Nocturnal enuresis-theoretic background and practical guidelines

Tryggve Nevéus, Tryggve Nevéus

Abstract

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

References

    1. Nevéus T, Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W, Jørgensen TM, Rittig S, Vande Walle J, Yeung CK, Djurhuus JC. The standardization of terminology of lower urinary tract function in children and adolescents: report from the standardisation committee of the International Children's Continence Society (ICCS) J Urol. 2006;176:314–324. doi: 10.1016/S0022-5347(06)00305-3.
    1. Bower WF, Moore KH, Shepherd RB, Adams RD. The epidemiology of childhood enuresis in Australia. Br J Urol. 1996;78:602–606.
    1. Rittig S, Knudsen UB, Nørgaard JP, Pedersen EB, Djurhuus JC. Abnormal diurnal rhythm of plasma Vasopressin and urinary output in patients with enuresis. Am J Physiol. 1989;256:F664–F671.
    1. Rasmussen PV, Kirk J, Borup K, Nørgaard JP, Djurhuus JC. Enuresis nocturna can be provoked in normal healthy children by increasing the nocturnal urine output. Scand J Urol Nephrol. 1996;30:57–61. doi: 10.3109/00365599609182350.
    1. Hunsballe JM, Hansen TK, Rittig S, Nørgaard JP, Pedersen EB, Djurhuus JC. Polyuric and non-polyuric bedwetting—pathogenetic differences in nocturnal enuresis. Scand J Urol Nephrol. 1995;S173:77–79.
    1. Mattsson S, Lindström S. Diuresis and voiding pattern in healthy schoolchildren. Br J Urol. 1994;76:783–789.
    1. Fonseca EG, Bordallo AP, Garcia PK, Munhoz C, Silva CP. Lower urinary tract symptoms in enuretic and nonenuretic children. J Urol. 2009;182(4 Suppl):1978–1983. doi: 10.1016/j.juro.2009.04.083.
    1. Nevéus T, Tuvemo T, Läckgren G, Stenberg A. Bladder capacity and renal concentrating ability in enuresis—pathogenic implications. J Urol. 2001;165:2022–2025. doi: 10.1016/S0022-5347(05)66285-4.
    1. Yeung CK, Chiu HN, Sit FK. Bladder dysfunction in children with refractory monosymptomatic primary nocturnal enuresis. J Urol. 1999;162:1049–1055. doi: 10.1016/S0022-5347(01)68062-5.
    1. Page ME, Valentino RJ. Locus coeruleus activation by physiological challenges. Brain Res Bull. 1994;35:557–560. doi: 10.1016/0361-9230(94)90169-4.
    1. Nevéus T, Hetta J, Cnattingius S, Tuvemo T, Läckgren G, Olsson U, Stenberg A. Depth of sleep and sleep habits among enuretic and incontinent children. Acta Paediatr. 1999;88:748–752. doi: 10.1111/j.1651-2227.1999.tb00036.x.
    1. Wolfish NM, Pivik RT, Busby KA. Elevated sleep arousal thresholds in enuretic boys: clinical implications. Acta Paediatr. 1997;86:381–384. doi: 10.1111/j.1651-2227.1997.tb09027.x.
    1. Kayama Y, Koyama Y. Brainstem neural mechanisms of sleep and wakefulness. Eur Urol. 1998;33:12–15. doi: 10.1159/000052235.
    1. Holstege G, Griffiths D, Wall H, Dalm E. Anatomical and physiological observations on supraspinal control of bladder and urethral sphincter muscles in the cat. J Comp Neurol. 1986;250:449–461. doi: 10.1002/cne.902500404.
    1. Lightman SL, Todd K, Everitt BJ. Ascending noradrenergic projections from the brainstem: evidence for a major role in the regulation of blood pressure and Vasopressin secretion. Exp Brain Res. 1984;55:145–151. doi: 10.1007/BF00240508.
    1. Ornitz EM, Russell AT, Hanna GL, Gabikian P, Gehricke JG, Song D, Guthrie D. Prepulse inhibition of startle and the neurobiology of primary nocturnal enuresis. Biol Psychiatry. 1999;45:1455–1466. doi: 10.1016/S0006-3223(98)00205-4.
