Predictors of response and adherence to enuresis alarm therapy-a confirmatory study.

AIM: To look for predictors to response and adherence to the enuresis alarm while exploring the possibility of families managing therapy independently. METHODS: We used a body-worn alarm linked to a smartphone app. Subjects with enuresis were recruited both via paediatric nurses and independently as families bought the alarm and downloaded the app on their own. RESULTS: We recruited 385 nurse-supported and 1125 independent subjects. Many (79.9%) dropped out before 8 weeks, but among adherent subjects 48.2% had a full or partial response. Age was a predictor of non-response (p = 0.019). Daytime incontinence did not influence response. If enuresis frequency did not decrease during the first 4 weeks of therapy the chance of response was very small (p < 0.001). Adherence was higher among subjects supported by a nurse (p < 0.001), but for adherent subjects the outcome was similar regardless of nurse support (p = 0.554). CONCLUSIONS: Daytime incontinence is no contraindication to enuresis alarm therapy. Treatment can be managed independently by the families, but adherence is enhanced by nurse support. Alarm treatment should be reassessed after 4 weeks. Enuresis alarm treatment guidelines need to be updated.

Enuresi: del ritual màgic fins als tractaments actuals / Enuresis: desde el ritual mágico hasta los tratamientos actuales / Enuresis: From magic rituals to current treatments

Introducció. L’enuresi és un trastorn greu, per la gran prevalença i la repercussió que té sobre la qualitat de vida dels pacients i les seves famílies. Al llarg de la història s’han emprat diferents teràpies, i fins avui no es disposa d’una solució definitiva. Objectiu. Examinar l’evolució del concepte d’enuresi, les causes atribuïdes i els tractaments aplicats des de les primeres referències fins a l’actualitat. Mètode. Revisió bibliogràfica del concepte, les causes atribuïdes i els tractaments aplicats contra l’enuresi, estructurada en etapes històriques. Resultats. Al llarg de la història s’han donat diferents explicacions sobre l’origen de l’enuresi, des de la invasió del cos per animals fins a càstigs divins o debilitat de l’individu. La ciència ha descartat diferents teories fins a conèixer els veritables mecanismes fisiopatològics, dels quals encara queden molts aspectes per aclarir. Al llarg dels segles s’han aplicat càstigs, s’han elaborat pocions màgiques, dispositius complexos que inhibeixen la micció, teràpies conductuals, intervencions quirúrgiques i tractaments tòpics i sistèmics. També les alarmes d’enuresi evolucionen, des de les que aplicaven descàrregues elèctriques fins a les actuals que desperten el pacient mitjançant senyals acústics o vibratoris. Conclusions. Els tractaments aplicats per a l’enuresi al llarg de la història han estat relacionats amb el concepte de malaltia de cada època. Conèixer els mecanismes fisiopatològics ha permès trobar tractaments efectius que han millorat la qualitat de vida dels enurètics. Avançar en aquest coneixement és clau per trobar la solució definitiva. (AU)

Introducción. La enuresis es un trastorno grave por su gran prevalencia y repercusión sobre la calidad de vida de los pacientes y sus familias. A lo largo de la historia se han utilizado diferentes terapias y, hasta hoy, no se dispone de solución definitiva. Objetivo. Examinar la evolución del concepto, causas atribuidas y tratamientos aplicados para la enuresis, desde las primeras referencias hasta la actualidad. Método. Revisión bibliográfica del concepto, las causas atribuidas y tratamientos aplicados contra la enuresis, estructurada en etapas históricas. Resultados. A lo largo de la historia se han dado diferentes explicaciones sobre el origen de la enuresis, desde la invasión del cuerpo por animales hasta castigos divinos o debilidad del individuo. Diferentes teorías han sido descartadas por la ciencia hasta el conocimiento de los verdaderos mecanismos fisiopatológicos, de los cuales aún quedan muchos aspectos por aclarar. A lo largo de los siglos se han aplicado castigos, se han elaborado pociones mágicas, complejos dispositivos que inhiben la micción, terapias conductuales, intervenciones quirúrgicas y tratamientos tópicos y sistémicos. También las alarmas de enuresis evolucionan, desde las que aplicaban descargas eléctricas hasta las actuales que despiertan al paciente mediante señales acústicas o vibratorias. Conclusiones. Los tratamientos aplicados para la enuresis a lo largo de la historia se han relacionado con el concepto de enfermedad de cada época. Conocer los mecanismos fisiopatológicos ha permitido encontrar tratamientos efectivos que han mejorado la calidad de vida de los enuréticos. Avanzar en este conocimiento es clave para hallar la solución definitiva. (AU)

