the management of urinary incontinence in children (1)

8/11/2019 The Management of Urinary Incontinence in Children (1)

1/21

The Management of Urinary Incontinence in Children

Samih Al-Hayek and Paul AbramsBristol Urological Institute, Southmead Hospital, Bristol, UK

Introduction

The childhood period is characterized by marked development changes. Acquisition oftoileting skills is part of normal development. However, achievement of urinary control iscomplex and yet to be fully understood.

In newborns micturition occurs at frequent intervals and voiding may have an intermittentpattern, although bladder emptying efficiency is usually good. In over 80 percent of voidsthe bladder empties completely (1).

Between the age of 1 and 2, conscious sensation of bladder filling develops. During thesecond and third year of life, there is progressive development towards a socially consciouscontinence and a more voluntary type of micturition control develops. Through an activelearning process, the child acquires the ability to voluntarily inhibit and delay voiding untila socially convenient time, then actively initiate urination. This all depends on an intactnervous system. By age of 4, most children will be able to keep dry both day and night. Thatis influenced by family, social and environmental factors (2).

Urinary incontinence in children affects the whole family. To properly manage it, a fullappreciation of the problem, and thorough assessment of the child and the socialcircumstances is needed.

Definition

The standardization of terminology committee of the International Continence Society (ICS)has set the terms and definitions to be used when describing any lower urinary tractdysfunction (LUTD) (3) and these can be used to describe LUTD in children, with fewexceptions. Indeed, it is important that the same terminology is used in children and adultsin order not to confuse patients, their families and their nursing and medical caregivers.

Urinary incontinenceis defined as the complaint of any involuntary leakage of urine . It isclear that this definition does not apply to infants and small children, and when reportingincontinence in children further explanation is needed.

Urinary incontinence in children could be classified into two main categories:

Nocturnal enuresis: can be primary or secondary

Day and night incontinence: on the basis of urodynamics this could besubcategorized into:

1.

Detrusor overactivity (during filling)


2/21

2. Dysfunctional voiding(where there is urethral overactivity during voiding in theabsence of a neurological cause)

3. Detrusor underactivity

Nocturnal Enuresis (NE)Definition and classification

Nocturnal enuresis (NE) can be defined as an involuntary voiding of urine duringsleep, with a severity of at least three times a week, in children over 5 years of age inthe absence of congenital or acquired defects of the central nervous system (4).

It has been agreed that 5 years is appropriate, as it is around this time that a childnormally has complete bladder control and has developed cognitive control overvoiding.

Nocturnal enuresis could be classified asprimaryor secondary:

Primaryor persistent nocturnal enuresis describes children whohave never achieved a periodof up to 6 months free of bedwetting.Secondaryor onset nocturnal enuresis is the reemergence of loss of control (wetting) after aperiod of being dry. Secondary nocturnal enuresis appears to be associated with a higherincidence of stressful events, particularly parental separation, disharmony between parents,birth of a sibling, early separation of the child from parents and psychiatric disturbance in aparent (5-7).Both Jarvelin and Fergusson et al. argue that primary and secondary enuresis are aspects ofthe same problem (6, 8). They claim the two classifications share a common etiological basis.

Nocturnal enuresiscan also be classified according to the presenting symptoms as mono- ornon-monosymptomatic .Monosymptomatic nocturnal enuresis refers to those children who report no bladder orvoiding problems associated with their wetting.Non-monosymptomatic nocturnal enuresis refers to bedwetting, which is associated withother symptoms such as urgency and frequency during the day, with or without daytimewetting (9).This classification helps in directing the treatment appropriately.

Prevalence of NE

The extent of bedwetting is widespread. But as expected, the frequency decreases with age(10). It has been argued that nocturnal enuresis is the most prevalent of all childhoodproblems.

In the United Kingdom, estimates suggest around three quarters of a million children andyoung people over 7 years will regularly wet the bed. In the United States recent evaluationsof prevalence suggest some 5 to 7 million children regularly experience primary nocturnalenuresis (11).

In the literature, there is a wide variation in the reported prevalence. This may be due to thedefinition used for nocturnal enuresis related to the frequency of wet nights. Table I gives thepercentage of children with any episodes of nocturnal enuresis based on surveys undertakenin Great Britain, Holland, New Zealand and Ireland (12-14).


3/21

Table I: Percent of children with enuresis in four surveys.

AGE (YEARS) BOYS % GIRLS %

5 13-19 9-16

7 15-22 7-15

9 9-13 5-10

16 1-2 1-2

Girls are more likely to experience secondary enuresis and associated daytime incontinence

compared to boys, but less likely to have a family history or genetic predisposition tobedwetting (15-18). A recent survey of twin pairs in England and Wales found a significantdifference between boys and girls in the development of nocturnal bladder control with54.5% of girls and 44.2% of boys being dry at night (18, 19)

As mentioned before, primary NE usually remits with age (14). The risk of remainingenuretic during adult life if not treated actively during childhood is about 3%(20).

Treatment of NE

As it is not a life-threatening condition, most parents tend to delay consulting doctorsregarding their children. In England and Scotland only about 50% of children with NEconsult their doctors (21).

It is usually the frequency of bed wetting and how much the family is bothered by thecondition which drives the consultation. Fifteen percent (15%)of children with nocturnalenuresis wet every night, and most children wet more than once a week(12, 22).

There may be a lack of awareness of the local health care providers (mainly generalpractitioners) about the available options in managing NE. A French survey of schoolchildren, most mothers of those children with NE had a rather tolerant attitude, but if thechild had moderate to severe NE then two thirds of the mothers had consulted the doctor,mainly the general practitioner. However, most doctors suggested no solution or a wait-and-see approach (23).

The management of nocturnal enuresisdepends on the childs motivation to participate intreatment; confounding psychosocial factors should be addressed, and any interventionshould be regularly reviewed.

It is still not clear whether active treatment of nocturnal enuresis in childhood is able toreduce the number of adult enuretics.


4/21

A- General Measures

The approach in treating primary and secondary NE is the same. Nevertheless, co-morbidpsychiatric disorders in secondary NE should be taken into account.

