The role of adenotonsillectomy in the treatment of primary nocturnal enuresis in children: A systematic review.

INTRODUCTION: Primary nocturnal enuresis (PNE) is a challenging condition for physicians, patients and families. Although the etiology remains unclear, sleep-disordered breathing (SDB) and sleep apnea have been suggested to play an important role. Recent research has suggested a potential therapeutic benefit of adenotonsillectomy (T&A) and surgical management of upper airway obstruction in the treatment of PNE. OBJECTIVE: The aim was to conduct a systematic review of relevant literature to determine the effectiveness of T&A in treating children aged 2-19 years with PNE. STUDY DESIGN: This was a systematic review using a comprehensive electronic search strategy that included PubMed, Embase, CINAHL, Cochrane Library, conference proceedings, and the gray literature up to July 2015. We included all studies of children aged 2-19 years with PNE and SDB who underwent T&A. The primary outcome was resolution of PNE following surgery. Observational studies and randomized trials were reviewed. Risk of bias assessment and meta-analyses of included studies were performed. RESULTS: We screened 3254 citations; following title and abstract screening, 42 studies were selected for full-text screening by two independent reviewers. We included 18 studies (890 patients) in our final analysis. All studies were observational and only one included a control group. Meta-analysis of proportions of all (18) studies revealed a pooled complete resolution rate of 51% (43-60%), with significant heterogeneity among studies (I2 = 82.2%). Partial resolution was seen in 20% (14-27%), with similar heterogeneity to the complete resolution group. Sensitivity analysis including only studies with a low risk of bias and with patients ≥5 years (n = 244 patients) yielded a complete resolution rate of 43% (36-49%) with minimal heterogeneity (I2 = 0%; figure). CONCLUSION: In our systematic review, T&A resulted in improvement of nocturnal enuresis in more than 60% of patients, with complete resolution rates in excess of 50%. Findings were persistent on meta-analysis focused only on studies including older patients (≥5 years) and those with short follow-up after surgery (≤3 months), which imply a higher cure rate than would be expected based on natural history alone. The limitations of this review include the lack of controlled trials, the overall quality of the evidence reviewed and the heterogeneity between included studies. The role for systematic investigation and treatment of sleep disorders in patients with PNE should be scrutinized further, since a near 50% complete resolution rate for PNE may be expected with T&A in some settings.

The changes of urethral morphology recognized in voiding cystourethrography after endoscopic transurethral incision for posterior urethral valve in boys with intractable daytime urinary incontinence and nocturnal enuresis.

PURPOSE: Endoscopic transurethral incision (TUI) of posterior urethral valve (PUV) can improve daytime urinary incontinence (DUI) and nocturnal enuresis (NE). However, the underlying mechanism has not been elucidated. In this study, we retrospectively examined the mobility of the urethra before and after TUI by measuring the urethral angle with voiding cystourethrography (VCUG), to clarify the effects of TUI on the morphology of the urethra during voiding. METHODS: Between July 2010 and December 2014, 29 boys with intractable DUI and/or NE were diagnosed as PUV and underwent endoscopic TUI. VCUG during voiding phase was performed at sequential radiographic spot images (1 image per second) at a 45° angle in oblique standing position. The point at which the angle of the urethra was the smallest during urination was regarded as the minimum urethral angle. The maximum urethral angle during early voiding phase was compared with the minimum urethral angle, and the percentage by which this angle changed was calculated as the flexion rate. Then changes in minimum urethral angle and flexion rate were analyzed before and 3-4 months after TUI. RESULTS: After TUI, the minimum urethral angle on VCUG became more obtuse (before vs. after TUI, respectively: 112.7 vs. 124.5°, p < 0.001), the flexion rate decreased (before vs. after TUI, respectively: 11.8 vs. 4.1%, p < 0.001). CONCLUSIONS: This study demonstrated a significant difference in the degree of change. The findings may contribute to understanding of the mechanism of improvement in symptoms after TUI in patients with PUV.