Background. Enuresis is a severe disorder because of its high frequency and impact on the quality of life of affected children and their families. Although until today there is no established treatment for enuresis, diverse therapies have been applied over history. Objective. To examine the historic evolution of the concept, presumed causes, and treatments of enuresis from first references until today. Method. Bibliographical review of presumed causes and treatments applied in the treatment of enuresis, structured in historical stages. Results. Throughout history, enuresis has been considered as the invasion of human body by animals, divine punishments, or weakness. Different theories have been rejected by science until the knowledge of the true pathophysiological mechanisms. Punishments, potions and magic, complex devices inhibiting the urination, behavioral therapies, surgical trials, and topical and systemic treatments have been applied throughout history. In addition, different “alarm systems” have been used, evolving from applying electric shocks to wake patients by acoustic or vibrating signals. Conclusions. Treatments applied in the management of enuresis throughout the centuries have been closely related to the understanding of its cause over time. Knowing the pathophysiological mechanisms has made it possible to find effective treatments that have improved the quality of life of affected children. However, to establish a definitive treatment for enuresis, it is necessary to advance in the understanding the diverse mechanisms involved in its etiopathogenesis. (AU)

[Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment]. / Enuresis und nicht-organische (funktionelle) Harninkontinenz bei Kindern und Jugendlichen ­ klinische Leitlinie zur Diagnostik und Therapie.

Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment Abstract: Objective: Enuresis and daytime urinary incontinence are common disorders in children and adolescents and are associated with incapacitation and a high rate of comorbid psychological disorders. This interdisciplinary guideline summarizes the current state of knowledge regarding somatic and psychiatric assessment and treatment. We formulate consensus-based, practical recommendations. Methods: The members of this guideline commission consisted of 18 professional associations. The guideline results from current literature searches, several online surveys, and consensus conferences based on standard procedures. Results: According to the International Children's Continence Society (ICCS), there are four different subtypes of nocturnal enuresis and nine subtypes of daytime urinary incontinence. Organic factors first have to be excluded. Clinical and noninvasive assessment is sufficient in most cases. Standard urotherapy is the mainstay of treatment. If indicated, one can add specific urotherapy and pharmacotherapy. Medication can be useful, especially in enuresis and urge incontinence. Psychological and somatic comorbid disorders must also be addressed. Conclusions: The recommendations of this guideline were passed with a high consensus. Interdisciplinary cooperation is especially important, as somatic factors and comorbid psychological disorders and symptoms need to be considered. More research is required especially regarding functional (nonorganic) daytime urinary incontinence.

Initial outcomes using a novel bedwetting alarm (Gogoband®) that utilizes real time artificial intelligence to wake users prior to wetting.