It is essential to explain the problem to the child and their parents. Education about theproblem and a realistic discussion of the prognosis will help in achieving confidence in thetreatment offered and will improve both compliance and the outcome (24).Asking the childand parents to keep a record of the wet and dry nights may play a role in engaging them intreatment.

The family should be counseled to ensure that the child receives the optimal duration ofsleep (24). General advice such as to eat, drink and void regularly during the day, abstainfrom drinking too much during the late afternoon and evening, and asking the child to voidbefore bedtime (25). School teachers should also be informed about these therapeutic rules.A low calcium and sodium dietary content of the afternoon and evening meals may also be

useful (26, 27).

Regular family and child encouragement with positive attitude towards the child should beutilized with the explanation that bed-wetting does have a high chance of resolvingspontaneously with up to 19% of children becoming dry within the next 8 weeks withoutany further treatment(28-30).

B- Nonpharmacological

Therapy treatment modalities such as fluid restriction, dry-bed training, retention controltraining, psychotherapy, acupuncture and hypnosis all have been used but there is still not

enough evidence that they are effective(31-38).

A randomized, controlled trial on laser acupuncture was compared to desmopressintreatment. The authors concluded that this treatment should be considered as an alternative,noninvasive, painless, cost-effective and short-term therapy for children with primarynocturnal enuresis in case of a normal bladder function and high nighttime urine production.Success rates (about 65%) indicated no statistically significant differences between the well-established desmopressin therapy and the alternative laser acupuncture (37). However, thisis the only randomized, controlled trial available and included only 40 children.

Comparison of treatment outcome and cure rates for different treatment modalities isdifficult because of the inconsistent use of definitions, the inclusion of children with daytimesymptoms and the variable follow-up periods in most studies.

It is accepted that use of multiple treatment modalities achieves a significant reduction in thenumber of wet episodes and possible cure to start with. This will give the parent and thechild confidence that the problem is treatable.


5/21

Enuresis alarm

In a recent Cochrane review, C.M. Glazener et al. found that the enuresis alarm is the mosteffective means of facilitating arousal from sleepand remains the most effective way totreat monosymptomatic nocturnal enuresis (39). They reviewed the results of 53 trials,

involving 2862 children and found that most alarms used audio methods. Compared to notreatment, about two thirds of children became dry during alarm use. Nearly half whopersisted with alarm use remained dry after treatment finished, compared to almost noneafter no treatment. There was insufficient evidence to draw conclusions about different typesof alarm, or about how alarms compare to other behavioral interventions. Similarly, body-worn alarms were as effective as bedside ones. Relapse rates were lower when overlearningwas added to alarm treatment usually done by giving extra fluids at bedtime aftersuccessfully becoming dry for a considerable period of about 14 consecutive nights tostrengthen the bladder control. Alarms using electric shocks were unacceptable to childrenor their parents. Although desmopressin may have a more immediate effect, alarms appearmore effective by the end of a course of treatment (39).

Forsythe and Buttler have summarized the history and progress of the enuretic alarm over aperiod of 50 years and came to the same conclusion (40).

The systematic review by Mellon and McGrath reported 78% dry children which wassignificantly better than no treatment (41).

Alarm therapy has been shown in a meta-analysis to have a 43 percent lasting cure rate (42,43) which means that is more effective than other forms of treatment (44).Interestingly, theuse of alarm has been found to increase the functional bladder capacity, without any changein nocturnal urine production or vasopressin secretion, which may explain why children

after successful treatment are often able to sleep without nocturia (45, 46).

Alarms are usually suitable for children aged over 7 years who wants to be dry and can takeresponsibility for the alarm with the familys help. The key to success is not the stimulusintensity of the alarm triggering but the childs preparedness to awake and respond to thesignal.

Relapse may develop but this often responds to further alarm therapy. Failure does notpreclude future successful treatment in an older more motivated child.

Several factors may affect the efficacy of alarm use (Box 1) with potential difficulties (Box 2).

Box I: Factors which might affect the alarm use.


6/21

Factors which improve the efficacyof the alarm(2):

Optimal motivation of the child and family,

A higher frequency of wet nights and longer duration of use.

In a successfully treated child, alarm therapy should be continuedfor at least a month after sustained dryness.

Reduced efficacyis associated with(2):

Lack of concern shown by the child,

Lack of supervision, inconsistent use

Family stress

Abnormal scores on behavioral check lists

Psychiatric disorder in the child, failure to awaken in response to thealarm, unsatisfactory housing conditions, and more than onewetting episode per night.

Box II: Some difficulties when using the alarm.Common problemswith using the alarm (47):

Alarm treatment is slow in the beginning so it should be continuedat least 6 to 8 weeks before it is judged.

Compliance remains a problem. Dropout rates are rarely disclosedin reported studies. Family members may find this method toodisruptive. Lots of encouragement is needed.

The child may consider it as a punishment. Further explanation tothe child may help.

The alarm may fail to go off or go off for no reason which may causedisturbance to the child and family.

The child may not wake up to the alarm. Then a family membershould then take the responsibility to do so. It is not necessary forthe child to be fully awakened.

Proper guidance and instructions would resolve many of the above difficulties.

Arousal training


7/21

Van Londen et al. first described this procedure with a group of 41 children. He concludedthat arousal training is a fast, simple and effective form of bibliotherapy for nocturnalenuresis with nonclinical children between 6 and 12 years of age (48).

They reported a response rate of 100%, 98% (14 consecutive dry nights) compared to 73%

with alarm monotherapy, which is an unusually high rate.

Arousal trainingentails reinforcing appropriate behavior (waking and toileting) in responseto alarm triggering. The parents actas therapists. They reward the operant behavior-patternfollowing the urine alarm. The instructions involve (2):

setting up the alarm before sleep

when the alarm is triggered the child must respond by turning it off within 3 minutes the child completes voiding in the toilet, returns to bed and resets the alarm when the child reacts in this fashion he is rewarded with 2 stickers when the child fails to respond in this way the child pays back one sticker

Reward and positive reinforcement

Although star charts for dry beds has been traditionally used by many parents and healthprofessionals, they tend to be largely unsuccessful. That could be due to the way they areintroduced to the child with a reward for positive outcome, but the child has little or nocontrol on the outcome (dry night). It was even reported that rewards for actions the childwishes to engage in will decrease and undermine intrinsic motivation, by decreasing thechilds sense of self-determination and competence (49). For most children the dry night is areward in itself.

