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.

OCCULT AND SEMI-OCCULT CONSTIPATION IN CHILDREN WITH MONOSYMPTOMATIC OR NON MONOSYMPTOMATIC ENURESIS.

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.

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.

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.

Electrical nerve stimulation therapy in refractory primary monosymtomatic enuresis - A sistematic review.

OBJECTIVE: To analyze the effect of electrical nerve stimulation on urinary symptoms in pediatric patients with monosymptomatic primary enuresis refractory to conventional treatment. METHODS: Three databases (Medline, Embase, and Cochrane) were searched and 160 studies were identified by July 15, 2020. After establishing and applying the inclusion and exclusion criteria, a step-by-step analysis was performed using the title, abstract and full text. The Cochrane Collaboration Tool was then used to analyze the biases of the selected studies. RESULTS: Of the 160 articles found, 03 were selected for this systematic review. In 02 studies there was a significant reduction in the number of wet nights/week after electrical nerve stimulation. Urodynamic pattern was evaluated in 01 study, with improvement of maximum cystometric capacity in the intervention group. About maximum voided volume, there was no improvement in 01 study, but in other, there was increase in the intervention group. CONCLUSION: Electrical nerve stimulation might promote improvement in partial and total response scores over the number of dry nights, with no improvement in urodynamic parameters, and could be considered as an feasible option in the management of refractory monosymptomatic primary enuresis. However, it is worth emphasizing the need to conduct more RCTs with a larger sample for better evaluation of the role of neurostimulation.

Evaluación clínica de la enuresis no orgánica tratada con homeopatía / Clinical evaluation of non-organic enuresis treated with homeopathy

Introducción: La enuresis existe desde que el hombre salió de las cavernas y tuvo necesidad de mantener limpio el espacio donde habitaba. Objetivo: Evaluar la evolución clínica de pacientes de 5 a 18 años con enuresis nocturna, tratados con medicamentos homeopáticos. Materiales y Métodos: Se realizó estudio longitudinal prospectivo de cohorte transversal, para caracterizar la evolución clínica de pacientes pediátricos de 5 a 18 años con enuresis nocturna no orgánica tratados con medicamentos homeopáticos, remitidos a consulta de Homeopatía del Hospital General Docente Roberto Rodríguez Fernández de Morón en el periodo comprendido de septiembre del 2017 a septiembre del 2019. La muestra se conformó con 327 niños. Se seleccionaron al azar: Grupo estudio y Grupo control. Resultados: El grupo de edad de 5-11 años predominó (74.3%) y el sexo masculino (61,4%). En el grupo estudio 97 pacientes (89%) presentaron enuresis primaria, en el control 195 (89%). La incapacidad para despertar ocupó (80 casos 73,0%), en el grupo control 150 (68,9%). 73 (67%) pacientes del grupo estudio presentaron antecedentes familiares de enuresis de igual forma con el grupo control 98 (45%) pacientes. En el grupo estudio 83(76,1%) tuvo respuesta completa a la medicación empleada, solo un caso no tuvo respuesta, en el grupo control solo 18 (8,3%) de los pacientes obtuvo respuesta completa. Conclusiones: Se concluye que la Homeopatía es una modalidad terapéutica útil en el tratamiento de la enuresis no orgánica en niños.

Association between enuresis and obesity in children with primary monosymptomatic nocturnal enuresis

