Evaluation of Nocturnal Enuresis After Adenotonsillectomy in Children With Obstructive Sleep Apnea: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Children with obstructive sleep apnea (OSA) are at increased risk for nocturnal enuresis (NE). However, randomized clinical trials assessing NE outcomes in children randomized to adenotonsillectomy (AT) vs watchful waiting are lacking. Objective: To assess the outcomes of AT vs watchful waiting in children with nonsevere OSA who experience NE. Design, Setting, and Participants: Secondary analysis of data from a multicenter randomized clinical trial conducted at tertiary children's hospitals was performed. Participants included 453 children aged 5.0 to 9.9 years with nonsevere OSA who were randomized to either watchful waiting or AT as part of the multicenter Childhood Adenotonsillectomy Trial. Caregivers completed the Pediatric Sleep Questionnaire, which includes a binary item on bed-wetting, at baseline and 7-month follow-up. The trial was conducted between October 2007 and June 2012. Evaluation in this secondary analysis involving NE occurred from October 2019 to March 2021. Interventions: Adenotonsillectomy vs watchful waiting in children with NE. Main Outcomes and Measures: Prevalence of NE as defined by parental response to the Pediatric Sleep Questionnaire bed-wetting item at baseline and 7-month follow-up. Results: Of the 453 children enrolled, 393 were included in analysis; of these, 201 were girls (51.1%). Mean (SD) age at baseline was 6.54 (1.40) years. At baseline, the number of children with NE was similar (2.6%; 95% CI, -0.12% to 0.07%) between the AT (59 [30.7%]) and watchful-waiting (67 [33.3%]) groups. The odds of NE in the watchful-waiting group were approximately 2 times higher than the AT group after 7 months (odds ratio, 2.0; 95% CI, 1.3 to 3.1). Following AT, there was a decrease (-11.0%; 95% CI, -16.3% to -5.7%) in the number of children with NE (n = 38). The prevalence of NE did not change significantly (-0.5%; 95% CI, -5.4% to 6.4%) in the watchful-waiting group (n = 66) at follow-up. Although NE was less frequent in girls (adjusted odds ratio, 0.53; 95% CI, 0.33-0.85), other clinical factors, such as age, race and ethnicity, obesity, and apnea-hypopnea index, were not associated with improvement of NE. Conclusions and Relevance: In this secondary analysis of a randomized clinical trial, AT for the treatment of pediatric OSA appears to result in improvement in NE. Further research is needed to assess whether AT is associated with long-term benefits for NE compared with watchful waiting. Trial Registration: ClinicalTrials.gov Identifier: NCT00560859.

Alarm interventions for nocturnal enuresis in children.

BACKGROUND: Enuresis (bedwetting) affects up to 20% of five-year-olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs. OBJECTIVES: To assess the effects of enuresis alarms for treating enuresis in children. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles. SELECTION CRITERIA: We included randomised or quasi-randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed risk of bias and extracted data. MAIN RESULTS: We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) -2.68, 95% confidence interval (CI) -4.59 to -0.78; 4 trials, 127 children; low-quality evidence). Low-quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post-treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low-quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD -0.96, 95% CI -2.32 to 0.41; 1 trial, 47 children; very low-quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low-quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post-treatment. Compared with control alarms, code-word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate-quality evidence) but there is probably little to no difference in the number of children remaining dry post-treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate-quality evidence). Very low-quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry-bed training, and star chart plus rewards) (MD -0.81, 95% CI -2.01 to 0.38; low-quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low-quality evidence) and may slightly increase the number of children remaining dry post-treatment (RR 1.39, 95% CI 0.81 to 2.41; low-quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD -0.64, 95% CI -1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low-quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post-treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate-quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post-treatment, because the quality of evidence is very low. Due to very low-quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD -0.88, 95% CI -0.38 to -1.38; 2 trials, 156 children; low-quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low-quality evidence) and the number of children remaining dry post-treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low-quality evidence) compared with desmopressin alone. Alarm plus dry-bed training may increase the number of children achieving a complete response compared to dry-bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low-quality evidence). It is unclear if there is any difference in the number of children remaining dry post-treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low-quality evidence). Due to very low-quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code-word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate-quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate-quality evidence). Very low-quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments. AUTHORS' CONCLUSIONS: Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately-powered trials with robust randomisation are still needed to determine the full effect of alarm therapy.