We evaluated a new bedwetting alarm, GOGOband®® which utilizes real time heart rate variability (HRV) analysis and applied artificial intelligence (AI) to create an alarm that can wake the user prior to wetting. Our aim was to evaluate the efficacy of GOGOband® for users in the first 18-months of use. METHODS: A quality assurance study was conducted on data retrieved from our servers, of initial users of the GOGOband® which includes a heart rate monitor, moisture sensor, bedside PC-tablet, and a parent app. There are three sequential modes beginning with Training, Predictive mode and Weaning mode. Outcomes were reviewed and data analysis was done with SPSS and xlstat. RESULTS: All 54 subjects who used the system from Jan 1, 2020, to June 2021 for more than 30 nights were included in this analysis. The mean age of the subjects is 10.1 ± 3.7 yrs. Subjects wet the bed a median of 7 (IQR6-7) nights per week prior to treatment. Severity and number of accidents per night had no impact on the ability to achieve dryness with GOGOband®. A crosstab analysis was performed which indicated that high compliant users (>80%) can remain dry 93% of the time compared to the whole group 87.7%. Overall ability to achieve 14 dry nights in a row was 66.7% (36/54) with some achieving a median of 16 14-day periods of dryness (IQR 0-35.75). CONCLUSIONS: We found 93% dry night rate in high compliance users in Weaning, this translates to 1.2 wet nights per 30 days. This compares to all users who wet 26.5 nights prior to treatment and 11.3 wet nights per 30 days during Training. The ability to achieve 14 days straight of dry nights was 85%. Our findings indicate that GOGOband® provides a significant benefit to all its users reducing nocturnal enuresis rates.

[Enuresis: Perception and attitude in population of our country]. / Enuresis: percepción y actitud en la población de nuestro país.

OBJECTIVE: To know the perception and attitude towards enuresis from families and caregivers with the aim of establishing a rational therapeutic plan. MATERIAL AND METHODS: A 25-question survey was performed among parents over 18years old with at least a child between 5 and 13years old, maintaining national representativeness in terms of residence, social class and age of the children. Data collection was performed in April 2021. RESULTS: Data from 501 out of 626 sent surveys was obtained, mostly from middle-class families from Andalusia, Catalonia and the Community of Madrid. From all the participants, 47.9% knew about the existence of enuresis, although only 23.8% knew which was the medical term. Only 16.6% and 9.6% remembered that the pediatrician or the nurse, respectively, had referred to the condition at any time. Among the respondents with some knowledge about enuresis, their main information source were close cases (36.6%), media outlets (31.1%) and the pediatrician (27.8%). Parents would be very (35.3%) or somewhat (43.1%) worried in the event of an enuresis case. However, the level of knowledge was higher, and the level of concern was lower among parents with a child with enuresis in comparison to those without a case in their family. CONCLUSION: Improving parent knowledge about enuresis and changing their perception towards this condition might be of importance to improve their attention and anticipate its resolution.

The value of case history and early treatment data as predictors of enuresis alarm therapy response.

BACKGROUND AND AIM: Two central problems with the enuresis alarm are the family workload and the lack of predictors of therapy response. We wanted to look at predictors of alarm response in a setting reflecting clinical reality. METHODS: An alarm linked to a smartphone app was provided to enuretic children managed at pediatric outpatient wards. Baseline data (sex, age, daytime incontinence, urgency, previous therapies, arousal thresholds and baseline enuresis frequency) were recorded. Further information, such as enuretic episodes and actual alarm use, was gathered via the app during therapy. Therapy was given for 8-12 weeks or until 14 consecutive dry nights had been achieved. RESULTS: For the 196 recruited children the outcome was as follows: full responders (FR) 18.4%, partial responders (PR) 20.4%, nonresponders (NR) 22.4% and dropouts 38.8%. We found no clear predictors of response or adherence among baseline data. But as treatment progressed responders reduced their enuresis frequency as compared to NR (week two P = 0.003, week three and onwards P < 0.001). This is further illustrated in the Figure below. Furthermore, the children unable to complete the full treatment had more non-registered nights already from the second week (week two P = 0.005, week three P = 0.002 and so on). DISCUSSION: Anamnestic data give little predictive information regarding enuresis alarm response or adherence. Contrary to common belief neither daytime incontinence nor previous alarm attempts influenced treatment success. But after 2-4 weeks of therapy the children with a good chance of treatment success could be discerned by decreasing enuresis frequency, and the families that would not be able to comply with the full treatment showed incomplete adherence already during the first weeks. CONCLUSIONS: Maybe the enuresis alarm strategy should be changed so that the treatment is reassessed after one month and only children with a high chance of success continue. This way, unnecessary frustration for the families of therapy-resistant children may be reduced.

Can enuresis alarm therapy be managed by the families without the support of a nurse? A prospective study of a real-world sample.

