Pathophysiology and impact of nocturnal enuresis

Nocturnal enuresis in children is not a psychogenic disorder. It is caused by a hereditary delay in maturation of the somatic mechanisms (reduction of nocturnal urine production and a normal arousal to a full bladder) which prevent the child from wetting the bed. Traditionally, doctors treating bedwetting children have used an expectant attitude, because nocturnal enuresis has been looked upon as self-limiting and harmless. According to recent research this is not true. More than 5% of children and 0.5% of the adult population report nocturnal enuresis, meaning that 10% of enuretic children will remain bedwetters for life if left untreated, and nocturnal enuresis is perceived as a shameful condition, giving a significant impairment of self-esteem at an age when an intact self-image is extremely important for an optimal development of the child's personality. Treatment should be given when the enuretic child wants to sleep dry.     

Primary pulmonary hypertension

Justification of early treatment of nocturnal enuresis is founded in the negative psychological impact on the child. In fact nocturnal enuresis delays early autonomy and socialisation by decreasing in self-esteem and self-confidence. Nocturnal enuresis classification is the preliminary step to correct therapy. Enuresis must be classified as primary (never acquired nocturnal control) or secondary (at least 6 months of dry nights). A child is also classified as having monosymptomatic enuresis if she/he experienced only night wetting and symptomatic enuresis if she/he experienced night wetting associated with diurnal voiding symptoms (urinated > or = 7 times a day, urgency, damp pants, squatting, holding the perineum, sitting on one heel). Monosymptomatic patients must be treated with desmopressin nasal spray at the daily dose of 20 micrograms at bed time. If the reduction of at least the 50% of the basal number of the wet nights is not achieved, the dosage must be increased until 40 micrograms. For patients affected by rhinitis or asthma, desmopressin is now available in tablets. In symptomatic patients desmopressin therapy must be associated to oxybutinin (5 mg x 2). Therapy interruption must be gradual with desmopressin reduction of 10 micrograms every 30 days. In symptomatic patients oxybutinin must be introduced only at bed time. The efficacy of the drugs depends on the therapy length. The highest percentage of success is obtained if the treatment is protracted for at least six months. Antidepressants are also used for nocturnal enuresis especially imipramine. The dosage varies between 0.5-1.5 mg/ kg/daily. As plasmatic levels are achieved only in 30% of treated patients, a 3-5 fold increase in suggested. Nevertheless these levels result in near toxic threshold concentration. Sporadic treatment purposes include amytriptiline, diclofenac sodicum, viloxsazine and methilphenidate if giggle incontinence is present. Non responders may be treated with alarm. If after 16 weeks of treatment no success is obtained alarm use must be interrupted.     

Müllerianosis of the urinary bladder: clinical and immunohistochemical findings

BACKGROUND: Intranasal desmopressin has been used extensively to treat primary nocturnal enuresis. While it has proven to be a safe, effective agent for many who are affected by this condition, the potential for complications exists. OBJECTIVES: To report a case of severe hyponatremia associated with a generalized tonic-clonic seizure in a 10-year-old boy who had been receiving intranasal desmopressin nightly for nocturnal enuresis and to briefly review therapeutic options for nocturnal enuresis; and to present the role of desmopressin. SETTING: Georgetown University Medical Center, Washington, DC. INTERVENTION: Fluid restriction and intravenous isotonic saline solution with 5% dextrose was administered to raise the serum sodium level. OUTCOME: Prevention of further seizures with normalization of serum sodium levels without any obvious neurological sequelae. CONCLUSIONS: This case illustrates the importance of weighing the benefits and risks of intranasal desmopressin therapy.     