A better wayof using this method is to start rewarding what is controllable. For example,rewarding regular daytime voiding, waking up to go to the toilet, voiding before sleep andwaking quickly to an alarm triggering.

Cognitive restructuring

Butler suggested three cognitive processes: auto-suggestion, restructuring beliefs andvisualization. Few studies have, however, investigated cognitive change directly.

Normalized voiding

Normalized voiding involves increasing daytime fluid intake, increasing the frequency ofmicturitions during the day with voiding regularly at predetermined times (every 2-3 hours)with avoidance of postponing urination.

This is usually used in combination with other treatment modalities. It is an attempt tonormalize voiding, because many of the children postpone voiding. Although it seemsappealing, this approach has not been examined on its own.

Positive practice


8/21

The aim of positive practice is to develop an alternative response to bedwetting. Following awet bed, the child is encouraged to practice the following, both immediately and prior tobedtime the next night (2):

the child is encouraged to lie in bed with the lights off,

count to 50, go to the toilet and attempt to urinate, and repeat this few times.

Bollard and Nettelbeck have reported success rate of 83% (50).

It may be clear that this can only be attempted in motivated children and good parentalsupport.

Retention control training

This is to help the child increase his bladder capacity and the ability to retain urine. The childwill be asked to have a drink, when he or she indicates the need to void, they will be askedto hold and will be praised if they do. Using a enuresis alarm will increase the methodseffect.

Scheduled waking

The aim is to encourage arousability from sleep. As originally described, there are twoaspects: hourly waking on the first night and scheduled waking thereafter (51).

With the hourly waking on one night only, the child is:

woken each hour with a minimal prompt, asked to void in the toilet, and praised for having kept the sheets dry.

On subsequent nights, scheduled waking involved waking the child 3 hours after sleep andencouraging him or her to void. For every dry night the waking time is brought forward bya half hour until it is timed to occur one hour after going to sleep.

Bollard & Nettelbeck found this procedure was 100% effective when combined with thealarm in 12 children (50).

Dry bed training

This was first described by Azrin et al. in 1974 (51) with high success rate. Adjustments havebeen made to make the procedure easier, but it is still considered a complex, time-consumingand demanding procedure (52-54).

The procedure incorporates (2):


9/21

the enuresis alarm positive practice (practice of waking) cleanliness training (encouraging the child to take responsibility for removing of wet

night clothes and sheets, re-making the bed and resetting the alarm) waking schedules - to improve arousability from sleep as described above and

involving:

For the first night, waking the child each hour, praising a dry bed, encouraging the child todecide at the toilet door whether he or she needed to void, and on returning to bed the childis encouraged to have a further drink. On the second night, the child is woken and taken tothe toilet 3 hours after going to sleep. For each dry night the waking time is brought forwardby 30 minutes. If wet on any night the waking time stays at the time of the previous evening.The waking schedule was discontinued when the waking time reached 30 minutes followingthe child going to sleep. The waking schedule is resumed if the child begins wetting twice ormore in any week, stating again 3 hours after sleep.

social reinforcement and increased fluid intake.

Final message for nonpharmacological treatment

In a recent Cochrane review, 13 trials were assessed, involving 702 children of whom 387received a simple behavioral intervention. In single small trials, reward systems (e.g., starcharts), lifting and waking were each associated with significantly fewer wet nights, highercure rates and lower relapse rates compared to controls. There was not enough evidence toevaluate retention control training (bladder training). Cognitive therapy may have lowerfailure and relapse rates than star charts, but this finding was based on one small trial only.

This makes the evidence behind using these methods shaky. However, simple methods couldbe tried as first-line therapy before considering alarms or drugs, because these alternativetreatments may be more demanding and may have adverse effects (52).

The same group have reviewed 16 trials involving 1,081 children which included a complexor educational intervention for nocturnal enuresis. A complex intervention, such as dry bedtraining (DBT) or full-spectrum home training (FSHT) including an alarm, was better thanno-treatment control groups, but there was not enough evidence about the effects of complexinterventions alone if an alarm was not used. An alarm on its own was also better than DBTon its own, but there was some evidence that combining an alarm with DBT was better thanan alarm on its own, suggesting that DBT may augment the effect of an alarm. There wasalso some evidence that direct contact with a therapist might enhance the effects of anintervention (53).

C- Pharmacotherapy

Pharmacological treatment for nocturnal enuresis can have either a full, partial or noresponse. A full response has been defined as a reduction in wet nights of at least 90%, toallow for the occasional accidental wetting, partial response is defined as a reduction in wetnights of 50-90%; less than 50% reduction in wet nights is considered to be nonresponse (55,56).


10/21

A lasting cure is defined as a full response, still present 6 months or longer afterdiscontinuation of pharmacotherapy.

With a follow-up of at least 6 months, response can become a lasting cure (>90% reduction)or a lasting improvement (50-90% reduction).

This definition of full response means that a child could still be wet 2 or 3 times per month,and many would not regard this as a full response!

Desmopressin (dDAVP)

Desmopressin (dDAVP) is an analogue of vasopressin created by deaminating the cysteineresidue at position 1 and substituting D-arginine for L-arginine at position 8. These changesresult in significantly increased antidiuretic activity but loss of the vasopressor activity. Thehalf-life of dDAVP is 1.5-3.5 hours.

The normal circadian variation in urine production, with a nocturnal rise in vasopressin, isabsent in a significant proportion of patients with monosymptomatic nocturnal enuresis(MNE) (24).

When NE is a significant problem for the child and the child is older than 6 years, treatmentfor enuresis should be offered. Initial treatment will usually be the enuresis alarm ordesmopressin. Desmopressin is easy to administer and the clinical effects appearimmediately. The usual dose is 0.2-0.4 mg orally or 20 -40 g intranasally at bedtime. A smallgroup of children who do not respond to desmopressin in ordinary dosage will become drywhen the dose is doubled (57).