Adenotonsillectomy can decrease enuresis and sympathetic nervous activity in children with obstructive sleep apnea syndrome.

BACKGROUND: The nocturnal intermittent hypoxia caused by obstructive sleep apnea syndrome (OSAS) can provoke the sympathetic nervous activity (SNA). Salivary alpha-amylase (sAA) is a sensitive, non-invasive biomarker for reflecting the SNA, and a useful marker for pediatric OSAS subjects. Adenotonsillar hypertrophy (ATH) is the most commonly identified risk factor in OSAS childhood, therefore, several studies showed that the adenotonsillectomy (T&A) may alleviate nocturnal enuresis (NE) in children with OSAS. OBJECTIVE: The present study was to investigate the effect of T&A on NE, the change of sAA value in ATH and OSAS children, with/without NE, and with/without the operation. STUDY DESIGN: 37 children (Group A) were admitted for ATH and NE. The saliva samples were taken before and after polysomnography for the measure of sAA. After the T&A, the children were followed-up for 1 year. 35 OSAS children with NE but no T&A were as a NE watchful-waiting group (Group B), 32 subjects without OSAS or NE were as non-OSAS control (Group C), 42 cases who underwent T&A but did not have NE were admitted to evaluate the SNA (Group D). Follow-up included evaluations for NE, sAA and urinary catecholamine after the T&A or at the equivalent time points. RESULTS: The observational results in the present study showed a significant rate of the disappearance of NE 1 month after the T&A and had an almost complete resolution 1 year later. OSAS may irritate oxidative stress and increase SNA in pediatric subjects, which reflected by increased levels of sAA and urinary catecholamine, while the T&A can decrease enuresis and the SNA in children with OSAS (Figure). DISCUSSION: Little research has previously focused on the relationship between childhood OSAS and the SNA. No data are currently available regarding comparisons of sAA levels before and after the T&A in children with OSAS and enuresis. Our findings in this present study showed that there was a resolution or decrease in enuresis events and drops in sAA levels following T&A, which were consistent with earlier study. However, there was no significant difference in the urinary catecholamine levels was found between OSAS groups with or without NE. Furthermore, there was no correlation between the urinary catecholamine and polysomnography parameters. CONCLUSIONS: T&A has a favorable therapeutic effect on NE and may decrease SNA in children with OSAS. sAA might be associated with instability of ANS by OSAS and have a consistent relationship with the apnea-hypopnea index. Our studying aims had been met.

Impact of adenotonsillectomy on nocturnal enuresis in children with sleep-disordered breathing: A prospective study.

OBJECTIVES/HYPOTHESIS: To investigate the relationship between sleep-disordered breathing (SDB) and nocturnal enuresis (NE) in children and to prospectively evaluate the effectiveness of adenotonsillectomy on resolving enuresis in indicated SDB patients with NE. METHODS: We prospectively collected data from 183 children (121 males, mean age 8.17 ± 2.84 years) who underwent adenotonsillectomy to treat SDB between July 2011 and July 2013, and analyzed the prevalence of NE. Before and 3 months after surgery, all parents were requested to answer a self-reported SDB scale questionnaire (22 questions, 0-22 points) and a NE questionnaire (episodes of enuresis per month). Paired t test, Student t test, and Chi-square test were used to analyze the data. RESULTS: Overall prevalence of NE was 9.3% (17 patients) preoperatively and 1.5% postoperatively (four patients). After adenotonsillectomy, prevalence of NE and the mean SDB scale were significantly decreased (both P values < 0.001). After adenotonsillectomy, 13 of the 17 NE patients (76.5%) showed complete resolution. There was significantly higher prevalence of NE in patients with obstructive sleep apnea (OSA) than those without OSA (13.1%, 14 of 107 vs. 3.9%, 3 of 76; P = 0.036). CONCLUSION: There is strong association between NE and SDB, and adenotonsillectomy can markedly improve enuresis in the majority of children with NE and SDB. LEVELS OF EVIDENCE: 4. Laryngoscope, 126:1241-1245, 2016.

