenital or acquired defects. Objective: To validate a hypnotherapeutic algorithm designed for patients with nocturnal enuresis. Methods: A complex study was carried out at the Therapeutic Hypnosis Clinic of the University of Medical Sciences in Santiago de Cuba, from February 2021 to July 2022. It was structured in two methodological stages; in the first one the therapeutic algorithm was designed and in the second one the content of this algorithm was validated. For this purpose, a Likert scale questions, the content validity index, Kendall's coefficient of concordance, as well as Cronbach's alpha and cluster analysis were applied. Results: The content validation executed by the experts showed excellent internal consistency, with a Cronbach's alpha of 0.9221, which meant a very high reliability of the instrument. Likewise, the content validity index of the items was higher than 0.89 that also indicated high validity. Conclusions: The validation of the hypnotherapeutic algorithm designed and subjected to experts' criteria proved to be adequate, with high evaluative coherence and concordance.

Enuresis nocturna en un adolescente con trastorno de ansiedad durante la pandemia de COVID-19 / Nocturnal enuresis in an adolescent with anxiety disorder during the COVID-19 pandemic

RESUMEN Se presenta el caso de un adolescente con enuresis nocturna desde la niñez, y síntomas de ansiedad durante la adolescencia, asociado con factores psicosociales y dinámica familiar. Durante la pandemia COVID-19, los síntomas de enuresis se exacerbaron y presentó intensos síntomas de ansiedad en relación al temor de adquirir una enfermedad grave y miedo a morir, motivos por los cuales fue llevado a emergencia en varias oportunidades; la sintomatología ansiosa respondió favorablemente a fármacos antidepresivos y enfoques de psicoterapia individual y familiar. Enuresis nocturna es un trastorno de eliminación poco frecuente en la adolescencia, cuyo diagnóstico y tratamiento son de importancia debido a su impacto en el funcionamiento psicosocial y a mayores probabilidades de comorbilidad. Se discute asimismo los efectos de la pandemia COVID-19 en adolescentes y el riesgo de presentar ansiedad, depresión y estrés asociados con la enuresis.

SUMMARY The case of an adolescent with nocturnal enuresis since childhood, and anxiety symptoms during adolescence, associated with psychosocial factors and family dynamics, is presented. During the COVID-19 pandemic, he presented intense symptoms of anxiety related to fears of dying and/or experiencing a serious illness, reasoned for which he was taken to the emergency room on several occasions. The patient responded favorably to antidepressant medications, and individual and family psychotherapy approaches. Nocturnal enuresis es an elimination disorder rarely seen in adolescence, and whose diagnosis and treatment are important due to its impact on the patient's psychosocial functioning and greater probabilities of comorbidity. The effects of the COVID-19 pandemic on adolescents and its higher risk of presenting anxiety, depression and stress associated with enuresis, are also discussed.

Relationship between primary monosymptomatic enuresis and process toilet training: a case-control

ABSTRACT Objective: Primary monosymptomatic nocturnal enuresis (PMNE) is a prevalent condition in childhood, and the pathophysiology is multifactorial. This study investigated the relationship between the toilet training process (TT) and PMNE in children and adolescents. Patients and Methods: A case-control study was carried out from 2015 to 2020. The presence of PMNE was identified according to International Children's Continence Society criteria. A semi-structured questionnaire was applied to assess TT. Results: The study included 103 children and adolescents with PMNE and 269 participants with normal psychomotor development without PMNE (control group [CG]). Readiness signals were more remembered and less frequent in participants with PMNE (p=0.001) when compared to control group. No differences were found between the groups regarding the onset age of the daytime TT (p= 0.10), the nocturnal TT (p=0.08), the acquisition of daytime continence (p=0.06), and the type of equipment used for the TT (p=0.99). The use of Child-Oriented approach in group of children with enuresis was lower than in controls [87.4% (90/103) versus 94% (250/266)], respectively (OR= 0.44, 95% CI 0.21-0.94, p = 0.039). Conclusions: The age of onset of TT, acquisition of daytime continence, and the type of equipment were not associated with higher occurrence of PMNE. On the other hand, the Child-Oriented approach was a protective factor for the occurrence of PMNE.