AIM: The alarm is the first-line treatment of nocturnal enuresis. However, the therapy is labour-intensive for both families and healthcare providers. Our aim was to see whether the treatment could be successfully used by the families, without support from healthcare providers. METHODS: An alarm linked to an application on a parent's smartphone was used. The app recorded enuretic events and gave instructions. Group A were children supported by a nurse. Group B were patients whose families had bought the alarm and downloaded the app independently. RESULTS: There were 196 children in group A and 202 in group B. The percentages of full responders, partial responders, non-responders and dropouts were 18.4%, 20.4%, 22.4% and 38.8% in group A and 13.4%, 11.4%, 14.9% and 60.4% in group B. The risk for dropping out of therapy was higher in group B (p < 0.001), whereas the chance for adherent children to become dry did not differ between the groups (p = 0.905). CONCLUSION: For families who are able to adhere to alarm therapy the chance of success is just as good when managed independently as when supported by a nurse. But the latter children will have a greater chance of adhering to the full treatment.

Treating enuresis in children with neurodevelopmental disorders using bell and pad alarm.

OBJECTIVE: There is a high prevalence of enuresis in children with neurodevelopmental disorders, yet research regarding treatment for this group has been neglected. The efficacy of treatment using bell and pad alarm therapy is not well reported especially in children with neurodevelopmental disorders. This study sought to compare the treatment efficacy of practitioner-assisted bell-and-pad enuresis alarm therapy for children with neurodevelopmental disorders and typically developing children. STUDY DESIGN: This study utilized the data of Apos et al. (2018), a retrospective medical record audit collected from multiple clinical settings across Australia. A total of 2986 patient records (3659 treatment records) were included. The participants were children aged 5-16 years, who were diagnosed with enuresis. Children with a neurodevelopmental disorder (n = 158) had a clinical diagnosis present in the medical history of attention deficit disorder, autism spectrum disorder, or intellectual disability. Children who indicated any of the following comorbidities were excluded: cerebral palsy, brain injury, malformation of the renal tract, previous bladder or renal surgery, spinal cord malformation, spinal cord trauma or tumor, or a neurodegenerative disorder. Treatment success was defined as ≥ 14 dry nights. Relapse was defined as one symptom recurrence per month post-interruption of treatment, as defined by the International Children's Continence Society definitions. RESULTS: The success rate for children with neurodevelopmental disorders was 62% and typically developing children was 78%. There was no significant difference between the number of treatments received or relapse rates by those children with a neurodevelopmental disorder and typically developing children. The summary figure shows the percentage of children in each group after their first treatment who were successful (success defined as dry for ≥ 14 days), who succeeded (dry for ≥ 14 days) but then relapsed and those who showed no success. The percentage of children with no NDD who were successfully dry after the first treatment was 78%. Children with ID had success after the first treatment of 59%, the lowest of all groups analyzed. CONCLUSION: The type of alarm therapy reported in this study is effective for treating enuresis in children with neurodevelopmental disorders.

Psychological Intervention with Parents Improves Treatment Results and Reduces Punishment in Children with Enuresis: A Randomized Clinical Trial.

PURPOSE: This study aims to evaluate the impact of psychological intervention with parents of children with enuresis on treatment outcome. MATERIALS AND METHODS: A total of 66 children with enuresis were randomized into 2 groups. All children received urotherapy orientation and psychological counseling. Psychological intervention was performed with parents in the experimental group and not in the control group. All parents answered a questionnaire to evaluate violence against their children (Parent-Child Conflict Tactics Scale) and the Tolerance Scale. The Child Behavior Checklist was applied to evaluate behavior problems. Children responded to the Impact Scale and the Children and Youth Self-Concept Scale. Treatment results were assessed with a 14-day wet night diary. RESULTS: Mean age and gender were similar in both groups. Parent-Child Conflict Tactics Scale showed less violence after the treatment in the experimental group (p=0.007). The Tolerance Scale indicated that parents of children with enuresis were intolerant and that, after treatment, intolerance had a greater decrease in the experimental group (p <0.001). The Impact Scale showed that children suffer some impact from enuresis, and that in those in the experimental group this impact was smaller after treatment (p=0.008). No differences were seen in the Child Behavior Checklist or Children and Youth Self-Concept Scale after intervention. After treatment the percentage of dry nights had a greater improvement in the experimental group (52%, range 30% to 91%) than in the control group (10%, range 3% to 22.5%; p <0.001). Children in the experimental group had a 6.75 times greater chance of having a complete response to treatment. CONCLUSIONS: Psychological intervention with parents of children with enuresis during their treatment improved the percentage of dry nights and the impact of enuresis, while their parents started coping better with the problem and became more tolerant, reducing punishment toward their children.