The burden of nocturnal enuresis

Nocturnal enuresis is a well-known "low-severity high-prevalence" condition in paediatrics, with extensive psychosocial suffering. This suffering is not always realized by paediatricians and other professionals. The aim of this study is to show that enuresis not only has an impact on the child, but also frustrates the entire family. The literature shows that nocturnal enuresis causes distress and low self-esteem for the child. It also has major social and economic implications for the family, with an increasing intolerance as the child grows older. An analysis of nine studies on the impact of successful treatment on the psychological condition of enuretic children showed improved behaviour and personality scores. In five studies the improvement in mental health was significantly related to treatment success. Timely treatment will prevent psychosocial damage, favour a normal development of the child and bring practical relief to the family.     

Femoral anteversion related to side differences in hip rotation. Passive rotation in 1,140 children aged 8-9 years

To assess the prevalence and characteristics of enuresis nocturna in adults, the treatment they received and the perceived impact, a random sample of 13081 non-institutionalized adults (18-64 years old) were asked to participate in the study in January-March 1996. The response rate was 87%. A personal computer questionnaire included 23 questions on frequency of bedwetting, daytime wetting, treatment and perceived impact. Any respondent reporting bedwetting at least once during the previous 4 weeks was considered to have enuresis nocturna. The overall prevalence of enuresis nocturna was 0.5%. Differences between age groups and sexes were not significant. Fifty percent of men and 19% of women reporting enuresis nocturna had primary enuresis nocturna, of those with enuresis nocturna, 12% of men and 29% of women had always daytime incontinence. Fifty percent of the men and 35% of the women had never consulted a care provider for their bedwetting and 38% of the men and 26% of the women had done nothing to become dry. Only 30% believed that bedwetting was treatable. Bedwetting was associated with several psychosocial problems. Enuresis nocturna in adults is common and may lead to embarrassment and discomfort. It may affect careers, social life and personal relationships. Adults should be more aware that bedwetting is a treatable problem. More information should be given on this issue.     

Beneficial effect of intranasal desmopressin for nocturnal polyuria in Parkinson's disease

Patients with Parkinson's disease (PD) are known to experience autonomic nervous system dysfunction: this disruptive symptomatology includes urinary urgency, frequency, and nocturnal polyuria. Anticholinergic and tricyclic medications can be beneficial in controlling these urinary symptoms, but have unpleasant side effects in some patients. Desmopressin has been used to treat nocturnal polyuria successfully in a number of conditions, such as central diabetes insipidus, enuresis, and autonomic failure. The purpose of the present study was to assess the efficacy of desmopressin in patients with PD with significant nocturia. Eight patients were recruited into the study. They were first asked to establish a baseline of number of nocturnal voids; the patients were then prescribed the intranasal form of desmopressin and asked to continue to record the number of nocturnal voids. The five patients who completed the trial demonstrated clinically and statistically significant reductions in the frequency of nocturnal voids. One patient became hyponatremic and confused during desmopressin administration; his symptoms resolved soon after the desmopressin was discontinued. Two patients failed to complete the trial due to compliance problems. Thus, desmopressin appears to be a safe and effective medication for nocturnal polyuria in PD.     

Nocturnal enuresis should not be ignored

Doctors often dismiss nocturnal enuresis--bedwetting--as a minor problem and suggest that the child will 'grow out of it'. Bedwetting can damage the child's self-esteem, with long-lasting consequences. Given the range of psychological and pharmacological measures available to manage nocturnal enuresis, such a conservative approach is unacceptable. These measures are outlined and discussed in this article.     

Nutrient intake and food group consumption of 10-year-olds by sugar intake level: the Bogalusa Heart Study