Enuresis and upper airway obstruction: BNP and ADH hormones behavior before and after airway surgery

ABSTRACT Introduction: Upper airway obstruction (UAO) is a common condition in all pediatric population, with a 27% prevalence. Primary monosymptomatic nocturnal enuresis (PMNE) is a condition related to UAO in 8% to 47% of these children. The specific pathophysiological mechanism of this bond is not well understood. Some authors suggest a connection between brain natrituretic peptide (BNP) and anti-diuretic hormone (ADH) during sleep. The aim of this study was to evaluate hormone profile (ADH and BNP) and improvement in dry nights in a sample of children before and after surgical treatment of the UAO. Methods: This is a longitudinal prospective interventionist study in children, 5 to 14 years of age, with UAO and PMNE recruited in a specialty outpatient clinic. Children presenting UAO and PMNE were evaluated with a 30-day dry night diary and blood samples were collected to evaluate ADH and BNP before and after upper airway surgery. Data were analyzed prior to surgery and 90-120 days after surgery. Results: Twenty-one children with a mean age of 9.7 years were included. Mean BNP before surgery was 116.5 ± 126.5 pg/mL and 156.2 ± 112.3 pg/mL after surgery (p<0.01). Mean ADH was 5.8 ± 3.2 pg/mL and 14.6 ± 35.4 before and after surgery, respectively (p=0.26). The percentage of dry nights went from 32.3 ± 24.7 before surgery to 75.4 ± 33.4 after surgery (p<0.01). Conclusion: Surgery for airway obstruction contributed to an increase in BNP without increasing ADH. A total of 85.8% of the children presented partial or complete improvement of their enuresis.

Relationship between primary monosymptomatic enuresis and process toilet training: a case-control.

OBJECTIVE: Primary monosymptomatic nocturnal enuresis (PMNE) is a prevalent condition in childhood, and the pathophysiology is multifactorial. This study investigated the relationship between the toilet training process (TT) and PMNE in children and adolescents. PATIENTS AND METHODS: A case-control study was carried out from 2015 to 2020. The presence of PMNE was identified according to International Children's Continence Society criteria. A semi-structured questionnaire was applied to assess TT. RESULTS: The study included 103 children and adolescents with PMNE and 269 participants with normal psychomotor development without PMNE (control group [CG]). Readiness signals were more remembered and less frequent in participants with PMNE (p=0.001) when compared to control group. No differences were found between the groups regarding the onset age of the daytime TT (p= 0.10), the nocturnal TT (p=0.08), the acquisition of daytime continence (p=0.06), and the type of equipment used for the TT (p=0.99). The use of Child-Oriented approach in group of children with enuresis was lower than in controls [87.4% (90/103) versus 94% (250/266)], respectively (OR= 0.44, 95% CI 0.21-0.94, p = 0.039). CONCLUSIONS: The age of onset of TT, acquisition of daytime continence, and the type of equipment were not associated with higher occurrence of PMNE. On the other hand, the Child-Oriented approach was a protective factor for the occurrence of PMNE.

Enuresis and upper airway obstruction: BNP and ADH hormones behavior before and after airway surgery.

INTRODUCTION: Upper airway obstruction (UAO) is a common condition in all pediatric population, with a 27% prevalence. Primary monosymptomatic nocturnal enuresis (PMNE) is a condition related to UAO in 8% to 47% of these children. The specific pathophysiological mechanism of this bond is not well understood. Some authors suggest a connection between brain natrituretic peptide (BNP) and anti-diuretic hormone (ADH) during sleep. The aim of this study was to evaluate hormone profile (ADH and BNP) and improvement in dry nights in a sample of children before and after surgical treatment of the UAO. METHODS: This is a longitudinal prospective interventionist study in children, 5 to 14 years of age, with UAO and PMNE recruited in a specialty outpatient clinic. Children presenting UAO and PMNE were evaluated with a 30-day dry night diary and blood samples were collected to evaluate ADH and BNP before and after upper airway surgery. Data were analyzed prior to surgery and 90-120 days after surgery. RESULTS: Twenty-one children with a mean age of 9.7 years were included. Mean BNP before surgery was 116.5 ± 126.5 pg/mL and 156.2 ± 112.3 pg/mL after surgery (p<0.01). Mean ADH was 5.8 ± 3.2 pg/mL and 14.6 ± 35.4 before and after surgery, respectively (p=0.26). The percentage of dry nights went from 32.3 ± 24.7 before surgery to 75.4 ± 33.4 after surgery (p˂0.01). CONCLUSION: Surgery for airway obstruction contributed to an increase in BNP without increasing ADH. A total of 85.8% of the children presented partial or complete improvement of their enuresis.