Feasibility study of intelligent autonomous determination of the bladder voiding need to treat bedwetting using ultrasound and smartphone ML techniques : Intelligent autonomous treatment of bedwetting.

Unsatisfactory cure rates for the treatment of nocturnal enuresis (NE), i.e. bed-wetting, have led to the need to explore alternative modalities. New treatment methods that focus on preventing enuretic episodes by means of a pre-void alerting system could improve outcomes for children with NE in many aspects. No such technology exists currently to monitor the bladder to alarm before bed-wetting. The aim of this study is to carry out the feasibility of building, refining and evaluating a new, safe, comfortable and non-invasive wearable autonomous intelligent electronic device to monitor the bladder using a single-element low-powered low-frequency ultrasound with the help of Machine Learning techniques and to treat NE by warning the patient at the pre-void stage, enhancing quality of life for these children starting from the first use. The sensitivity and specificity values are 0.89 and 0.93 respectively for determining imminent voiding need. The results indicate that customised imminent voiding need based on the expansion of the bladder can be determined by applying a single-element transducer on a bladder in intermittent manner. The acquired results can be improved further with a comfortable non-invasive device by adding several more features to the current features employed in this pilot study. Graphical Abstract Ultrasound device design: echoed US pulses reflected from the bladder and related tissues around the bladder is detected. These pulses are analysed, and an alarm is triggered when needed to treat nocturnal enuresis.

Examining the effectiveness of parental strategies to overcome bedwetting: an observational cohort study.

OBJECTIVE: To examine whether a range of common strategies used by parents to overcome bedwetting in 7½-year-old children (including lifting, restricting drinks before bedtime, regular daytime toilet trips, rewards, showing displeasure and using protection pants) are effective in reducing the risk of bedwetting at 9½ years. DESIGN: Prospective cohort study. SETTING: General community. PARTICIPANTS: The starting sample included 1258 children (66.7% boys and 33.2% girls) who were still bedwetting at 7½ years. OUTCOME MEASURE: Risk of bedwetting at 9½ years. RESULTS: Using propensity score-based methods, we found that two of the parental strategies used at 7½ years were associated with an increased risk of bedwetting at 9½ years, after adjusting the model for child and family variables and other parental strategies: lifting (risk difference=0.106 (95% CI 0.009 to 0.202), ie, there is a 10.6% (0.9% to 20.2%) increase in risk of bedwetting at 9½ years among children whose parents used lifting compared with children whose parents did not use this strategy) and restricting drinks before bedtime (0.123 (0.021 to 0.226)). The effect of using the other parental strategies was in either direction (an increase or decrease in the risk of bedwetting at 9½ years), for example, showing displeasure (-0.052 (-0.214 to 0.110)). When we re-analysed the data using multivariable regression analysis, the results were mostly consistent with the propensity score-based methods. CONCLUSION: These findings provide evidence that common strategies used to overcome bedwetting in 7½-year-olds are not effective in reducing the risk of bedwetting at 9½ years. Parents should be encouraged to seek professional advice for their child's bedwetting rather than persisting with strategies that may be ineffective.

Effects of Food and Pharmaceutical Formulation on Desmopressin Pharmacokinetics in Children.

INTRODUCTION: Desmopressin is used for treatment of nocturnal enuresis in children. In this study, we investigated the pharmacokinetics of two formulations-a tablet and a lyophilisate-in both fasted and fed children. METHODS: Previously published data from two studies (one in 22 children aged 6-16 years, and the other in 25 children aged 6-13 years) were analyzed using population pharmacokinetic modeling. A one-compartment model with first-order absorption was fitted to the data. Covariates were selected using a forward selection procedure. The final model was evaluated, and sensitivity analysis was performed to improve future sampling designs. Simulations were subsequently performed to further explore the relative bioavailability of both formulations and the food effect. RESULTS: The final model described the plasma desmopressin concentrations adequately. The formulation and the fed state were included as covariates on the relative bioavailability. The lyophilisate was, on average, 32.1 % more available than the tablet, and fasted children exhibited an average increase in the relative bioavailability of 101 % in comparison with fed children. Body weight was included as a covariate on distribution volume, using a power function with an exponent of 0.402. Simulations suggested that both the formulation and the food effect were clinically relevant. CONCLUSION: Bioequivalence data on two formulations of the same drug in adults cannot be readily extrapolated to children. This was the first study in children suggesting that the two desmopressin formulations are not bioequivalent in children at the currently approved dose levels. Furthermore, the effect of food intake was found to be clinically relevant. Sampling times for a future study were suggested. This sampling design should result in more informative data and consequently generate a more robust model.