We studied the occurrence of nocturnal enuresis (bedwetting) after the age of 4 years, using a questionnaire in a well-defined population, the Finnish Twin Cohort, which consists of 11,220 subjects aged 33-60 years, including 1298 monozygotic and 2419 dizygotic twin pairs. Structural equation modeling techniques were used to estimate variance components to compare different genetic models. Females reported enuresis in childhood "often" in 3.4% (males in 4.0%) and "sometimes" in 5.7% (8.0%). As adults, females had experienced enuresis "weekly" in 0.3% (males in 0.2%) and "monthly" in 0.07% (0.1%). Those who had experienced enuresis in childhood had had "at least sometimes" enuresis as adults in 5.4% of males and in 5.5% of females. Among those who reported they never had experienced enuresis as adults, 70.8% of males and in 77.9% of females had never experienced enuresis in childhood. For enuresis in childhood, the probandwise concordance rate was 0.43 for monozygotic and 0.19 for dizygotic pairs, and in adults 0.25 and 0, respectively. The proportion of total phenotypic variance attributed to genetic influences (due to dominance) was 67% in males (95% confidence interval 57-76%) and 70% in females (61-78%) in childhood enuresis. In conclusion, nocturnal enuresis is common in childhood and rare in adulthood. Our results confirm the central role of genetic liability in enuresis.     

Desmopressin versus indomethacin treatment in primary nocturnal enuresis and the role of prostaglandins

OBJECTIVES: To compare the efficacy of desmopressin and indomethacin and also determine the prostaglandin E2 (PGE2) concentrations in the patient and control groups. METHODS: Eighty-five children with primary nocturnal enuresis were followed up for a baseline period of 4 weeks, during which they recorded wet and dry nights. After this period, the patients were divided into three groups that used desmopressin, indomethacin, or placebo for 4 weeks. The dosage of desmopressin (group A, n = 31 ) was 20 microg/day and the dosage of indomethacin (group B, n = 29) was 100 mg/day. The placebo group (group C) consisted of 25 patients. We determined the serum PGE2 and urine PGE2 concentrations before and after treatment in the three groups and in a control group. RESULTS: Treatment with desmopressin and indomethacin resulted in significantly more dry nights during the 4 weeks of observation than did placebo (P <0.005). The number of dry nights was also significantly different in the desmopressin group than in the indomethacin group (P <0.01). In the total patient group, the mean serum and urine PGE2 concentrations were significantly different from the control group's serum and urine PGE2 concentrations (P <0.001). There was a significant decrease in the serum and urine PGE2 concentrations in group A and group B after the treatment period (P <0.01). CONCLUSIONS: Desmopressin and indomethacin were found to be more effective than placebo. We conclude that prostaglandins have an important role in the pathophysiology of primary nocturnal enuresis.     

Evaluation of 20 years' experience of enuresis in children

The clinical and urodynamic approach to enuretic children over a period of more than 20 years has allowed the authors to develop a multifactorial pathophysiological concept of this disorder. The main factors involved are psychological, familial, genetic, vesical, due to bladder immaturity, hormonal, due to a defect of nocturnal ADH secretion, hygiene and dietary habits, etc. The sleep factor is predominant in the majority of cases. Although nocturnal enuresis is apparently isolated in many cases, it is often associated with a state of bladder immaturity, sometimes latent during the day, but occurring at night with episodes of detrusor hyperactivity, occurring during various phases of sleep. In practice, the recognition, in children, of these factors, some of which require specific treatments, implies a management combining several of these therapeutic modalities.     

Routine urodynamic studies is not indicated in children with enuresis

From January 1980 to January 1992, urodynamic examinations were performed in 339 enuretic children without constipation or anatomical or neurogenic causes of incontinence. Nocturnal enuresis was seen in 178 patients, 130 children suffered from nocturnal and diurnal enuresis, and 31 had only diurnal enuresis. M. detrusor instability was found in 44% of the children and 73% showed more than 15% reduction in functional bladder capacity. In 5% an infravesical obstruction was suspected on pressure-flowmetry and in 12% dysfunctional voiding was seen. Routine urodynamic studies are not indicated in children with enuresis.     

Traitement d'un cas d'énurésie diurne et nocturne.

Describes the treatment given to a nocturnal and diurnal enuretic female child (aged 7 yrs 9 mo), consisting of increasing the intensity of bladder stimulations by the absorption of liquid, attracting the S's attention to these stimulations, urging the S to react correctly, and reinforcing this response. Findings indicate that control exercised by bladder stimulations on a proper response is almost perfect at the end of the diurnal enuretic treatment. The nocturnal enuresis was resolved without any further intervention. (English abstract) (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sociodemographic factors associated with nocturnal enuresis

This study examined the school nursing/medical examination records of 6206 national school children for sociodemographic factors associated with reported nocturnal enuresis. A point prevalence of 10.7% (n = 666) for nocturnal enuresis was reported by parents during 1970-1993 in children aged 4-14 years. Although a downward linear trend (from 11.5% to 10.7%) was seen for the reported prevalence of nocturnal enuresis over the 23-year period, this trend was not statistically significant. Age, as expected, large family size and low ordinal position in the family were all statistically associated with reported nocturnal enuresis. Gender was statistically associated with reported nocturnal enuresis only in the 6-14 years age group. Paternal social class was not statistically associated with reported nocturnal enuresis, although 15% of children in families where the father was absent were reported enuretic compared with only 10% of children whose father was in social class 1. These findings contribute to an understanding of the relationship between sociodemographic factors and enuresis as reported at school medical examinations and have implications for the planning and development of health services at local levels.     

Desmopressin for the treatment of nocturnal polyuria in the elderly: a dose titration study

OBJECTIVE: To evaluate the decrease in nocturnal polyuria and the tolerability of three different doses of oral desmopressin in elderly subjects. SUBJECTS AND METHODS: Subjects were included in the study if they; (i) were healthy and free from medication with possible influence on their diuresis or voiding pattern: (ii) had an increased nocturnal frequency (> or = 2 nocturnal voids, as reported in the pre-screening period); and (iii) had a nocturnal urinary output of > or = 0.9 mL/min. Seventeen men and six women (mean age 68.1, SD 4.7 years) met these criteria and were treated with 0.1, 0.2 and 0.4 mg oral desmopressin given at bedtime, each dose taken for one week on three consecutive weeks. RESULTS: The mean (SD) nocturnal diuresis before treatment was 1.6 (0.7) mL/min, which decreased significantly to 1.1 (0.4) mL/min when 0.1 mg desmopressin was given. A dose of 0.2 mg desmopressin resulted in a further small decrease in the nocturnal diuresis to 0.9 (0.4) mL/min, whereas the 0.4 mg dose produced no additional effect. The reduction in nocturnal diuresis occurred almost exclusively in the group with a nocturnal urinary output of > or =1.3 mL/min. After treatment, diuresis returned to pretreatment levels. There was no change in body weight or in ankle circumference during desmopressin treatment and no serious adverse effects were observed. CONCLUSION: Desmopressin reduces nocturnal diuresis in polyuric elderly subjects and this reduction, occurring with doses of 0.1 mg given at bedtime, does not increase in a dose-dependent way.     

Zone therapy of children with nocturnal enuresis

The purpose of the study was to clarify whether reflexology is a relevant treatment for enuresis nocturna, and to test a research design applicable to controlled experiments with reflexology. An unblinded method was used comparing a treatment group (1) receiving reflexology to a non-treatment group (2) keeping the same record of symptoms. At the start of the study, the volumes of night urine in the two groups were comparable. By the end of the study, there was no significant decrease in the volume of night urine in either of the groups. Two children in the treatment group and one in the non-treatment group became dry during the night in the course of the study. In conclusion, reflexology given as 14 treatment sessions over a period of four months did not result in a significant fall in enuresis nocturna in children aged seven to eleven years old. It must be concluded that the treatment result can not be distinguished from the conditions in the non-treatment group even though the average night diuresis in group one showed a slightly decreasing tendency while morning diuresis increased, in contrast to group two which exhibited a slight increase in night diuresis. As the total diuresis remained constant, this could be interpreted as an increased urinary bladder capacity, but in both cases the changes were far from significant.     

Effectiveness of psychological and pharmacological treatments for nocturnal enuresis.

Provides a quantitative integration of research on the effectiveness of psychological and pharmacological treatments for nocturnal enuresis. With the use of experiments that compared treatments with either no treatment or another form of treatment, this article assesses (1) the overall effectiveness of psychological and pharmacological treatments, (2) the relative effectiveness of specific types of treatments, and (3) moderators of treatment effectiveness including investigator allegiance. Findings from the review confirm that enuretic children benefit substantially from treatment. However, more children improve from psychological than from pharmacological interventions. Moreover, psychological treatments involving a urine alarm are most likely to yield benefits that are maintained once treatment has ended. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

GABA-induced synaptic facilitation at type B to A photoreceptor connections in Hermissenda

The aim of this paper was to establish if there is a correlation between desmopressin administration and modification of psychological experience in enuretic children. 22 enuretic children (18 treated with desmopressin, 4 not treated) were enrolled in the study. They underwent a complete psychological examination, differentiated on the basis of chronological age, before the beginning and at the end of the treatment (duration 4 months). The psychologist was not informed if they were treated or not. In the 17 of 18 treated children with basal psychological problems, 14 became normal, 2 demonstrated a significative amelioration and 1 remained pathologic at the end of the treatment. No modification was observed in not treated patients, all presenting psychological problems. 6 emblematic cases with psychological findings and paintings are presented. The results seem interesting, despite the low number of children enrolled.     

Enuresis nocturna--neu studies of genetic, pathophysiologic and psychiatric correlations

Nocturnal enuresis is characterized by a highly complex interaction of somatic and psychiatric factors. A primary monosymptomatic, a symptomatic (with diurnal rnicturition problems) and a secondary form (following a dry interval) can be differentiated. Despite deep sleep with difficult arousal, the sleep architecture itself is normal and enuretic episodes occur in every sleep stage without urodynamic changes. Changes in the circadian AVP-rhythm with nocturnal polyuria have been demonstrated repeatedly. Formal genetically, many families are compatible with an autosomal dominant mode of inheritance. Linkage studies have shown a linkage of nocturnal enuresis with regions on chromosomes Nr. 8, 12 and 13. There is a significantly increased rate of psychiatric problems. The associations are complex, with psychiatric factors occurring both reactively following the enuresis, as well as being causally involved in secondary, but not in primary monosymptomatic nocturnal enuresis.     

Fréquence de l'énurésie chez les enfants agés de 4 à 7 ans.

Studied the incidence of diurnal and nocturnal enuresis in children and the age at which children stop exhibiting enuresis during the day and through the night. Human subjects: 2,007 male and female French children (4–7 yrs) (nursery school and kindergarten students). Data on diurnal and nocturnal enuresis and age at which a child stopped exhibiting enuresis were obtained via a questionnaire administered to the Ss' parents. The incidence and frequency of nocturnal and diurnal enuresis were compared between male and female Ss. (English abstract) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use of cytosolic enzyme increase in cerebrospinal fluid of patients resuscitated after cardiac arrest. Brain Resuscitation Clinical Trial I Study Group

OBJECTIVE: To perform bladder neck suspension simultaneously with augmentation cystoplasty in female patients where sphincteric incompetence was not the sole cause of impaired functional bladder capacity. PATIENTS AND METHODS: During an 8-year-period, 26 female patients (mean age 14, range 5-39) were treated with a Marshall-Marchetti plus cystoplasty (Liverpool) or a colposuspension plus clam cystoplasty (Sheffield). All had marked sphincteric incompetence compounded by detrusor hyper-reflexia and/or non-compliance. The patients were followed up for a mean period of 30 months (range 8-80). RESULTS: There were no major complications. At follow-up 23 (88%) were dry by day on a regime of intermittent self-catheterization. Nine patients were taking adjuvant medication, usually for prevention of nocturnal enuresis. CONCLUSION: The results compare tolerably with those of all alternative procedures, including the more elaborate reconstructions (e.g. Kropp procedure) and the expensive artificial urinary sphincter.