Desmopressin can also be helpful in children who have failed to respond to, or who havewithdrawn from alarm therapy, or for whom alarm therapy is unacceptable. Also, it is usefulwhen the child would like to attend an overnight school trip or stay at a friends house (28).

Placebo-controlled studies have shown that the antidiuretic drug dDAVP is significantlymore effective than placebo (58).

Patients on desmopressin were 4.6 times more likely to achieve 14 consecutive dry nightscompared with placebo (59). However, there was no difference after treatment was finished.

Kruse et al. found that the best results were obtained in older children who respond to 20 g.dDAVP and who do not wet frequently (60).

A better response to desmopressin has been found in children with larger bladder capacities(25).

Relapse after short-term treatment is rather the rule, whereas long-term treatment may yieldbetter cure rates (61). Intermittent therapy appears to decrease the number of relapses (62).

It has recently been shown that the chances of permanent cure may increase by adopting astructured withdrawal program. This implies a gradual discontinuation of the drug (over an

8-week period) and positive reinforcement of dry nights without medication. At week 10with complete cessation of medication, 75% of children remained dry (63).


11/21

Although several studies have shown that dDAVP is a well-tolerated and safe drug, evenduring long-term usage, one has to be aware that dDAVP is a potent antidiuretic drug andthat there have been reports on severe water retention with hyponatremia and convulsions,but these are infrequent (64-68).

Combined treatment with alarm and desmopressin

Combined treatment is superior to alarm alone especially for nonresponders of eachindividual treatment. Both treatments are started at the same time: the rapid action ofdDAVP is believed to facilitate the childs adaptation to the alarm. Leebeek reported atemporary, positive effect on enuresis using desmopressin combined with alarm therapy.However, both treatment modalities had a low long-term success rate of 36-37% (69, 70).Compared with either therapy alone, the combination has been found to be particularlyeffective in children with high wetting frequencies and behavioral problems.

Combination with full-spectrum therapy may even yield higher success rates (71, 72).

Van Kampen et al. reported their results of full-spectrum therapy in 60 patients: they weretreated for 6 months with a combination of alarm, bladder training, motivational therapy andpelvic floor muscle training: 52 patients became dry (71).

Antimuscarinic drugs

Antimuscarinic drugs are mainly used for patients with overactive bladder symptoms (OAB)which might lead to daytime incontinence. They might therefore be of use for the subset ofenuretic patients who have restricted bladder capacity due to detrusor overactivity at night,a pattern found at nocturnal cystometry in 30% or more of enuretic children (19). Because it

is difficult to perform a nighttime cystometry in children, antimuscarinic drugs may be usedin children who have more than 2 wetting episodes per night and who do not respond todDAVP. They could also be used in combination with alarm or dDAVP (73, 74).

Tricyclic antidepressants

The mechanism by which imipramine helps NE is not clear. The therapeutic effect does notappear to be mediated via its antidepressant effect; a suggested mechanism of action isreduced detrusor activity and increased bladder capacity due to anticholinergic and smoothmuscle relaxant effects and sympathomimetic or central noradrenergic mechanisms.

Due to major cardiotoxic side effects, even in therapeutic doses, and the possibility of deathwith overdose, they cannot be generally recommended for treatment of this nonlethaldisorder (75).

Only in selected cases (like adolescent boys with attention deficit hyperactivity disorder andpersistent nocturnal enuresis) should it be considered (76).

Other medications


12/21

Carbamazepine is chemically related to imipramine. It can reduce prostaglandin E2-likeactivity in inflammation. It has been recently tried in NE with 30-day treatment periods ofeither placebo or carbamazepine (200 mg) tablets, in a randomized, double-blind, crossoverdesign. There was 1 week washout period between medications. The patients or their parentsreceived a calendar sheet to record wet and dry nights and offered subjective opinions

concerning changes in sleep patterns, occurrence of nocturia and appearance of side effects.The difference in response to placebo and carbamazepine was statistically significant.Indomethacin had also been investigated (77-79). However, these are still pilot studies with asmall number of patients preventing their use from being recommended at present.

D- Refractory NE

About one third of children do not respond to treatment with alarm and/or dDAVP.

There is a role for anticholinergics especially if the child voids more frequently than his/herpeers or has urgency and daytime incontinence. Treatment success is usually noted between

1-2 months. Treatment should be continued for 6-12 months, but good clinical evidence islacking for efficacy.

On the other hand, some of these children may have functional incontinence. They should begiven a strict voiding regimen and a combination of dDAVP with the alarm (80).

If all the above do not work, then absorptive nocturnal hypercalciuria may be responsible forthe nocturnal enuresis in some of these patients. With an appropriate (low-calcium) dietthese patients became desmopressin responders (81).

Day and Night Incontinence

If the development process of bladder control is not completed, the child may have urinaryincontinence. This can be with no obvious cause (functional) but occasionally is secondary tocauses such as congenital or neurological.

Urinary incontinence in children may be due to disturbances of the filling phase, the voidingphase or a combination of both.

Those who have incontinence they usually have other symptoms such as frequency, urgencyand infection. The use of urodynamics investigations (82, 83) helped to classify those childreninto different categories:

Detrusor overactivity (during filling) Dysfunctional voiding (where there is urethral overactivity during voiding in the

absence of a neurological cause) Detrusor underactivity

Prevalence of Day and Night Incontinence


13/21

Most have looked at childrens incontinence as either diurnal or nocturnal, and less often atthe subcategories of daytime incontinence. This makes it difficult to have a representativepicture of the prevalence of the different types.

Overall, the prevalence varies from 1% to 10%, but in general for 6- to 7-year-old children,

the prevalence is somewhere between 2% and 4%, and rapidly decreases during thefollowing years (10-16 yrs): it is more common in girls than in boys (82-84).