    1. Danysz W, Kostowski W, Hauptmann M. Evidence for the locus coeruleus involvement in desipramine action in animal models of depression. Pol J Pharmacol Pharm. 1985;37:855–864.
    1. Roche EF, Menon A, Gill D, Hoey H. Clinical presentation of type 1 diabetes. Pediatr Diab. 2005;6:75–78. doi: 10.1111/j.1399-543X.2005.00110.x.
    1. Yazbeck S, Schick E, O'Regan S. Relevance of constipation to enuresis, urinary tract infection and reflux. A review. Eur Urol. 1987;13:318–321.
    1. Umlauf MG, Chasens ER. Sleep disordered breathing and nocturnal polyuria: nocturia and enuresis. Sleep Med Rev. 2003;7:403–411. doi: 10.1053/smrv.2002.0273.
    1. Glazener CM, Evans JH (2002) Desmopressin for nocturnal enuresis. Cochrane Database Syst Rev:CD002112
    1. Schulz-Juergensen S, Rieger M, Schaefer J, Neusuess A, Eggert P. Effect of 1-desamino-8-d-arginine vasopressin on prepulse inhibition of startle supports a central etiology of primary monosymptomatic enuresis. J Pediatr. 2007;151:571–574. doi: 10.1016/j.jpeds.2007.05.024.
    1. Hjälmås K, Hanson E, Hellström A-L, Kruse S, Sillén U. Long-term treatment with desmopressin in children with primary monosymptomatic nocturnal enuresis: an open multicentre study. Swedish Enuresis Trial (SWEET) Group. Br J Urol. 1998;82:704–709.
    1. Robson WL, Nørgaard JP, Leung AK. Hyponatremia in patients with nocturnal enuresis treated with DDAVP. Eur J Pediatr. 1996;155:959–962. doi: 10.1007/BF02282887.
    1. Nevéus T, Eggert P, Evans J, Macedo A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. Evaluation and treatment of monosymptomatic enuresis - a standardisation document from the International Children's Continence Society (ICCS) J Urol. 2010;183:441–447. doi: 10.1016/j.juro.2009.10.043.
    1. Kruse S, Hellström A-L, Hjälmås K. Daytime bladder dysfunction in therapy-resistant nocturnal enuresis. A pilot study in urotherapy. Scand J Urol Nephrol. 1999;33:49–52. doi: 10.1080/003655999750016276.
    1. Robson LM, Leung AK. Urotherapy recommendations for bedwetting. J Natl Med Assoc. 2002;94:577–580.
    1. Harris LS, Purohit AP. Bladder training and enuresis: a controlled trial. Behav Res Ther. 1977;11:289–297.
    1. Nevéus T, Läckgren G, Stenberg A, Nørgaard JP. Anticholinergic treatment for nocturnal enuresis: current understanding and future expectations. Dialogues Pediatr Urol. 2005;26:9–11.
    1. Lovering JS, Tallett SE, McKendry BI. Oxybutynin efficacy in the treatment of primary enuresis. Pediatrics. 1988;82:104–106.
    1. Austin PF, Ferguson G, Yan Y, Campigotto MJ, Royer ME, Coplen DE. Combination therapy with desmopressin and an anticholinergic medication for nonresponders to desmopressin for monosymptomatic nocturnal enuresis: randomized, double-blind, placebo-controlled trial. Pediatrics. 2008;122:1027–1032. doi: 10.1542/peds.2007-3691.
    1. Gish P, Mosholder AD, Truffa M, Johann-Liang R. Spectrum of central anticholinergic adverse effects associated with oxybutynin: comparison of pediatric and adult cases. J Pediatr. 2009;155:432–434. doi: 10.1016/j.jpeds.2009.01.074.
    1. Oredsson AF, Jørgensen TM. Changes in nocturnal bladder capacity during treatment with the bell and pad for monosymptomatic nocturnal enuresis. J Urol. 1998;160:166–169. doi: 10.1016/S0022-5347(01)63082-9.
    1. Glazener CM, Evans JH. Alarm interventions for nocturnal enuresis in children (Cochrane Review). The Cochrane Library. Oxford: Update Software; 2007.