Practical recommendations of the EAU-ESPU guidelines committee for monosymptomatic enuresis-Bedwetting.

BACKGROUND AND AIMS: The objective of this update of the EAU-ESPU guidelines recommendations for nocturnal enuresis was to review the recent published literature of studies, reviews, guidelines regarding the etiology, diagnosis and treatment options of nocturnal enuresis and transform the information into a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist and urologist. MATERIAL AND METHODS: Since 2012 a monthly literature search using Scopus® was performed and the relevant literature was reviewed and prospectively registered on the European Urology bedwetting enuresis resource center (http://bedwetting.europeanurology.com/). In addition, guideline papers and statements of the European Society for Paediatric Urology (ESPU), the European Association of Urology (EAU), the National Institute for Health and Care Excellence (NICE) and the International Children Continence Society (ICCS) were used to update the knowledge and evidence resulting in this practical recommendation strategy. Recommendations have been discussed and agreed within the working group of the EAU-ESPU guidelines committee members. RESULTS: The recommendations focus to place the child and his family in a control position. Pragmatic analysis is made of the bedwetting problem by collecting voiding and drinking habits during the day, measuring nighttime urine production and identification of possible risk factors such as high-volume evening drinking, nighttime overactive bladder, behavioral or psychological problems or sleep disordered breathing. A questionnaire will help to identify those risk factors. CONCLUSION: Motivation of the child is important for success. Continuous involvement of the child and the family in the treatment will improve treatment compliance, success and patient satisfaction.

Brazilian consensus in enuresis-recomendations for clinical practice

ABSTRACT Introduction Enuresis, defined as an intermittent urinary incontinence that occurs during sleep, is a frequent condition, occurring in about 10% of children at 7 years of age. However, it is frequently neglected by the family and by the primary care provider, leaving many of those children without treatment. Despite of many studies in Enuresis and recent advances in scientific and technological knowledge there is still considerable heterogeneity in evaluation methods and therapeutic approaches. Materials and Methods The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Enuresis and elaborated a draft of the document. On September 2018 the panel met to review, discuss and write a consensus document. Results and Discussion Enuresis is a multifactorial disease that can lead to a diversity of problems for the child and family. Children presenting with Enuresis require careful evaluation and treatment to avoid future psychological and behavioral problems. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.

Brazilian consensus in enuresis-recomendations for clinical practice.

INTRODUCTION: Enuresis, defined as an intermittent urinary incontinence that occurs during sleep, is a frequent condition, occurring in about 10% of children at 7 years of age. However, it is frequently neglected by the family and by the primary care provider, leaving many of those children without treatment. Despite of many studies in Enuresis and recent advances in scientific and technological knowledge there is still considerable heterogeneity in evaluation methods and therapeutic approaches. MATERIALS AND METHODS: The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Enuresis and elaborated a draft of the document. On September 2018 the panel met to review, discuss and write a consensus document. RESULTS AND DISCUSSION: Enuresis is a multifactorial disease that can lead to a diversity of problems for the child and family. Children presenting with Enuresis require careful evaluation and treatment to avoid future psychological and behavioral problems. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.

Daytime urinary incontinence in children and adolescents.