This prevalence obviously depends on the criteria used to define incontinence. Sureshkumaret al. in a population based survey of over 2000 new entrant primary school children (age 4-6years) in Sydney, Australia, noted an overall prevalence of daytime wetting of 19.2% whenconsidering at least one daytime wetting episode in the prior 6 months, with a further 16.5%having experienced more than one wetting episode and only 0.7% experienced wetting on adaily basis (85).

Children with daytime or mixed wetting were found to suffer from urgency in 50.7% of the

cases, with 79.1% wetting themselves at least once in 10 days (15). Urgency as a symptomseems to peak at age 6-9 years and diminish towards puberty, with an assumed spontaneouscure rate for daytime wetting of about 14% per year (86, 87).

Swithinbank et al. have found a prevalence of day wetting of 12.5% in children age 10-11years, which decreases to 3.0% at age 15-16 years but this included "occasional" wetting (88).

Treatment of Day and Night Incontinence

Overactive bladder (OAB)

The treatment of OAB involves a multimodal approach. Behavioral modification is importantand in some children may be all that is necessary. Others will require the addition ofantimuscarinic medication. In some children, the addition of biofeedback is useful. It isimportant to treat other underlying and potentially complicating conditions such asconstipation and UTIs (2).

Dysfunctional voiding

Treatment is aimed at optimizing bladder emptying and inducing full relaxation of theurinary sphincter and pelvic floor, prior to and during voiding.

Strategies include pelvic floor muscle awareness and timing training, repeated sessions ofbiofeedback, visualization of pelvic floor activity and relaxation, clean intermittent self-catheterization for large post-void residual volumes of urine, and antimuscarinic drugtherapy if detrusor overactivity is present. If the bladder neck is implicated in increasedresistance to voiding, -blocker drugs may be introduced (89-91).

Recurrent urinary infections and constipation should be treated and prevented during thetreatment period.

A review of interventions for children with dysfunctional voiding revealed 17 studies; eightevaluating biofeedback or pelvic floor muscle awareness training, five reporting -blockade


14/21

pharmacotherapy, two relating to electrical stimulation and one each describing cleanintermittent catheterization and the use of anticholinergic medication. Only one study wasrandomized, none were controlled and five were retrospective.

As with overactive bladder, the natural history of untreated dysfunctional voiding is not well

delineated, and thus the optimum duration of therapy is not well described.

Detrusor underactivity (DUA)

Treatment is aimed at optimizing bladder emptying after each void. Clean intermittent (self-) catheterization is the procedure of choice to promote complete bladder emptying, incombination with treatment of infections and constipation (which may be extreme in thesepatients). Intravesical electrostimulation has been described, but at this time it is notrecommended as a routine procedure for children.

Giggle incontinence

Since the etiology of giggle incontinence is not known it is difficult to determine theappropriate form of treatment. Positive results have been reported with conditioningtraining, methylphenidate and imipramine (75, 92-94). Others have tried antimuscarinicagents and -sympathomimetics. There is no acceptable evidence that any form of treatmentis superior to no intervention.

Conclusion

Although some studies have been conducted on possible treatment for daytime incontinence,most lack proper randomization, long-term follow-up or good number of participants. Thiswas confirmed by the Cochrane review for the period between 1996 and 2001: the authorsidentified only five trials that compared two or more interventions using a randomizedcontrolled design (95). Of these five studies, four evaluated pharmacotherapy. Of the fourpharmacotherapy studies, two evaluated the use of terodiline, one evaluated the use ofimipramine and the remaining abstract the use of oxybutynin versus biofeedback (96-98).

The remaining study evaluated the use of alarm therapy for daytime incontinence (99).

Terodiline is no longer available due to its adverse effect profile, imipramine is not the first

choice for daytime incontinence due to its side effects, and alarm therapy is not felt to be auseful therapy for daytime incontinence. Therefore only one study in over 30 years was feltto be of high quality. This review highlights the need for properly designed studies to assessthe impact of the various forms of therapy on daytime incontinence.

The limited number of identified randomized controlled trials does not allow a reliableassessment of the benefits and harms of different methods of management in children.Further work is required in this difficult clinical area.

References


15/21

1. Yeung, C.K., Godley, M.L., Duffy, P.G., Ransley, P.G. Natural filling cystometry in infants andchildren. Br J Urol 1995, 75: 531-7.

2. Nijman, R.J., Butler, R.J., Van Gool, J.D., Yeung, C.K., Bower, W., Hjalmas, K. Conservativemanagement of urinary incontinence in childhood. In: Incontinence. P. Abrams, L. Cardozo, S.

Khoury, A. Wein (Eds.). 2002, 515-51.

3. Abrams, P., Cardozo, L., Fall, M. et al. The standardization of terminology of lower urinary tractfunction: report from the Standardization Sub-committee of the International Continence Society.Neurourol Urodyn 2002, 21: 167-78.

4. Forsythe, W.I., Butler, R.J. Fifty years of enuretic alarms. Arch Dis Child 1989, 64: 879-85.

5. Fergusson, D.M., Horwood, L.J., Shannon, F.T. Secondary enuresis in a birth cohort of NewZealand children. Paediatr Perinat Epidemiol 1990, 4: 53-63.

6. Jarvelin, M.R., Moilanen, I., Vikevainen-Tervonen, L., Huttunen, N.P. Life changes andprotective capacities in enuretic and non-enuretic children. J Child Psychol Psychiatry 1990, 31:763-74.

7. von, G.A., Hollmann, E., Eiberg, H., Benden, B., Rittig, S., Lehmkuhl, G. Clinical enuresisphenotypes in familial nocturnal enuresis. Scand J Urol Nephrol Suppl 1997, 183: 11-6.

8. Jarvelin, M.R., Moilanen, I., Kangas, P. et al.Aetiological and precipitating factors for childhoodenuresis. Acta Paediatr Scand 1991, 80: 361-9.

9. Van Gool, J.D., Nieuwenhuis, E., Ten, D.I., Messer, T.P., de Jong, T.P. Subtypes inmonosymptomatic nocturnal enuresis., I.I. Scand J Urol Nephrol Suppl 1999, 202: 8-11.