    1. Morgan RTT. Relapse and therapeutic response in the conditioning treatment of enuresis: a review of recent findings on intermittent reinforcement, overlearning and stimulus intensity. Behav Res Ther. 1978;16:273–279. doi: 10.1016/0005-7967(78)90025-6.
    1. Glazener CM, Evans JH. Tricyclic and related drugs for nocturnal enuresis in children. Cochrane Database Syst Rev. 2000;2000:CD002117.
    1. Gepertz S, Nevéus T. Imipramine for therapy resistant enuresis: a retrospective evaluation. J Urol. 2004;171:2607–2610. doi: 10.1097/01.ju.0000110613.51078.93.
    1. Varley CK. Sudden death of a child treated with imipramine. Case study. J Child Adolesc Psychopharmachol. 2000;10:321–325. doi: 10.1089/cap.2000.10.321.
    1. Seabrook JA, Gorodzinsky F, Freedman S. Treatment of primary nocturnal enuresis: a randomized clinical trial comparing hypnotherapy and alarm therapy. Paediatr Child Health. 2005;10:609–610.
    1. Glazener CM, Evans J, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev. 2005;18:CD005230.
    1. Glazener CM, Evans JH (2004) Simple behavioural and physical interventions for nocturnal enuresis in children. Cochrane Database Syst Rev:CD003637
    1. Hirasing RA, Leerdam FJ, Bolk-Bennink L, Janknegt RA. Enuresis nocturna in adults. Scand J Urol Nephrol. 1997;31:533–536. doi: 10.3109/00365599709030657.
    1. Yeung CK, Sihoe JD, Sit FK, Bower WF, Sreedhar B, Lau J. Characteristics of primary nocturnal enuresis in adults: an epidemiological study. BJU Int. 2004;93:341–345. doi: 10.1111/j.1464-410X.2003.04612.x.
    1. Yeung CK, Sreedhar B, Sihoe JD, Sit FK, Lau J. Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int. 2006;97:1069–1073. doi: 10.1111/j.1464-410X.2006.06074.x.
    1. Kuh D, Cardozo L, Hardy R. Urinary incontinence in middle aged women: childhood enuresis and other lifetime risk factors in a British prospective cohort. J Epidemiol Community Health. 1999;53:453–458. doi: 10.1136/jech.53.8.453.
    1. Coyne KS, Kaplan SA, Chapple CR, Sexton CC, Kopp ZS, Bush EN, Aiyer LP. Risk factors and comorbid conditions associated with lower urinary tract symptoms: EpiLUTS. BJU Int. 2009;103:24–32. doi: 10.1111/j.1464-410X.2009.08438.x.
    1. Hägglöf B, Andrén O, Bergström E, Marklund L, Wendelius M. Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scand J Urol Nephrol. 1997;31:79–82.
    1. Duel BP, Steinberg-Epstein R, Hill M, Lerner M. A survey of voiding dysfunction in children with attention deficit-hyperactivity disorder. J Urol. 2003;170:1521–1524. doi: 10.1097/01.ju.0000091219.46560.7b.
    1. Baeyens D, Roeyers H, Hoebeke P, Verte S, Hoecke E, Vande Walle J. Attention deficit/hyperactivity disorder in children with nocturnal enuresis. J Urol. 2004;171:2576–2579. doi: 10.1097/01.ju.0000108665.22072.b2.
    1. Elia J, Takeda T, Deberardinis R, Burke J, Accardo J, Ambrosini PJ, Blum NJ, Brown LW, Lantieri F, Berrettini W, Devoto M, Hakonarson H. Nocturnal enuresis: a suggestive endophenotype marker for a subgroup of inattentive attention-deficit/hyperactivity disorder. J Pediatr. 2009;155:239–244. doi: 10.1016/j.jpeds.2009.02.031.
    1. Gontard A, Mauer-Mucke K, Pluck J, Berner W, Lehmkuhl G. Clinical behavioral problems in day- and night-wetting children. Pediatr Nephrol. 1999;13:662–667. doi: 10.1007/s004670050677.
    1. Bijos A, Czerwionka-Szaflarska M, Mazur A, Romanczuk W. The usefulness of ultrasound examination of the bowel as a method of assessment of functional chronic constipation in children. Pediatr Radiol. 2008;37:1247–1252. doi: 10.1007/s00247-007-0659-y.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera