Article

Assessment of Nocturnal Enuresis Management in Children in the Advanced Diagnostic Center in Khartoum State

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Abstract

Nocturnal enuresis is defined as nighttime bedwetting in children five years of age or older in the absence of neurological or structural problems affecting the bladder. A wide variety of interventions are used to treat nocturnal enuresis include simple behavioral intervention, enuresis alarm, and pharmacological treatment—the aim of the study to assess the management of nocturnal enuresis in children. A prospective cross-sectional study included 150 children attend the advanced diagnostic center. Data collected by direct interview questionnaire was tested –coded and analyzed by SPSS version 20 in tables and graph &excel. The result of this study showed that the highest treatment adopted was simple-cognitive behavioral therapy (87%), with the highest (94.7%) of patient surveyed adopted lifting and awaking technique,(38%) of patient surveyed have taken imipramine, (26%) of patient surveyed have taken 75mg dose of imipramine, (37%)of patients surveyed had a full response from imipramine therapy. The study showed that the first-line treatment that is needed is simple-cognitive behavioral therapy with instruction regarding diet and fluids, and it is very useful. The main drug was used in the treatment of nocturnal enuresis is imipramine with a dose of 75mg.

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Background: Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 20% of five-year olds and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis. Objectives: To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions. Search methods: We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi-randomised trials. The reference lists of relevant articles were also searched. Selection criteria: All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded. Data collection and analysis: Two review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author. Main results: A total of 40 randomised or quasi-randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials.For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights.Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects. Authors' conclusions: There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials.
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To investigate the efficacy of alarm treatment in a sample of Brazilian children and adolescents with nocturnal enuresis and relate treatment success to age and type of clinical support. During 32 weeks, 84 children and adolescents received alarm treatment together with weekly psychological support sessions for individual families or groups of 5 to 10 families. 71% of the participants achieved success, defined as 14 consecutive dry nights. The result was similar for children and adolescents and for individual or group support. The time until success was shorter for participants missing fewer support sessions. Alarm treatment was effective for the present sample, regardless of age or type of support. Missing a higher number of support sessions, which may reflect low motivation for treatment, increased the risk of failure.
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To develop and evaluate a parent-completed questionnaire for use by clinicians as part of routine care to assess the burden of diurnal and nocturnal enuresis on children and their families. The questionnaire consisted of items that measure the impact on the child and his/her parent, the child's coping ability and commitment to treatment, previous treatment success, family frustration and overall cohesion, and parental attitudes about enuresis and its treatment. Questionnaires (n = 208) were completed by parents during the child's scheduled office visit for enuresis at 5 specialty clinics across the United States. Traditional criteria were used to assess reliability and validity of the questionnaire, including analysis of variance. Success rates provide evidence that many of the items in the child scale (79%) and all items in the parent scale (100%) met stringent criteria. alpha values were.62 and.77, respectively. Statistically significant differences were observed for the scales across responses on all but 1 global item, the majority of parental attitude items, whether the child urinated at bedtime, and the number of pads used. These findings suggest that the child's coping ability and commitment and the family's overall cohesion and frustration with the problem influence parental perceptions about the impact of enuresis on the child and the family. Findings about the performance of the new measure were satisfactory and suggest that, after further refinement, it should prove as a useful tool for clinicians treating enuresis in children.
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To determine the differences or similarities in the clinical presentation between patients with primary and secondary nocturnal enuresis. A total of 170 patients with nocturnal enuresis were assessed at a busy tertiary care pediatric voiding dysfunction clinic at the University of Oklahoma Health Sciences Center. Patients with primary nocturnal enuresis (PNE) were compared with patients with secondary nocturnal enuresis (SNE) for a variety of clinical features, including gender, age when first voiding on their own, age on presentation, infrequent voiding, frequent voiding, urgency, daytime wetting, nocturia, urinary tract infection, constipation, vesicoureteral reflux, attention-deficit/hyperactivity disorder, uroflow results, and ultrasound evidence of a postvoid residual. The only significant difference between the patients with PNE and those with SNE was in the prevalence of constipation. Constipation was significantly associated with PNE (74.59% vs 57.54%; odds ratio: 2.17; 95% confidence interval: 1.07-4.41). When adjusted for a history of constipation, the age at which a child began to void on his or her own became statistically significant. Patients with SNE started to void on their own at 2.13 years (SD: 0.61), an average of 0.22 years earlier than those with PNE, who started to void on their own at 2.35 years. PNE and SNE likely share a common pathogenesis. Symptoms of daytime voiding dysfunction are common in patients with PNE and SNE. Daytime voiding habits might influence how the central nervous system responds at night to a full or contracting bladder.
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In a subgroup of children with enuresis an increase in nighttime water and solute excretion has been documented. To investigate if modifications in renal function are involved in nocturnal enuresis, we assessed circadian variation in natriuresis and tubular sodium handling in polyuric hypercalciuric children. A total of 10 children with proved hypercalciuria and nocturnal polyuria and 10 age matched controls were included in the study. A 24-hour urine collection was performed in 8 sampling periods for measurement of urinary sodium excretion. Segmental tubular sodium transport was investigated during a daytime oral water load test and calculated according to standardized clearance methodology. The children with enuresis showed a marked increase in the fractional excretion of sodium during the night (0.93% +/- 0.36%), while daytime sodium excretion was decreased (0.84% +/- 0.23%). Analysis of segmental tubular sodium transport revealed decreased delivery of sodium to distal tubule (C(H2O) + C(Na) = 10.7 ml/100 ml glomerular filtration rate), indicating increased proximal tubular sodium reabsorption but also stimulation of distal sodium reabsorption as demonstrated by increased fractional distal sodium reabsorption (92.9% +/- 2.2%, controls 90.5% +/- 2.9%). Increased distal reabsorption was associated with increased fractional potassium excretion (17.5% +/- 2.7%, controls 13.6% +/- 6.4%), indicating increased distal tubular sodium/potassium exchange. No intrinsic defect in renal tubular sodium transport was found, but during the day increased sodium reabsorption in proximal and distal tubules was observed, suggesting extrarenal factors to be involved in altered circadian variation in solute and water excretion by the kidney.