10. Shaffer, D. Enuresis. In: Child and Adolescent Psychiatry: Modern Approaches. M. Rutter,E. Tayloer, L. Hersov (Eds.). 1994.

11. Warzak, W.J. Psychosocial implications of nocturnal enuresis. Clin Pediatr (Phila) 1993, SpecNo: 38-40.

12. Verhulst, F.C., van der Lee, J.H., Akkerhuis, G.W., Sanders-Woudstra, J.A., Timmer, F.C.,Donkhorst, I.D. The prevalence of nocturnal enuresis: do DSM III criteria need to be changed? A brief

research report. J Child Psychol Psychiatry 1985, 26: 989-93.

13. Devlin, J.B. Prevalence and risk factors for childhood nocturnal enuresis. Ir Med J 1991, 84: 118-20.

14. Feehan, M., McGee, R., Stanton, W., Silva, P.A. A 6 year follow-up of childhood enuresis:prevalence in adolescence and consequences for mental health. J Paediatr Child Health 1990, 26: 75-9.

15. Jarvelin, M.R., Vikevainen-Tervonen, L., Moilanen, I., Huttunen, N.P. Enuresis in seven-year-old children. Acta Paediatr Scand 1988, 77: 148-53.


16/21

16. Butler, R.J., Brewin, C.R., Forsythe, W.I. Maternal attributions and tolerance for nocturnalenuresis. Behav Res Ther 1986, 24: 307-12.

17. Butler, R.J., Galsworthy, M.J., Rijsdijk, F., Plomin, R. Genetic and gender influences onnocturnal bladder control--a study of 2900 3-year-old twin pairs. Scand J Urol Nephrol 2001, 35:

177-83.

18. Bakwin, H. Enuresis in twins. Am J Dis Child 1971, 121: 222-5.

19. Yeung, C.K., Sit, F.K., To, L.K. et al. Reduction in nocturnal functional bladder capacity is acommon factor in the pathogenesis of refractory nocturnal enuresis. BJU Int 2002, 90: 302-7.

20. Forsythe, W.I., Redmond, A. Enuresis and spontaneous cure rate. Study of 1129 enuresis. ArchDis Child 1974, 49: 259-63.

21. Rona, R.J., Li, L., Chinn, S. Determinants of nocturnal enuresis in England and Scotland in the

90s.Dev Med Child Neurol 1997, 39: 677-81.

22. Foxman, B., Valdez, R.B., Brook, R.H. Childhood enuresis: prevalence, perceived impact, andprescribed treatments. Pediatrics 1986, 77: 482-7.

23. Lottmann, H. Enuresis treatment in France. Scand J Urol Nephrol Suppl 1999, 202: 66-9.

24. Neveus, T., LAckgren, G., Tuvemo, T., Hetta, J., Hjalmas, K., Stenberg, A. Enuresis--background and treatment. Scand J Urol Nephrol Suppl 2000: : 1-44.

25. Eller, D.A., Austin, P.F., Tanguay, S., Homsy, Y.L. Daytime functional bladder capacity as apredictor of response to desmopressin in monosymptomatic nocturnal enuresis. Eur Urol 1998, 33Suppl 3: 25-9.

26. Valenti, G., Laera, A., Pace, G. et al. Urinary aquaporin 2 and calciuria correlate with theseverity of enuresis in children. J Am Soc Nephrol 2000, 11: 1873-81.

27. Aceto, G., Penza, R., Coccioli, M.S. et al. Enuresis subtypes based on nocturnal hypercalciuria:a multicenter study. J Urol 2003, 170(4 Pt 2): 1670-3.

28. Hjalmas, K., Arnold, T., Bower, W. et al. Nocturnal enuresis: an international evidence based

management strategy. J Urol 2004, 171(6 Pt 2): 2545-61.

29. Butler, R.J., Robinson, J.C., Holland, P., Doherty-Williams, D. Investigating the three systemsapproach to complex childhood nocturnal enuresis--medical treatment interventions. Scand J UrolNephrol 2004, 38: 117-21.

30. Devlin, J.B., OCathain, C. Predicting treatment outcome in nocturnal enuresis. Arch Dis Child1990, 65: 1158-61.

31. Hunsballe, J., Rittig, S., Pedersen, E.B., Djurhuus, J.C. Fluid deprivation in enuresis--effect onurine output and plasma arginine vasopressin. Scand J Urol Nephrol Suppl 1999, 202: 50-1.


17/21

32. Bjorkstrom, G., Hellstrom, A.L., Andersson, S. Electro-acupuncture in the treatment ofchildren with monosymptomatic nocturnal enuresis. Scand J Urol Nephrol 2000, 34: 21-6.

33. Honjo, H., Kawauchi, A., Ukimura, O., Soh, J., Mizutani, Y., Miki, T. Treatment ofmonosymptomatic nocturnal enuresis by acupuncture: A preliminary study. Int J Urol 2002, 9: 672-

6.

34. Hu, J.Acupuncture treatment of enuresis. J Tradit Chin Med 2000, 20: 158-60.

35. Mantle, F. Hypnosis in the treatment of enuresis. Paediatr Nurs 1999, 11: 33-6.

36. Serel, T.A., Perk, H., Koyuncuoglu, H.R., Kosar, A., Celik, K., Deniz, N. Acupuncturetherapy in the management of persistent primary nocturnal enuresis--preliminary results. Scand JUrol Nephrol 2001, 35: 40-3.

37. Radmayr, C., Schlager, A., Studen, M., Bartsch, G. Prospective randomized trial using laser

acupuncture versus desmopressin in the treatment of nocturnal enuresis. Eur Urol 2001, 40: 201-5.

38. Heller, G., Langen, P.H., Steffens, J. [Laser acupuncture as third-line therapy for primarynocturnal enuresis. First results of a prospective study]. Urologe A 2004, 43: 803-6.

39. Glazener, C.M., Evans, J.H., Peto, R.E.Alarm interventions for nocturnal enuresis in children.Cochrane Database Syst Rev 2003: CD002911.