Enuresi nocturna primària monosimptomàtica: paper de l'atenció primària en el diagnòstic i el tractament / Enuresis nocturna primaria monosintomática: papel de la atención primaria en el diagnóstico y el tratamiento / Primary monosymptomatic nocturnal enuresis: the role of primary health care in its diagnosis and treatment

Fonament: l'enuresi nocturna primària monosimptomàtica (ENPM) és la micció involuntària durant el son a edats i freqüències socialment inacceptables. El període en què no s'ha mantingut mai sec ha de ser igual o superior a 6 mesos. No hi ha d'haver símptomes diürns que suggereixin patologia neurològica o urològica de base. La prevalença oscil•la entre el 10 i el 15% a Catalunya i Espanya; a Europa varia entre el 15 i el 20%. Objectiu: descriure les característiques dels infants amb ENPM tractats mitjançant intervenció educativa i disposi-tiu d'alarma, i mesurar l'associació del sexe i la procedència dels pares en el resultat. Mètode: estudi observacional descriptiu transversal. S'inclouen els infants entre 6 i 14 anys amb ENPM als quals s'havia indicat el tractament esmentat en el període de 1998 a 2012. Es calcula l'oportunitat relativa (OR) amb interval de confiança (IC) del 95%. Resultats: s'inclouen 144 pacients, 92 eren nens (63,9%) i 52 nenes (36,1%). La mitjana d'edat a l'inici del tractament era de 8,28 anys, amb una mitjana de temps de tractament en els casos d'èxit de 3,6 mesos en els nens i de 3,3 mesos en les nenes. La intervenció va ser un èxit en el 67,3% de les nenes i en el 58,7% dels nens (valor p 0,67). L'11,5% de les nenes va presentar fracàs terapèutic enfront del 7,6% dels nens (valor p 0,21). L'èxit es va associar més als fills de pares autòctons (OR 0,48; IC 0,24-0,95; valor p 0,03). Els resultats de fracàs van ser més elevats en fills de pares marroquins (OR 5,4; IC: 1,4-20,6; valor p 0,007). Conclusions: l'atenció primària és el context més idoni per abordar aquest problema. Seria convenient dissenyar un nou protocol d'intervenció i adequar-lo per als fills de pares nascuts al Marroc

Fundamento. La enuresis nocturna primaria monosintomática (ENPM) es la micción involuntaria durante el sueño en edades y frecuencias socialmente inaceptables. El periodo en que no se ha mantenido nunca seco debe ser igual o superior a 6 meses. No deben existir síntomas diurnos que sugieran patología neurológica o urológica de base. La prevalencia oscila entre el 10 y el 15% en Cataluña y España; en Europa varía entre el 15 y el 20%. Objetivo. Describir las características de los niños con ENPM tratados mediante intervención educativa y dispositivo de alarma, y medir la asociación del sexo y la procedencia de los padres en el resultado. Método. Estudio observacional descriptivo transversal. Se incluyen los niños entre 6 y 14 años con ENPM a los cuales se había indicado el tratamiento mencionado en el periodo de 1998 a 2012. Se calcula la oportunidad relativa (OR) con intervalo de confianza del 95% (IC). Resultados. Se incluyen 144 pacientes, 92 niños (63,9%) y 52 niñas (36,1%). La media de edad al inicio del tratamiento fue de 8,28 años, con una media de tiempo de tratamiento en los casos de éxito de 3,6 meses en los niños y 3,3 meses en las niñas. La intervención fue un éxito en el 67,3% de las niñas y en el 58,7% de los niños (valor p 0,67). El 11,5% de las niñas presentó fracaso terapéutico frente al 7,6% de los niños (valor p 0,21). El éxito se asoció más a los hijos de padres autóctonos (OR 0,48; IC 0,24-0,95; valor p 0,03). Los resultados de fracaso fueron más elevados en hijos de padres marroquíes (OR 5,4; IC 1,4-20,6; valor p 0,007). Conclusiones. La atención primaria es el contexto más idóneo para abordar este problema. Sería conveniente diseñar un nuevo protocolo de intervención y adecuarlo para hijos de padres nacidos en Marruecos (AU)

Background. Primary monosymptomatic nocturnal enuresis (PMNE) is the involuntary micturition that takes place during sleep at an age and frequency that are socially unacceptable. The period in which the individual has not been continuously dry must be equal or superior to 6 months. There must be no diurnal symptoms suggestive of an underlying neurological or urological disorder. The prevalence ranges between 10% and 15% in Catalonia and Spain, whereas it has been reported to be between 15% and 20% in Europe. Objective. The purpose of this study is to describe the characteristics of children with PMNE treated with an educational intervention and an alarm device, and to analyze the association between the outcome and the gender and parents’origin. Methods. Transversal observational descriptive study. Children 6 to 14 years old with PMNE who received the intervention from 1998 to 2012 were included. The odds ratio (OR) and 95% confidence interval (CI) was calculated. Results. A total of 144 patients (92 boys, 63.9%) were included. The average age at the beginning of treatment was 8 years, with an average time of treatment on the successful cases of 3.6 months for boys and 3.3 months for girls. The success rates were 67.3% and 58.7% in girls and boys, respectively (p 0.67). Therapeutic failure occurred in 11.5% of boys and 7.6% of girls (p 0.21). The success was associated with children whose parents were born in Spain (OR 0.48; CI 0.24-0.95; p 0.03). Failure rates were higher in children whose parents were born in Morocco (OR 5.4; CI 1.4-20.6; p 0.007). Conclusions. Primary health care is the most appropriate context to manage PMNE. Interventions dedicated to children born to immigrant parents should be developed (AU)

Enuresis nocturna. Estudio epidemiológico en población escolar / Nocturnal enuresis. Epidemiological study in school population

Introducción: la enuresis nocturna (EN) es un problema de salud infantil frecuente, con repercusión personal y social, que requiere un manejo adecuado y personalizado por parte de los profesionales sanitarios. Se ha realizado un estudio cuyo objetivo es establecer la prevalencia de EN en la ciudad de Burgos (España) en población pediátrica entre siete y diez años de edad. Pacientes y métodos: estudio observacional transversal en el que se han obtenido datos de una muestra aleatoria de niños escolarizados entre segundo y quinto curso de Educación Primaria Obligatoria en la ciudad de Burgos mediante la cumplimentación de una encuesta. Resultados: se ha obtenido una prevalencia de EN del 7,3%. La EN es más frecuente en varones, con antecedentes familiares de enuresis nocturna, con algún tipo de enfermedad crónica, que asocian trastornos del sueño y del comportamiento y con bajo rendimiento escolar. Conclusiones: la prevalencia es menor a la de otras poblaciones de características similares. Los niños con EN de Burgos presentan características epidemiológicas semejantes a las de otras poblaciones. La EN es un problema de salud infradiagnosticado en nuestro medio (AU)

Introduction: nocturnal enuresis (NE) is a common childhood health condition. This problem causes personal and social repercussion. The health professionals have to make an individualized and adequate management of this problem. The aim of this study is to know the prevalence of NE in children between seven and ten years old of the city of Burgos. Patients and methods: to this end, we have designed an observational and transversal study. We have selected a random sample of school children in Burgos between 2nd and 5th year of Obligatory Primary Education. They have completed a questionnaire. Results: the prevalence of NE was 7.3%. NE is more frequent in males and children with familiar precedents of NE, with some type of chronic illness, with associated disorders of the sleep and behavior and with low academic performance. Conclusions: the prevalence of NE in children in Burgos city is lower than in another child groups of similar characteristics. There is a low diagnosis rate of NE in Burgos city (AU)

Effect of rapid maxillary expansion on monosymptomatic primary nocturnal enuresis.

OBJECTIVE: To evaluate the effects of rapid maxillary expansion (RME) on nocturnal enuresis (NE) related to the nasal airway, nasal breathing, and plasma osmolality (as an indicator for antidiuretic hormone). MATERIALS AND METHODS: Nineteen patients with monosymptomatic primary NE, aged 6-15 years, were treated with RME for 10-15 days. To exclude a placebo effect of the RME appliance, seven patients were first treated with a passive appliance. Computed tomography of nasal cavity, rhinomanometric, and plasma osmolality measurements were made 2-3 days before and 2-3 months after the RME period. RME effects on NE were followed for three more years. RESULTS: Two to three months after the expansion there were significant improvements in the breathing function and a decrease in the plasma osmolality. NE decreased significantly in all patients after the RME period, and all patients showed full dryness after 3 years. CONCLUSIONS: This study demonstrates that RME causes complete dryness in all patients, with significant effects on pathophysiological mechanisms related to NE.

"Nobody asked us if we needed help": Swedish parents experiences of enuresis.

OBJECTIVE: To explore the everyday dilemmas of parents living with a child with nocturnal enuresis and to describe their support needs in relation to healthcare professionals. SUBJECTS AND METHODS: The study was conducted in 2011 in Uppsala County, Sweden. Parents of 13 children with enuresis, 10 mothers and three fathers, participated in qualitative semi-structured in-depth interviews, which were analysed using systematic text condensation. RESULTS: The analysis of the material resulted in six themes: enuresis is socially stigmatising and handicapping; all practices and home remedies are tested; it creates frustration in the family; protecting the child from gossip or teasing; support from healthcare providers would have helped; it's something we just have to live with. Two patterns of coping were identified: the Unworried wet-bed-fixers and the Anxious night-launderers. CONCLUSION: Having a child with enuresis can be stressful for parents, although they tried hard not to blame their child. Because parents can feel reluctant to bring up enuresis themselves, they want child health nurses to routinely raise the issue of bedwetting at the yearly check-up. Parents' information needs included causes of and available treatment options for enuresis as well as access to aids and other support for affected families.

Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics).

BACKGROUND: Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 20% of five-year olds and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis. OBJECTIVES: To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi-randomised trials. The reference lists of relevant articles were also searched. SELECTION CRITERIA: All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author. MAIN RESULTS: A total of 40 randomised or quasi-randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials.For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights.Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects. AUTHORS' CONCLUSIONS: There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials.

A consultant paediatrician led and public health nurse (PHN) provided Community Enuresis Clinic as a model of care.

A dedicated Community Enuresis Clinic was established in 2004 in Cavan and Monaghan. The service was audited using ERIC (Education and Resources for Improving Childhood Continence) guidelines. There were 106 males and 47 females, giving an M: F ratio of 2.3:1. Monosymptomatic Nocturnal Enuresis (MNE) accounted for 127 (83%). Adequate follow-up was available for 108 children with MNE and in this group Initial Success was 49% (ERIC target 50%). 71% were dry at 1 year. There was a dropout rate of 20% in the MNE group (ERIC minimum standard < 25%). We believe the structure of this community based clinic and its approach to MNE management has been successful.

Nocturnal enuresis-theoretic background and practical guidelines.

Nocturnal polyuria, nocturnal detrusor overactivity and high arousal thresholds are central in the pathogenesis of enuresis. An underlying mechanism on the brainstem level is probably common to these mechanisms. Enuretic children have an increased risk for psychosocial comorbidity. The primary evaluation of the enuretic child is usually straightforward, with no radiology or invasive procedures required, and can be carried out by any adequately educated nurse or physician. The first-line treatment, once the few cases with underlying disorders, such as diabetes, kidney disease or urogenital malformations, have been ruled out, is the enuresis alarm, which has a definite curative potential but requires much work and motivation. For families not able to comply with the alarm, desmopressin should be the treatment of choice. In therapy-resistant cases, occult constipation needs to be ruled out, and then anticholinergic treatment-often combined with desmopressin-can be tried. In situations when all other treatments have failed, imipramine treatment is warranted, provided the cardiac risks are taken into account.