Daytime urinary incontinence is common in the paediatric population and affects approximately 7-10% of children (aged 5-13 years). Several subtypes of daytime incontinence, which are classified according to their relation to the storage and voiding phases of bladder function, exist. Risk factors for these subtypes of incontinence can be genetic, demographic, environmental, behavioural, or physical. Therefore, treatment is multidisciplinary and needs an adequate diagnosis to be successful. Urotherapy is the first-line treatment for all types of daytime incontinence. It can be defined as bladder re-education or rehabilitation, aiming at correcting the filling and voiding function of the bladder-sphincter unit. Comorbid problems, such as constipation, urinary tract infections, and behavioural problems should also be treated during urotherapy. For comorbidities and severe bladder overactivity, medication might be necessary. Although usually effective, treatment of daytime urinary incontinence in children is often complex and requires patience. Nonetheless, patients and parents are usually motivated for urotherapy, since quality of life is severely reduced in in children with incontinence.

Effect of traditional Chinese medicine Zhiyi decoction and acupuncture on serum ADH & inflammatory factors in patients of enuresis.

.This study was designed to investigate the curative effect of traditional Chinese medicine Zhiyi decoction combined with acupuncture in the treatment of enuresis and its influence on serum ADH and inflammatory factors. A total of 84 enuresis patients treated were selected as cases from September 2014 to January 2017, randomly divided into study and control group with 42 cases each. The control group was treated with traditional Chinese medicine Zhiyi decoction while the study group was treated with traditional Chinese medicine Zhiyi decoction combined with acupuncture. The clinical efficacy and levels of serum ADH, serum inflammatory factors (TNF-α and IL-6) were compared between two groups before and after treatment. In study group, there were 34 cases cured and 5 cases were improved. Total effective rate was 92.9% and recurrence rate was 4%. In control group, there were 23 and 7 cases cured and improved respectively. Total effective rate was 71.4% and recurrence rate was 14.3%. The total efficiency of study group was significantly higher than that of control group (P<0.05), and the recurrence rate was significantly lower than control group (P<0.05). After treatment, there was no significant change in ADH level of study group at 10am and 11pm (P>0.05). In control group, the level of ADH at 11pm before treatment was lower than that after treatment (P<0.05) and the level of ADH at 10am before treatment was not significantly different from that after treatment (P>0.05). The levels of serum TNF-α and IL-6 in study group and control group decreased at 10am and 11pm after treatment (P<0.05) There was no significant difference in serum TNF-α and IL-6 levels between study group and control group before treatment (P>0.05). Compared with simple acupuncture, traditional Chinese medicine Zhiyi decoction combined with acupuncture of children had more exact effect, changed enuresis symptoms effectively.

A consecutive case series analysis of a behavioral intervention for enuresis in children with developmental disabilities.

Children with developmental disabilities (DD) are more likely than typically developing peers to have issues with enuresis. Past research has shown the success of behavioral treatments consisting of scheduled sits and reinforcement for continent voids. However, this research has included small sample sizes, while studies with larger numbers have lacked key information (i.e., baseline rates and follow-up data to evaluate maintenance and generalization). The current study conducted a consecutive case series analysis of 44 individuals with developmental disabilities who completed a 2-week program for enuresis. Results showed significant improvement in continent voids and follow-up data suggested positive results maintained when treatment was implemented by caregivers in a home environment.

Voiding school as a treatment for daytime incontinence or enuresis: Assessing the effectiveness of intervention by measuring changes in wetting episodes.