Article
This population-based study investigated the psychological problems associated with daytime wetting in children. A sample of 8213 children (age range: 7 years 6 months to 9 years 3 months) who were enrolled in the population-based Avon Longitudinal Study of Parents and Children participated in this study. Parents completed a postal questionnaire asking about their children's toileting behavior and assessing psychological problems, including childhood emotional and behavioral problems (99% completed the questionnaire by the time their child was 8 years 3 months of age). The rate of psychological problems was compared in children with daytime wetting and in those with no daytime wetting. Analyses adjusted for developmental delay, gender, sociodemographic background, stressful life events, and soiling. Chi2 tests of association and multivariable logistic regression indicate that children with daytime wetting have a higher rate of parent-reported psychological problems than children who have no daytime wetting. It is particularly notable that the reported rates of attention and activity problems, oppositional behavior, and conduct problems in daytime wetting children were around twice the rates reported in children with no daytime wetting. The increased vulnerability to psychological problems in children as young as 7 years of age with daytime wetting highlights the importance of parents seeking early intervention for the condition to help prevent later psychological problems. Although treatment in a pediatric setting is often successful, clinicians should be aware of the increased risk of disorders, such as attention-deficit/hyperactivity disorder, in children with daytime wetting, because this is likely to interfere with treatment.
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Daytime wetting is a common problem with various causes that can usually be identified through a careful history, thorough physical examination, and urinalysis. Conservative approaches to therapy have a successful outcome in most children. Invasive diagnostic imaging studies and pharmacologic or surgical intervention are necessary only for carefully selected children.
Article
Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. To assess the effects of tricyclic and related drugs on nocturnal enuresis in children, and to compare them with other interventions. We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles including two previously published versions of this review. Date of the most recent searches: December 2002. All randomised and quasi-randomised trials of tricyclics or related drugs for nocturnal enuresis in children were included in the review. Comparison interventions included placebo, other drugs, alarms, behavioural methods or complementary/miscellaneous interventions. Trials focused solely on daytime wetting were excluded. Two reviewers independently assessed the quality of the eligible trials, and extracted data. Fifty four randomised trials met the inclusion criteria, involving 3379 children. The quality of many of the trials was poor. Most comparisons or outcomes were addressed only by single trials. Treatment with most tricyclic drugs (such as imipramine, amitriptyline, viloxazine, nortriptyline, clomipramine and desipramine) was associated with a reduction of about one wet night per week while on treatment (eg imipramine compared with placebo, weighted mean difference (WMD) -1.19, 95% CI -1.56 to -0.82). The exception was mianserin, where results from one small trial did not reach statistical significance. About a fifth of the children became dry while on treatment (relative risk for failure (RR) 0.77, 95% CI 0.72 to 0.83), but this effect was not sustained after treatment stopped (eg imipramine versus placebo, RR 0.98, 95% CI 0.95 to 1.03). There was not enough information to assess the relative performance of one tricyclic against another, except that imipramine was better than mianserin. The evidence comparing desmopressin with tricyclics was unreliable or conflicting, but in one small trial all the children failed or relapsed after stopping active treatment with either drug.The evidence comparing tricyclics with alarms was also unreliable or conflicting during treatment. In one small trial all the children failed or relapsed after tricyclics stopped, compared with about half after alarms. This result was compatible with the results in the Cochrane review of alarm treatment, which found that about half the children remained dry after alarm treatment was finished. There was a little evidence from single trials to suggest that imipramine might be better than a simple reward system with star charts during treatment; worse than a complex intervention involving education, counseling, waking and retention control training; better than a restricted diet; and worse than hypnosis. However, these results need to be confirmed by further research. Although tricyclics and desmopressin are effective in reducing the number of wet nights while taking the drugs, most children relapse after stopping active treatment. In contrast, only half the children relapse after alarm treatment. Parents should be warned of the potentially serious adverse effects of tricyclic overdose when choosing treatment. Further research is needed into comparisons between drug and behavioural or complementary treatments, and should include relapse rates after treatment is finished.
Article
Although epidemiological surveys generally indicate declining rates of bedwetting with age, recent studies show that children with severe nocturnal enuresis have lower prevalence rates, which persist into adolescence. This study reports prevalence rates of both infrequent bedwetting (IB) and nocturnal enuresis (NE) at five time points during childhood with a large cohort of children. The Avon Longitudinal Study of Parents and Children provided a cohort of 13,973 singleton/twin infants alive at 12 months. These were followed up at 54, 65, 78, 91 and 115 months with a questionnaire relating to frequency of bedwetting and other variables. The prevalences of IB and NE were derived from these measures with missing data imputation being used to correct for possible loss-to-follow-up bias. The overall prevalence rate of bedwetting declined from 30% (54 months) to 9.5% (115 months), being most pronounced between 54 and 65 months. Children with NE (wet at least twice a week) had lower prevalence rates at all ages but were more likely to persist with the problem over time and to have the non-monosymptomatic type of bedwetting compared to children with IB. Children with the severest form of bedwetting are likely to persist with the problem and to have the more complex form (non-monosymptomatic). The results are discussed in relation to the clinical importance of early identification.
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