Adenotonsillectomy improves quality of life in children with sleep-disordered breathing regardless of nocturnal enuresis outcome.

BACKGROUND: Nocturnal enuresis (NE) and sleep-disordered breathing (SDB) have both been associated with impaired health-related quality of life (HRQoL). The following were investigated: (1) whether tonsillectomy and/or adenoidectomy (T&A) significantly affect the HRQoL in children with NE and SDB, and 2) differences in HRQoL between children with NE persistence versus resolution post-T&A. METHODS: This was a prospective study comparing the HRQoL of children with SDB and NE (study group) pre- and 4 weeks post-T&A, and the HRQoL of children with SDB without NE (control group) (independent t-tests). HRQol was assessed using the Obstructive Sleep Apnea Quality of Life 18 questionnaire (OSAS-18), a validated measure containing five subscales that combine to create a total score. Individual items were scored on a Likert-type scale ranging from 1 (none of the time) to 7 (all of the time). Symptoms of SDB were evaluated using the validated Pediatric Sleep Questionnaire (PSQ). Mixed ANOVA was conducted to evaluate changes in the measures between the wet and dry children post-T&A. Pre- and post-T&A change scores were calculated for both the PSQ and the OSAS-18. RESULTS: There were 30 children in the study group (18 male, mean age 9.07 years, SD 2.19), and 30 age-matched controls (16 male). There were no statistically significant differences between the two groups in regards to OSAS-18 total, PSQ total, BMI, diagnosis of snoring or OSAS on sleep study, or race. Overall, OSAS-18 and PSQ scores significantly improved in all children post-surgery (p < 0.001; p < 0.001, respectively), with no significant differences between dry and wet children post-T&A. The correlation between the pre- and post-T&A change scores on the OSAS-18 and PSQ was significant (r(29) = 0.58, p = 0.001), suggesting that a reduction in SDB symptoms post T&A is related to improved HRQoL. CONCLUSIONS: T&A significantly improved HRQoL in all children with SDB and NE, regardless of NE outcomes. These findings support recommendations for T&A in children with SDB with or without NE.

Efficacy and safety of urethral de-obstruction in boys with overactive bladder complaints.

OBJECTIVE: To gain insight into the efficacy and safety of urethral de-obstruction in boys with overactive bladder (OAB) complaints refractory to conservative treatment. MATERIALS AND METHODS: All boys, older than 5 years, referred in 2009 for OAB complaints were included, n = 180. Nine had abdominal or penile pain as predominant complaint. 82% were tertiary referrals after unsuccessful conservative treatment with antimuscarinic medication and/or urotherapy for OAB. In 121, urethral obstruction was urodynamically proven or seriously suspected, and they underwent urethrocystoscopy with relief of obstruction, when present. Average duration of unsuccessful conservative pre-treatment in this group of patients was 1.2 years. Postoperative results, in terms of relief of complaints, were analyzed. Safety was assessed by analyzing those patients who had a secondary transurethral procedure in the same year, or in the 3 years after primary treatment. RESULTS: Of 106 boys with OAB, urge incontinence or therapy-resistant bedwetting, after de-obstruction 33 became free of complaints and 39 showed significant improvement, totaling 72 (68%); dry after additional urotherapy 11 (10%); no change 21 (20%). Nine boys had de-obstruction because of penile or abdominal pain, with 5 completely cured after the procedure. Follow-up treatment was cognitive training in 39, temporary anticholinergic treatment in 26 and CIC in 2 cases. Recurrence of obstruction was seen in 10% during the 3-year follow-up period. CONCLUSION: After failure of conservative therapy, one should actively look for any urethral obstruction as underlying cause of OAB. For such patients, urethral de-obstruction is highly effective, with only a few minor late complications resulting in recurrence of obstruction.