BACKGROUND: Most urotherapy interventions are planned for children with daytime incontinence or symptoms, and are based on individual education. This study conducted a voiding school (VS) program with groups of 4-6 children with daytime incontinence or enuresis with or without daytime symptoms. OBJECTIVE: The aim of this quasi-experimental study with a one-group pretest-posttest design was to assess the effectiveness of the VS intervention for treating children's daytime incontinence or enuresis. MATERIALS AND METHODS: Sixty-nine 6-12-year-old children with incontinence classified as treatment resistant participated in the VS at an outpatient clinic. Based on a power analysis, a sample of 52 participants was required. The VS involved two whole-day group visits 2 months apart. The educational content of the intervention was based on the International Children's Continence Society's standards for urotherapy, and was delivered with child-oriented teaching methods, including group discussions with peers. The primary outcome measure was the number of dry days and nights. The amount of wetting was also estimated, and the frequency of voiding measured. Data were collected with 1-week voiding diaries before and after each visit. Changes in dependent variables between four measurement points was measured by using repeated measures variance analysis. The long-term effectiveness was evaluated from patient records concerning 3-month follow-up phone calls or other contacts 8-18 months after the VS. RESULTS: Fifty-eight children, 34 girls and 24 boys, completed the study. Twelve children had daytime incontinence, 18 had enuresis, and 28 had both. The number of dry days increased from a mean of 3.5-5.3 (P < 0.001), and the number of dry nights increased from a mean of 2.4-3.9 (P < 0.001) (Summary table). Thirteen (22%) children became completely dry. Three of them had daytime incontinence, five enuresis, and five both. Twenty-four out of 40 (60%) children with daytime incontinence, and 23 out of 46 (50%) children with enuresis showed ≥50% decrease in wetting episodes. The amount of wetting reduced, but the voiding frequency remained unchanged based on the voiding diaries. Twenty-two (45%) of the children were completely dry (six had daytime incontinence, nine enuresis, and seven both), and 16 (39%) showed further improvement, but eight (16%) children remained unchanged 8-18 months after the VS. CONCLUSIONS: Voiding school (VS) was an effective intervention for treating both daytime incontinence and nocturnal enuresis in children who had not benefited from standard treatment and were classified as treatment resistant.

Enuresis Management in Children: Retrospective Clinical Audit of 2861 Cases Treated with Practitioner-Assisted Bell-and-Pad Alarm.

OBJECTIVE: To establish the treatment efficacy of practitioner-assisted bell-and-pad alarm therapy in children with enuresis between the ages of 5 and 16 years by retrospective medical chart review of 2861 children in multiple clinical settings. STUDY DESIGN: This review was conducted across 7 Australian clinical practices. The primary outcome measure was the time taken for children with either primary, secondary, monosymptomatic, or nonmonosymptomatic enuresis to be dry for 14 consecutive nights. The secondary outcome measure was to determine relapse rates, defined as 1 symptom recurrence per month post interruption of treatment. Data were analyzed by correlation and χ2 test via IBM SPSS Statistics (version 22). RESULTS: The overall success rate of the bell and pad treatment was 76%, irrespective of age. The mean treatment time to achieve dryness was 62.1 ± 30.8 days, and the relapse rate was 23%. Concurrent bowel dysfunction was associated with a slightly lower success rate (74%). Concurrent lower urinary tract symptoms were associated with a lower success rate (73%) and greater relapse (1.75 times more likely to relapse). Children with secondary enuresis had significantly greater success than those with primary enuresis (82% vs 74%). CONCLUSION: The type of alarm therapy reported in this study is highly effective. This study will provide the basis for clinical guidelines and practice tools for clinicians, which will help to reduce variation in care pathways for alarm treatment for enuresis.

Persistent Encopresis, Enuresis, and Anxiety in a 7-Year-Old Girl.

CASE: Sonia is a 7-year-old old girl who was referred to the Developmental-Behavioral Pediatrics Clinic by the Pediatric Urology Clinic because of persistent wetting and soiling behaviors. Since age 3 years, she has had a history of encopresis (and wetting) for which she has seen gastroenterology and urology specialists. The mother reports that Sonia has accidents almost daily, and she is not upset when sitting in her urine or feces. She dislikes going into the bathroom or sitting on the toilet by herself. She participated in a behavior modification program associated with the pediatric urology clinic, which helps children learn healthy voiding habits and achieve continence.Sonia also has anxious behaviors. She bites her nails and chews on her hair or shirt. She is afraid of small spaces such as those between the bed and the wall and needs to have stuffed animals cover them. Other instances that trigger her anxious behaviors include loud noises, having a substitute teacher, being separated from her mother, and going to certain bathrooms or new places. She also has severe tantrums, which involve throwing and breaking objects, kicking, and hitting her head against doors.A cognitive behavioral therapy program was recommended to target anxiety symptoms, in addition to timed toileting after meals and polyethylene glycol. At a clinic visit several months later, symptoms of anxiety, encopresis, and enuresis persisted. Cognitive behavior therapy was continued and sertraline 25 mg was prescribed for anxiety. In addition, she was referred to a pediatrician who specializes in relaxation techniques and hypnotherapy.Sonia showed modest improvement with these interventions. There were fewer episodes of angry outbursts and a decrease in soiling and wetting, but at times, but she continued to have intermittent periods of wetting and soiling and fear of going to the bathroom by herself persisted.(This Challenging Case extends observations reviewed in a previous Challenging Case: J Dev Behav Pediatr 2010;531:513-515; DOI: 10.1097/DBP.0b013e3181e5a464.).

Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment.

CONTEXT: Enuresis is a common and possibly underestimated condition. While 5-10% of school-aged children suffer from the condition, a lack of background knowledge may impede timely child-adapted and successful therapy. OBJECTIVE: To provide a comprehensive overview of the pathophysiology, diagnosis, and treatment of enuresis. EVIDENCE ACQUISITION: Guideline and position papers from the European Society of Pediatric Urology, the European Association of Urology, and the International Children's Continence Society were acquired. PubMed was searched for literature on enuresis, and all papers published in the last 5 yr were considered. The most relevant information from the papers with the highest level of evidence was extracted and incorporated into the review. EVIDENCE SYNTHESIS: An altered antidiuretic hormone profile, arousal failure, and delayed bladder maturation are the main pathophysiological factors in primary enuresis. Coexisting constipation, obstructive airway disease, attention deficit hyperactivity disorder, obesity, and genetic preconditions influence its prevalence. Diagnosis relies on history-taking and simple noninvasive examinations to differentiate monosymptomatic enuresis and patients with daytime symptoms. It is essential to exclude daytime voiding symptoms, overactive bladder, dysfunctional voiding, and urinary tract infections. Further imaging is indicated in complex cases with a suspicion of underlying congenital malformations or systemic or endocrine diseases and in children refractory to initial therapy. In secondary enuresis, psychological causes should also be taken into consideration. While desmopressin melt tablets and alarm systems constitute the mainstays of treatment in monosymptomatic enuresis, anticholinergics and urotherapy play an additional role in nonmonosymptomatic enuresis. For therapy-refractory cases, after a thorough re-investigation to identify any missed comorbidities and anatomical or functional causes of enuresis, combination therapy and stationary urotherapy might be promising options. CONCLUSIONS: While enuresis seems to be an often underestimated condition in terms of the suffering that children and their families, there are efficacious therapy options once a correct and full diagnosis is made. PATIENT SUMMARY: This article reviews primary and secondary nocturnal enuresis, which is the medical term for the condition whereby children wet their beds regularly after their first birthday. We describe the background of enuresis,including its complex underlying mechanisms, as well as diagnosis and treatment in the light of current scientific publications. We conclude that while enuresis seems to be an often underestimated condition in terms of the suffering that children and their families may undergo, there are efficacious therapy options once a correct and full diagnosis is made.

CPAP Treats Enuresis in Adults With Obstructive Sleep Apnea.

ABSTRACT: Enuresis, or "bedwetting," in children is associated with obstructive sleep apnea (OSA), and often resolves with treatment of OSA. However, it is poorly understood whether a similar relationship exists in adults. We describe a case series of 5 adult patients in whom OSA was diagnosed by laboratory polysomnography, who presented with enuresis that resolved after treatment with continuous positive airway pressure (CPAP). All cases occurred in the setting of obesity, in addition to other known risk factors for urinary incontinence and enuresis. OSA was diagnosed as severe in all but one case, which was mild. One patient noted recurrence of enuresis that coincided with malfunction of his CPAP machine. There is growing evidence that CPAP therapy may alleviate OSA and enuresis in adults with both conditions. Clinicians should routinely ask about enuresis in patients suspected of having OSA. A systematic study of the association between enuresis and OSA in adults is warranted.