40. Forsythe, W.I., Butler, R.J. Fifty years of enuretic alarms. Arch Dis Child 1989, 64: 879-85.

41. Mellon, M.W., McGrath, M.L. Empirically supported treatments in pediatric psychology:nocturnal enuresis. J Pediatr Psychol 2000, 25: 193-214.

42. Houts, A.C., Berman, J.S., Abramson, H. Effectiveness of psychological and pharmacologicaltreatments for nocturnal enuresis. J Consult Clin Psychol 1994, 62: 737-45.

43. Butler, R.J., Robinson, J.C. Alarm treatment for childhood nocturnal enuresis: an investigationof within-treatment variables. Scand J Urol Nephrol 2002, 36: 268-72.

44. Woo, S.H., Park, K.H. Enuresis alarm treatment as a second line to pharmacotherapy in childrenwith monosymptomatic nocturnal enuresis. J Urol 2004, 171(6 Pt 2): 2615-7.

45. Oredsson, A.F., Jorgensen, T.M. Changes in nocturnal bladder capacity during treatment withthe bell and pad for monosymptomatic nocturnal enuresis. J Urol 1998, 160: 166-9.

46. Hvistendahl, G.M., Kamperis, K., Rawashdeh, Y.F., Rittig, S., Djurhuus, J.C. The effect ofalarm treatment on the functional bladder capacity in children with monosymptomatic nocturnalenuresis. J Urol 2004, 171(6 Pt 2): 2611-4.

47. Lukeman, D. Mainly children: childhood enuresis and encopresis. In: Promoting Continence.Getliffe, K., Dolman, M. (Eds.). 2003.

48. van, L.A., van Londen-Barentsen, M.W., van Son, M.J., Mulder, G.A. Arousal training forchildren suffering from nocturnal enuresis: a 2 1/2 year follow-up. Behav Res Ther 1993, 31: 613-5.


18/21

49. Harter, S. The effects of social reinforcement and task difficulty level on the pleasure derived bynormal and retarded children from cognitive challenge and mastery. J Exp Child Psychol 1977, 24:476-94.

50. Bollard, J., Nettelbeck, T. A component analysis of dry-bed training for treatment for bedwetting.

Behav Res Ther 1982, 20: 383-90.

51. Azrin, N.H., Sneed, T.J., Foxx, R.M. Dry-bed training: rapid elimination of childhood enuresis.Behav Res Ther 1974, 12: 147-56.

52. Glazener, C.M., Evans, J.H. Simple behavioral and physical interventions for nocturnal enuresisin children. Cochrane Database Syst Rev 2004, CD003637.

53. Glazener, C.M., Evans, J.H., Peto, R.E. Complex behavioral and educational interventions fornocturnal enuresis in children. Cochrane Database Syst Rev 2004, CD004668.

54. Pennesi, M., Pitter, M., Bordugo, A., Minisini, S., Peratoner, L. Behavioral therapy forprimary nocturnal enuresis. J Urol 2004, 171: 408-10.

55. Butler, R.J. Establishment of working definitions in nocturnal enuresis. Arch Dis Child 1991,66: 267-71.

56. Djurhuus, J.C., Norgaard, J.P., Hjalmas, K. What is an acceptable treatment outcome?Scand JUrol Nephrol Suppl 1997, 183: 75-7.

57. Neveus, T., LAckgren, G., Tuvemo, T., Olsson, U., Stenberg, A. Desmopressin resistantenuresis: pathogenetic and therapeutic considerations. J Urol 1999, 162: 2136-40.

58. Terho, P. Desmopressin in nocturnal enuresis. J Urol 1991, 145: 818-20.

59. Glazener, C.M., Evans, J.H. Desmopressin for nocturnal enuresis in children. CochraneDatabase Syst Rev 2002: CD002112.

60. Kruse, S., Hellstrom, A.L., Hanson, E., Hjalmas, K., Sillen, U. Treatment of primarymonosymptomatic nocturnal enuresis with desmopressin: predictive factors. BJU Int 2001, 88: 572-6.

61. Miller, K., Klauber, G.T. Desmopressin acetate in children with severe primary nocturnal

enuresis. Clin Ther 1990, 12: 357-66.

62. Akbal, C., Ekici, S., Erkan, I., Tekgul, S. Intermittent oral desmopressin therapy formonosymptomatic primary nocturnal enuresis. J Urol 2004, 171(6 Pt 2): 2603-6.

63. Butler, R.J., Holland, P., Robinson, J. Examination of the structured withdrawal program toprevent relapse of nocturnal enuresis. J Urol 2001, 166: 2463-6.

64. Tullus, K., Bergstrom, R., Fosdal, I., Winnergard, I., Hjalmas, K. Efficacy and safety duringlong-term treatment of primary monosymptomatic nocturnal enuresis with desmopressin. SwedishEnuresis Trial Group. Acta Paediatr 1999, 88: 1274-8.


19/21

65. Wolfish, N.M., Barkin, J., Gorodzinsky, F., Schwarz, R. The Canadian Enuresis Study andEvaluation--short- and long-term safety and efficacy of an oral desmopressin preparation . Scand JUrol Nephrol 2003, 37: 22-7.

66. Apakama, D.C., Bleetman, A. Hyponatraemic convulsion secondary to desmopressin treatment

for primary enuresis. J Accid Emerg Med 1999, 16: 229-30.

67. Lebl, J., Kolska, M., Zavacka, A., Eliasek, J., Gut, J., Biolek, J. Cerebral oedema in enureticchildren during low-dose desmopressin treatment: a preventable complication . Eur J Pediatr 2001,160: 159-62.

68. Gairi, A., Martin, E., Bosch, J., Goma, A. [Incorrect dosage in the use of inhaled desmopressinassociated with convulsions due to hypnatremia]. An Esp Pediatr 2000, 53: 385-6.

69. Bradbury, M.G., Meadow, S.R. Combined treatment with enuresis alarm and desmopressin fornocturnal enuresis. Acta Paediatr 1995, 84: 1014-8.

70. Leebeek-Groenewegen, A., Blom, J., Sukhai, R., Van Der, H.B. Efficacy of desmopressincombined with alarm therapy for monosymptomatic nocturnal enuresis. J Urol 2001, 166: 2456-8.