ABSTRACT Objective The purpose of this study was to determine whether the presence of obesity was related with symptoms of nocturnal enuresis (NE) and the efficacy of behavioral intervention in the treatment of NE. Materials and Method The patients diagnosed with primary monosymptomatic nocturnal enuresis (PMNE) were studied retrospectively. NE severity was classified as mild, moderate, and severe according to the frequency of enuresis. The children were divided into three groups, namely normal weight (5th-84th percentile), overweight (85th-94th percentile), and obesity (≥95th percentile), according to their Body Mass Index (BMI) percentage. The relationship between obesity level and enuresis severity was analyzed. After three months of behavioral therapy, the efficacy of treatment among normal, overweight, and obese groups were evaluated. Moreover, the predictive risk factors for treatment failure were investigated. Results The rates of severe enuresis in patients with normal weight, overweight, and obesity were 63.9%, 77.5%, and 78.6%, respectively. Obese children depicted higher odds of having severe enuresis compared with normal-weight children (OR: 1.571; 95% confidence interval [CI]: 1.196-2.065; P=0.001). The odds of presenting with severe enuresis were 1.99 times higher in children who are obese or overweight compared to children with normal weight (OR: 1.994; 95% CI: 1.349-2.946; P=0.001). The complete response of the normal group was higher than those of the overweight and obese groups (26.8% vs. 14.0%, P=0.010; 26.8% vs. 0.0%, P=0.000). Overweight children showed higher complete response than obese ones (14.0% vs. 0.0%, P=0.009). Logistic regression analysis revealed that obesity level and enuresis frequency were significantly related to the treatment failure of behavioral intervention. Conclusions Obesity is associated with severe enuresis and low efficacy of behavioral therapy in children with nocturnal enuresis.

Pelvic floor muscle training alone or in combination with oxybutynin in treatment of nonmonosymptomatic enuresis. A randomized controlled trial with 2-year follow up.

OBJECTIVE: To compare the results of the standard urotherapy alone and associated with pelvic floor muscle training alone, and in combination with oxybutynin in treatment of nonmonosymptomatic nocturnal enuresis. METHODS: A total of 38 children aged 5 to 10 years were randomized into three groups: Group I (n=12) that was submitted to standard urotherapy; Group II (n=15), standard urotherapy associated with pelvic floor muscle training; and Group III (n=11), standard urotherapy associated with pelvic floor muscle training and oxybutynin; the treatment lasted 12 weeks. The assessment tools used were playful bladder diary, and a 48-hour bladder diary, before and after treatment. After 2 years, patients were assessed by telephone using a standardized questionnaire. RESULTS: The data of children from the three groups were homogeneous at baseline. After 12-week treatment, all children showed improved symptoms and signs of nonmonosymptomatic nocturnal enuresis, but the differences were not significant among the groups. After 2 years, the three groups showed maintenance of treatment results, but no differences among them. CONCLUSION: All treatment modalities were effective regarding improved enuresis and lower urinary tract symptoms, but the sample was not large enough to show differences among groups.

Association between enuresis and obesity in children with primary monosymptomatic nocturnal enuresis.

OBJECTIVE: The purpose of this study was to determine whether the presence of obesity was related with symptoms of nocturnal enuresis (NE) and the efficacy of behavioral intervention in the treatment of NE. MATERIALS AND METHODS: The patients diagnosed with primary monosymptomatic nocturnal enuresis (PMNE) were studied retrospectively. NE severity was classifi ed as mild, moderate, and severe according to the frequency of enuresis. The children were divided into three groups, namely normal weight (5th-84th percentile), overweight (85th-94th percentile), and obesity (≥95th percentile), according to their Body Mass Index (BMI) percentage. The relationship between obesity level and enuresis severity was analyzed. After three months of behavioral therapy, the effi cacy of treatment among normal, overweight, and obese groups were evaluated. Moreover, the predictive risk factors for treatment failure were investigated. RESULTS: The rates of severe enuresis in patients with normal weight, overweight, and obesity were 63.9%, 77.5%, and 78.6%, respectively. Obese children depicted higher odds of having severe enuresis compared with normal-weight children (OR: 1.571; 95% confi dence interval [CI]: 1.196-2.065; P=0.001). The odds of presenting with severe enuresis were 1.99 times higher in children who are obese or overweight compared to children with normal weight (OR: 1.994; 95% CI: 1.349-2.946; P=0.001). The complete response of the normal group was higher than those of the overweight and obese groups (26.8% vs. 14.0%, P=0.010; 26.8% vs. 0.0%, P=0.000). Overweight children showed higher complete response than obese ones (14.0% vs. 0.0%, P=0.009). Logistic regression analysis revealed that obesity level and enuresis frequency were significantly related to the treatment failure of behavioral intervention. CONCLUSIONS: Obesity is associated with severe enuresis and low effi cacy of behavioral therapy in children with nocturnal enuresis.

Study of the profile of behavioral problems and quality of life indexes in a pediatric cohort of monosymptomatic enuresis / Estudo do perfil dos problemas de comportamento e dos índices de qualidade de vida numa coorte pediátrica de enurese monossintomática

Abstract Objective: To evaluate and correlate, before and after the therapeutic intervention, the behavioral problem scores evaluated by the CBCL/6-18 questionnaire and the quality of life indexes evaluated by the PedsQL™ 4.0 in patients with monosymptomatic nocturnal enuresis. Method: After the initial evaluation and completion of the CBCL/6-18 questionnaire, a multidisciplinary evaluation and completion of the PedsQL™ 4.0 questionnaire was performed. Of the initially evaluated 140 children and adolescents aged 6-16 years, 58 were excluded due to non-monosymptomatic enuresis or associated comorbidities. Of the initially included 82 patients, who were randomized to three treatment groups, 59 completed the CBCL/6-18 and PedsQL™ 4.0 questionnaires at the end of the treatment and were included in this study. The α error was set at 5% for ruling out the null hypothesis. Results: Of the total of 59 participants, 45.8% responded with total success, 23.7% were partially successful, 23.7% did not reach the improvement criteria, and 6.8% gave up the treatment. There was a significant increase in quality of life indexes and a reduction of post-intervention behavioral problem scores, in the three proposed modalities, in patients who had a total or partial response to treatment. There was no correlation between higher scores of pre-treatment behavior problems and therapeutic failure. Conclusions: Only the participants who successfully responded to interventions showed improvement in quality of life and behavioral problems, which indicates that enuresis is a primary problem that has a negative impact on these parameters. The authors suggest that it is possible to achieve success in the treatment of monosymptomatic enuresis, even in patients with high pre-intervention behavioral problem scores.

Resumo Objetivo: Avaliar e relacionar, pré e pós-intervenção terapêutica, em pacientes com enurese noturna monossintomática, os escores de problemas de comportamento, avaliados pelo questionário CBCL/6-18, e os índices de qualidade de vida, avaliados pelo PedsQL™ 4.0. Método: Após avaliação inicial e preenchimento CBCL6/18, procedeu-se avaliação multidisciplinar e preenchimento do PedsQL™ 4.0. Das 140 crianças e adolescentes de 6 a 16 anos inicialmente avaliados, 58 foram excluídos por enurese não monossintomática ou comorbidades associadas. Dos 82 pacientes inicialmente incluídos e randomizados em três grupos de tratamento, 59 preencheram o CBCL/6-18 e PedsQL™ 4.0 no fim do tratamento e puderam ser incluídos neste trabalho. O erro alfa foi estabelecido em 5% para descarte da hipótese de nulidade. Resultados: Dos 59 participantes 45,8% responderam com sucesso total, 23,7% tiveram sucesso parcial, 23,7% não atingiram critério de melhoria e 6,8% desistiram do tratamento. Verificou-se aumento significativo dos índices de qualidade de vida e redução dos escores de problemas de comportamento pós-intervenção, nas três modalidades propostas, nos pacientes que obtiveram resposta total ou parcial ao tratamento. Não se demonstrou correlação entre maiores escores de problemas de comportamento pré-tratamento e insucesso terapêutico. Conclusões: Apenas os participantes que responderam com sucesso às intervenções melhoraram em sua qualidade de vida e problemas comportamentais, o que indica que a enurese é um problema primário que impacta negativamente esses parâmetros. Sugere-se que é viável obter sucesso no tratamento da enurese monossintomática, mesmo em pacientes com altos escores de problemas de comportamento pré-intervenção.

Study of the profile of behavioral problems and quality of life indexes in a pediatric cohort of monosymptomatic enuresis.