71. Van, K.M., Bogaert, G., Feys, H., Baert, L., De, R.I., De, W.W. High initial efficacy of full-spectrum therapy for nocturnal enuresis in children and adolescents. BJU Int 2002, 90: 84-7.

72. Van, K.M., Bogaert, G., Akinwuntan, E.A., Claessen, L., Van, P.H., De, W.W. Long-termefficacy and predictive factors of full spectrum therapy for nocturnal enuresis . J Urol 2004, 171(6 Pt2): 2599-602.

73. Tahmaz, L., Kibar, Y., Yildirim, I., Ceylan, S., Dayanc, M. Combination therapy of imipraminewith oxybutynin in children with enuresis nocturna. Urol Int 2000, 65: 135-9.

74. Kosar, A., Arikan, N., Dincel, C. Effectiveness of oxybutynin hydrochloride in the treatment ofenuresis nocturna--a clinical and urodynamic study. Scand J Urol Nephrol 1999, 33: 115-8.

75. Geller, B., Reising, D., Leonard, H.L., Riddle, M.A., Walsh, B.T. Critical review of tricyclicantidepressant use in children and adolescents. J Am Acad Child Adolesc Psychiatry 1999, 38:513-6.

76. Gepertz, S., Neveus, T. Imipramine for therapy resistant enuresis: a retrospective evaluation. JUrol 2004, 171(6 Pt 2): 2607-10.

77. Glazener, C.M., Evans, J.H., Peto, R.E. Drugs for nocturnal enuresis in children (other thandesmopressin and tricyclics). Cochrane Database Syst Rev 2003: CD002238.

78. Al-Waili, N.S. Carbamazepine to treat primary nocturnal enuresis: double-blind study. Eur JMed Res 2000, 5: 40-4.

79. Al-Waili, N.S. Increased urinary nitrite excretion in primary enuresis: effects of indomethacintreatment on urinary and serum osmolality and electrolytes, urinary volumes and nitrite excretion.

BJU Int 2002, 90: 294-301.


20/21

80. Kruse, S., Hellstrom, A.L., Hjalmas, K. Daytime bladder dysfunction in therapy-resistantnocturnal enuresis. A pilot study in urotherapy. Scand J Urol Nephrol 1999, 33: 49-52.

81. Pace, G., Aceto, G., Cormio, L. et al. Nocturnal enuresis can be caused by absorptivehypercalciuria. Scand J Urol Nephrol 1999, 33: 111-4.

82. Glazier, D.B., Murphy, D.P., Fleisher, M.H., Cummings, K.B., Barone, J.G. Evaluation of theutility of video-urodynamics in children with urinary tract infection and voiding dysfunction. Br JUrol 1997, 80: 806-8.

83. Weerasinghe, N., Malone, P.S. The value of videourodynamics in the investigation ofneurologically normal children who wet. Br J Urol 1993, 71: 539-42.

84. Kuh, D., Cardozo, L., Hardy, R. Urinary incontinence in middle aged women: childhoodenuresis and other lifetime risk factors in a British prospective cohort. J Epidemiol CommunityHealth 1999, 53: 453-8.

85. Sureshkumar, P., Craig, J.C., Roy, L.P., Knight, J.F. Daytime urinary incontinence in primaryschool children: a population-based survey. J Pediatr 2000, 137: 814-8.

86. Forsythe, W.I., Redmond, A. Enuresis and spontaneous cure rate. Study of 1129 enuretis . ArchDis Child 1974, 49: 259-63.

87. Himsl, K.K., Hurwitz, R.S. Pediatric urinary incontinence. Urol Clin North Am 1991, 18:283-93.

88. Swithinbank, L.V., Brookes, S.T., Shepherd, A.M., Abrams, P. The natural history of urinarysymptoms during adolescence. Br J Urol 1998, 81 Suppl 3: 90-3.

89. Austin, P.F., Homsy, Y.L., Masel, J.L., Cain, M.P., Casale, A.J., Rink, R.C. alpha-Adrenergicblockade in children with neuropathic and nonneuropathic voiding dysfunction. J Urol 1999, 162(3 Pt2): 1064-7.

90. Cain, M.P., Wu, S.D., Austin, P.F., Herndon, C.D., Rink, R.C. Alpha blocker therapy forchildren with dysfunctional voiding and urinary retention. J Urol 2003, 170(4 Pt 2): 1514-5.

91. Yang, S.S., Wang, C.C., Chen, Y.T. Effectiveness of alpha1-adrenergic blockers in boys with low

urinary flow rate and urinary incontinence. J Formos Med Assoc 2003, 102: 551-5.

92. Arena, M.G., Leggiadro, N., Arcudi, L. et al. "Enuresis risoria": evaluation and management.Funct Neurol 1987, 2: 579-82.

93. Sher, P.K., Reinberg, Y. Successful treatment of giggle incontinence with methylphenidate. JUrol 1996, 156(2 Pt 2): 656-8.

94. Chandra, M., Saharia, R., Shi, Q., Hill, V. Giggle incontinence in children: a manifestation ofdetrusor instability. J Urol 2002, 168: 2184-7.


21/21

95. Sureshkumar, P., Bower, W., Craig, J.C., Knight, J.F. Treatment of daytime urinaryincontinence in children: a systematic review of randomized controlled trials. J Urol 2003, 170: 196-200.

96. Hellstrom, A.L., Hjalmas, K., Jodal, U. Terodiline in the treatment of children with unstable

bladders. Br J Urol 1989, 63: 358-62.

97. Elmer, M., Norgaard, J.P., Djurhuus, J.C., Adolfsson, T. Terodiline in the treatment of diurnalenuresis in children. Scand J Prim Health Care 1988, 6: 119-24.

98. Meadow, R., Berg, I. Controlled trial of imipramine in diurnal enuresis. Arch Dis Child 1982,57: 714-6.

99. Halliday, S., Meadow, S.R., Berg, I. Successful management of daytime enuresis using alarmprocedures: a randomly controlled trial. Arch Dis Child 1987, 62: 132-7.

the management of urinary incontinence in children (1)

Documents