OBJECTIVE: To evaluate and correlate, before and after the therapeutic intervention, the behavioral problem scores evaluated by the CBCL/6-18 questionnaire and the quality of life indexes evaluated by the PedsQL™ 4.0 in patients with monosymptomatic nocturnal enuresis. METHOD: After the initial evaluation and completion of the CBCL/6-18 questionnaire, a multidisciplinary evaluation and completion of the PedsQL™ 4.0 questionnaire was performed. Of the initially evaluated 140 children and adolescents aged 6-16 years, 58 were excluded due to non-monosymptomatic enuresis or associated comorbidities. Of the initially included 82 patients, who were randomized to three treatment groups, 59 completed the CBCL/6-18 and PedsQL™ 4.0 questionnaires at the end of the treatment and were included in this study. The α error was set at 5% for ruling out the null hypothesis. RESULTS: Of the total of 59 participants, 45.8% responded with total success, 23.7% were partially successful, 23.7% did not reach the improvement criteria, and 6.8% gave up the treatment. There was a significant increase in quality of life indexes and a reduction of post-intervention behavioral problem scores, in the three proposed modalities, in patients who had a total or partial response to treatment. There was no correlation between higher scores of pre-treatment behavior problems and therapeutic failure. CONCLUSIONS: Only the participants who successfully responded to interventions showed improvement in quality of life and behavioral problems, which indicates that enuresis is a primary problem that has a negative impact on these parameters. The authors suggest that it is possible to achieve success in the treatment of monosymptomatic enuresis, even in patients with high pre-intervention behavioral problem scores.

Pelvic floor muscle training alone or in combination with oxybutynin in treatment of nonmonosymptomatic enuresis. A randomized controlled trial with 2-year follow up / Exercícios dos músculos do assoalho pélvico exclusivos ou em combinação com oxibutinina no tratamento da enurese não monossintomática. Um estudo randomizado controlado com 2 anos de seguimento

Abstract Objective To compare the results of the standard urotherapy alone and associated with pelvic floor muscle training alone, and in combination with oxybutynin in treatment of nonmonosymptomatic nocturnal enuresis. Methods A total of 38 children aged 5 to 10 years were randomized into three groups: Group I (n=12) that was submitted to standard urotherapy; Group II (n=15), standard urotherapy associated with pelvic floor muscle training; and Group III (n=11), standard urotherapy associated with pelvic floor muscle training and oxybutynin; the treatment lasted 12 weeks. The assessment tools used were playful bladder diary, and a 48-hour bladder diary, before and after treatment. After 2 years, patients were assessed by telephone using a standardized questionnaire. Results The data of children from the three groups were homogeneous at baseline. After 12-week treatment, all children showed improved symptoms and signs of nonmonosymptomatic nocturnal enuresis, but the differences were not significant among the groups. After 2 years, the three groups showed maintenance of treatment results, but no differences among them. Conclusion All treatment modalities were effective regarding improved enuresis and lower urinary tract symptoms, but the sample was not large enough to show differences among groups.

Resumo Objetivo Comparar os resultados da uroterapia padrão isolada e associada ao treinamento dos músculos do assoalho pélvico isoladamente e em combinação com a oxibutinina no tratamento da enurese noturna não monossintomática. Métodos Trinta e oito crianças entre 5 e 10 anos de idade foram randomizadas em três grupos: Grupo I (n=12) realizou uroterapia padrão; Grupo II (n=15) realizou uroterapia padrão associada ao treinamento muscular do assoalho pélvico; e Grupo III (n=11) realizou uroterapia padrão associada ao treinamento muscular do assoalho pélvico e oxibutinina. O tratamento teve duração de 12 semanas. Os instrumentos de avaliação foram diário miccional lúdico e diário miccional de 48 horas, antes e depois do tratamento. Após 2 anos, os pacientes foram avaliados por telefone, usando um questionário padronizado. Resultados Os dados das crianças dos três grupos eram homogêneos no início do estudo. Após 12 semanas de tratamento, todas as crianças apresentaram melhora em relação aos sinais e sintomas de enurese noturna não monossintomática, mas as diferenças não foram significativas entre os grupos. Depois de 2 anos, os resultados do tratamento se mantiveram nos três grupos, mas não houve diferenças entre os grupos. Conclusão As três modalidades de tratamento foram eficazes na melhora da enurese e dos sintomas do trato urinário inferior, mas o tamanho da amostra não foi grande o suficiente para mostrar diferenças entre os grupos.

Are uroflowmetry and post - void residual urine tests necessary in children with primary nocturnal enuresis?

ABSTRACT Objectives: To examine the benefits of repetitive uroflowmetry and post void residual urine (PVR) tests in children with primary nocturnal enuresis (PNE). Material and methods: Children aged ≥6 years with PNE who visited our clinics for management of enuresis were included for study. Patients were requested to complete a questionnaire including baseline characteristics and Dysfunctional Voiding Symptom Score (DVSS), 2-day bladder diary, and Rome III criteria for constipation. Two uroflowmetry and PVR tests were requested. Children with congenital or neurogenic genitourinary tract disorders were excluded. All children underwent urotherapy and desmopressin combined with anticholinergics or laxatives if indicated. The definition of abnormal flow patterns (≥1 abnormal), elevated PVR (≥1 abnormal), small maximal voided volume (MVV), nocturnal polyuria (NP) and response to treatment complied with the ICCS standardization document. Kaplan-Meier survival analysis and Cox proportional-hazards regression tests were used to evaluate the predictors of response. Results: In total, 100 children aged 8.5±2.3 years were enrolled for study (M: F=66:34) with 7.3±7.4 months of follow-up. Poor correlation was observed between DVSS/small MVV and PVR (p>0.05). Univariate analysis revealed that elevated PVR is associated with significantly less hazard of complete response to medical treatment (HR: 0.52, p=0.03), while not significantly associated with abnormal flow patterns, NP, constipation or small MVV. Multivariate analysis revealed that only elevated PVR (HR 0.30, 95% CI 0.12-0.80) and NP (HR 2.8, 95% CI 1.10-7.28) were significant predictors for complete response. Conclusions: In managing pediatric enuresis, elevated PVR is a significant predictor for lower chance of complete response to treatment whether they had high DVSS or not.

Do uroflowmetry and post - void residual urine tests necessary in children with primary nocturnal enuresis?

OBJECTIVES: To examine the benefits of repetitive uroflowmetry and post void residual urine (PVR) tests in children with primary nocturnal enuresis (PNE). MATERIAL AND METHODS: Children aged ≥6 years with PNE who visited our clinics for management of enuresis were included for study. Patients were requested to complete a questionnaire including baseline characteristics and Dysfunctional Voiding Symptom Score (DVSS), 2-day bladder diary, and Rome III criteria for constipation. Two uroflowmetry and PVR tests were requested. Children with congenital or neurogenic genitourinary tract disorders were excluded. All children underwent urotherapy and desmopressin combined with anticholinergics or laxatives if indicated. The definition of abnormal flow patterns (≥1 abnormal), elevated PVR (≥1 abnormal), small maximal voided volume (MVV), nocturnal polyuria (NP) and response to treatment complied with the ICCS standardization document. Kaplan-Meier survival analysis and Cox proportional-hazards regression tests were used to evaluate the predictors of response. RESULTS: In total, 100 children aged 8.5±2.3 years were enrolled for study (M: F=66:34) with 7.3±7.4 months of follow-up. Poor correlation was observed between DVSS/small MVV and PVR (p>0.05). Univariate analysis revealed that elevated PVR is associated with significantly less hazard of complete response to medical treatment (HR: 0.52, p=0.03), while not significantly associated with abnormal flow patterns, NP, constipation or small MVV. Multivariate analysis revealed that only elevated PVR (HR 0.30, 95% CI 0.12-0.80) and NP (HR 2.8, 95% CI 1.10-7.28) were significant predictors for complete response. CONCLUSIONS: In managing pediatric enuresis, elevated PVR is a significant predictor for lower chance of complete response to treatment whether they had high DVSS or not.

Adaptation of Monosymptomatic Enuresis Guide in Spanish / Adaptación en español de la "Guía de enuresis monosintomática"

The general objective is to adapt recommendations on monosymptomatic primary enuresis (ME) to the regional context. The instruments used were "Guide for the Adaptation of Clinical Practice Guidelines" and "Guidelines for creation of Consensus" (Sociedad Argentina de Pediatría). ME is called intermittent urinary incontinence during the sleep of children > 5 years of age, with no other symptoms of the urinary tract. It is differentiated from non-monosymptomatic enuresis, defined by the presence of other symptoms of the lower urinary tract, mainly during the day. The ME is a transitory condition with spontaneous resolution so the decision to start treatment must be agreed with the child and their family environment. The primary care pediatrician should be the first contact with a child with ME, who implements the initial general behaviors and eventual indication of specific first-line medication, such as alarm and desmopressin.

El objetivo general es adaptar las recomendaciones del abordaje de enuresis primaria monosintomática (EM) al contexto regional. Se utilizaron los instrumentos "Guía para la adaptación de guías de práctica clínica" y "Lineamientos para la elaboración de consensos" (Sociedad Argentina de Pediatría). EM se denomina a la incontinencia urinaria intermitente durante el sueño en niños > 5 años de edad, sin otro síntoma urinario. Se diferencia de la enuresis no monosintomática, que se acompaña de otros síntomas del tracto urinario bajo, principalmente, durante el día. La EM es una afección transitoria y de resolución espontánea, por lo que la decisión de iniciar tratamiento debe ser consensuada con el niño y su entorno familiar. El pediatra de atención primaria debe ser el primer contacto con un niño con EM, quien implemente las conductas generales iniciales y la eventual indicación de medicación específica de primera línea, como alarma y desmopresina

Monosymptomatic nocturnal enuresis in pediatric patients: multidisciplinary assessment and effects of therapeutic intervention.

BACKGROUND: Few studies manage patients with isolated monosymptomatic enuresis (MNE) with multidisciplinary evaluation and pre- and long-term post-intervention monitoring. METHODS: This was a prospective study of MNE patients, aged 6-16 years, diagnosed by multidisciplinary assessment. Of the 140 initial applicants (58.6%) with MNE, 82 were included in the study and randomized for therapeutic intervention in three treatment groups, namely: alarm, desmopressin and alarm + desmopressin. Therapeutic response was evaluated 12 months after treatment withdrawal. RESULTS: Of the 82 patients [mean age 9.5 (SD ± 2.6) years, n = 62 males (75.6%)], 91.1% had a family history of nocturnal enuresis (NE) in first-/second-degree relatives, 81.7% had constipation and 40.7% had mild-to-moderate apnea. Prior to randomization, management of constipation and urotherapy led to remission in seven of the 82 patients; 75 patients were randomized to intervention. There were 14/75 (18.7%) dropouts during the intervention, especially in the alarm group (p = 0.00). Initial complete/partial response was achieved in 56.6% of the alarm group, 70% of the desmopressin group and 64% in the combined group (p = 0.26). Continued success occurred in 70% of the alarm group, 84.2% of the desmopressin group and 100% of the combined group (p = 0.21). Recurrence occurred in 3/20 (15%) patients in the alarm group and 1/19 (5.2 %) patients of the desmopressin group. Post-intervention Child Behavior Checklist (CBCL) and PedsQL 4.0 scores showed significant improvement. CONCLUSIONS: The three therapeutic modalities were effective in managing MNE with low relapse rates; the alarm group showed the highest dropout rate. Therapeutic success was associated with improvement of behavioral problems and quality of life scores.

Adesão em saúde e psicoterapia: conceituação e aplicação na enurese noturna / Adherence in health and psychotherapy: conceptualization and application in nocturnal enuresis / L'adhésion dans la santé et la psychothérapie: concepts et l'application avec l'énurésie nocturne / La adhesión en la salud y la psicoterapia: conceptuación y aplicación en la enuresis nocturna

Existem diversos estudos sobre preditores da não adesão, mas poucos mostram estratégias efetivas para lidar com esse problema. Uma revisão da literatura sobre desistência em psicoterapia mostrou que quase metade dos pacientes que ingressam num atendimento não o concluem. A medida na psicoterapia em geral é a de não adesão, ou desistência do tratamento; no presente trabalho serão apresentados dados relativos à adesão ao tratamento da enurese com alarme de urina. A taxa de desistência em um grupo de 61 crianças e adolescentes foi levantada considerando três condições: suas famílias não compareceram aos atendimentos, não responderam ao contato telefônico ou relataram ter abandonado os procedimentos. A desistência correspondeu a 19,6% da amostra e a idade do grupo dos desistentes era significativamente inferior, quando comparada à daqueles que aderiram ao tratamento. A já demonstrada associação entre a intolerância parental e a idade do filho explica os resultados e aponta para a necessidade de trabalho educativo intenso com os pais de adolescentes portadores de enurese.(AU)

Although there are several studies about adherence prevalence and predictors, few of them demonstrate efficient strategies to deal with this issue. A literature review found that about half of the patients that initiate psychotherapy do not conclude the process. Therefore, the measure of adherence is usually non-adherence, assessed by treatment dropout. In this paper, we present data related to dropout of alarm treatment for nocturnal enuresis. Sixty-one children and adolescents that initiated alarm treatment were included. Families missing appointments, not replying to phone calls or stating that treatment procedures were abandoned characterized dropout. Twelve families dropped out from treatment, corresponding to 19.6% of the sample. Only age was significantly related to dropout: younger children were more likely to abandon treatment. The already known relation between age and parents’s intolerance explains the results and determinates the necessity of an intense informative work with parents of enuretic children.(AU)

Il existe plusieurs études sur l’adhésion avec une ênfase dans la prévalence et les facteurs prédictifs de non-adhésion, mais peu de ces montre des stratégies efficaces pour faire face à ce problème. Une revue de la littérature sur l'abandon dans la psychothérapie a montré que près de la moitié des patients admis dans un soin de ne pas conclure. La mesure de la psychothérapie en général cést la non adhésion, représenté par l'abandon ou la cessation du traitement. Le document présente des données sur le traitement d'énurésie nocturne avec l’alarm de urine. Nous avons mené une enquête sur les niveaux de retrait d'un groupe de 61 enfants et adolescents. Lorsque les familles n'ont pas assisté aux séances, ne répondent pas au téléphone ou auraient abandonné les procédures ont été considérés comme des décrocheurs. Le retrait est intervenu dans 12 des 61 cas, représentant 19,6% de l'échantillon. Considérant l'âge moyen des participantesverifica que ceux qui ont abandonné le traitement étaient significativement plus jeunes. L'association précédemment établie entre l'intolérance des parents et l'âge de l'enfant explique les résultats et les points à la nécessité d'un travail pédagogique intensif avec les parents d'adolescents atteints d'énurésie.(AU)

Hay diversos estudios sobre la prevalencia y predictores de la no adhesión, pero pocos muestran estrategias efectivas para hacer frente a este problema. Una revisión de la literatura sobre la deserción en la psicoterapia mostró que casi la mitad de los pacientes que ingresan en la atención no la concluyen. La medida en la psicoterapia en general es la de no adhesión, representada por el abandono o deserción del tratamiento. En este trabajo serán presentados datos relativos a la deserción al tratamiento de la enuresis través de la alarma de orina. Fue realizada una investigación sobre los niveles de la deserción de un grupo de 61 niños y adolescentes. Cuando las familias no comparecerán a las sesiones, no contestarán al telefono, o relatabán tener abandonado los procedimientos, fueron considerados desertores. La deserción ocurrió en 12 de 61 casos, lo que representa 19,6% de la muestra. La asociación ya establecida entre la intolerancia de los padres y la edad del niño explica los resultados y señala la necesidad de una intensa labor educativa con los padres de los adolescentes con enuresis.(AU)