Richard J. Butler

The Three Systems: a Conceptual Way of Understanding Nocturnal Enuresis

Childhood nocturnal enuresis has traditionally been regarded as a multifaceted problem with a variety of treatment interventions. This paper proposes a model based on the notion that nocturnal enuresis arises through the ill functioning of one or more of the following three systems - a lack of vasopressin release during sleep; bladder instability; and/or an inability to arouse from sleep to bladder sensations. Clinical signs of each system are outlined and the appropriate treatment intervention for each is discussed. It is argued that addressing nocturnal enuresis in this way will enhance overall treatment effectiveness.

Nocturnal enuresis at 7.5 years old: prevalence and analysis of clinical signs

To determine the prevalence of nocturnal enuresis (NE) in a large cohort of children at 7.5 years old, and to examine the frequency of variables such as gender, severity, associated elimination problems, and clinical signs within the identified group.

The prevalence of infrequent bedwetting and nocturnal enuresis in childhood. A large British cohort.

Objective. 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. Material and methods. 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. Results. 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. Conclusions. 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.

Night wetting in children : Psychological aspects

von Gontards annotation (1998) on day- and night-wetting children takes a paediatric perspective on these prevalent and distressing conditions. This review addresses some of the major psychological issues relevant to nocturnal enuresis. Daytime wetting, which encapsulates a number of conditions each with separate aetiologies, distinct presentations, and specific treatment interventions, has been the focus of two recent reviews (Edens & Surwit, 1995; Robson, Leung, & Bloom, 1996) and will thus not be discussed in this annotation.

Impact of Nocturnal Enuresis on Children and Young People

An understanding of the psychological impact of nocturnal enuresis has been consistently hampered by inter-changeability of terminology, varied inclusion criteria, diverse methodologies and equivocal findings. This paper reviews the impact on children and young people by examining both qualitative and quantitative findings. Aspects of functioning that are explored include social adjustment, emotional state, personality, self- concept and behaviour. Generally the findings suggest children do experience bedwetting as distressing but those with mono-symptomatic nocturnal enuresis are no different from the normal population or from matched controls across all aspects of functioning. Those children most vulnerable to psychological distress as a consequence of bedwetting are identified. Interestingly there is consistent evidence for improvement in emotional functioning and self-esteem following treatment although this may not be necessarily due to the treatment itself. Methodological issues are addressed in terms of future research directions.

Enuresis alarm treatment

Objective. Treatment for childhood nocturnal enuresis emphasizes either a psychological or pharmacological approach. The enuresis alarm, in comparative studies, has emerged as the most effective psychological treatment. In this review we investigate both outcome rates and influential factors from recently published studies. Material and methods. A search of papers published between 1980 and 2002 in the English language involving at least 10 children in which the enuresis alarm was employed as a stand-alone intervention revealed 38 studies. Results. Heterogeneity in terms of inclusion and outcome parameters made comparison between studies problematic. The most frequently adopted definitions were “wet at least 3 times a week” in terms of severity at inclusion, “14 consecutive dry nights” as a success criterion and “> 1 wet night a week” as a relapse criterion. Success rates across all studies ranged from 30% to 87% and were influenced by the type of enuresis, the treatment duration and the success criteria adopted. In an homogenous subset of 20 studies, 65% success with alarm treatment was found. Further analysis revealed equivalence between different forms of alarm, pre- and within-treatment predictors of outcome and possible mode of action. Relapse rates (ranging between 4% and 55%) were reported in 20 studies, with an homogeneous subset indicating that 42% of children relapsed following alarm treatment. Conclusions. The enuresis alarm is an effective intervention for children with nocturnal enuresis. There are a number of factors, both pre- and within-treatment, that appear to influence its effectiveness and may assist clinical decisions concerning its appropriateness for any particular child.

Exploring potential mechanisms in alarm treatment for primary nocturnal enuresis

Objective. In the treatment of childhood nocturnal enuresis the enuresis alarm has consistently proved effective. However, the various proposals advanced to explain its therapeutic mechanism generally lack empirical support. In this clinical trial we investigated the hypothesis that the alarm promotes reduced nocturnal urine production through increased urine concentration (enabling the child to sleep through the night). Material and methods. Measurements of urinary vasopressin and osmolality were made pre- and post-alarm treatment in a group (n=12) of outpatient children (aged 7–12 years) with severe (more than four times a week) nocturnal enuresis. Results. Of the study group, 75% achieved the success criteria, with 89% predominantly sleeping through the night on dry nights, confirming that arousability is unlikely to be the principal mode of action. All those becoming dry showed an increase in urine concentration post-treatment. For half this was associated with an increase in post-treatment vasopressin whilst for the rest, although increases in osmolality were observed, there was no associated increase in vasopressin. Conclusions. Although based on a small sample this study offers an insight into possible therapeutic mechanisms of an enuresis alarm. It suggests that most children who become dry sleep through the night and that increased nocturnal urine concentration (and thus reduced urine volume) is likely to be the means whereby this is achieved. Furthermore, the study suggests two possible mechanisms whereby nocturnal urine concentration is achieved: either increased production of vasopressin or enhanced water transport across the urothelium.

EXAMINATION OF THE STRUCTURED WITHDRAWAL PROGRAM TO PREVENT RELAPSE OF NOCTURNAL ENURESIS

PURPOSE A variety of treatment options are available for children with nocturnal enuresis. The success of any intervention depends on if the child remains dry once the treatment is withdrawn. All interventions for children with nocturnal enuresis are vulnerable to some degree of relapse. Pharmacological interventions, involving either desmopressin or imipramine, seem particularly susceptible to relapse occurring rapidly once medication is withdrawn. The usual practice is to taper the dose gradually although this is time-consuming and of questionable effectiveness. An alternative approach is to use a time-limited structured withdrawal program, the success of which has been recently documented. We investigated the effectiveness of the structured withdrawal program to understand the variables related to success. MATERIALS AND METHODS A total of 51 patients 7 to 16 years old were included in the 8-week structured withdrawal program. Patients were 90% dry with medication taken for 4 to 24 months before the program and had experienced 2 unsuccessful withdrawal attempts. Patients were offered the choice of using an enuresis alarm on medication-free nights. Progress was monitored at 2, 5 and 8 weeks, and long-term success was defined as no relapse 6 months after cessation of treatment. RESULTS At weeks 9 and 10 with complete cessation of medication 74.5% of children remained dry, and success was not related to use of an enuresis alarm. CONCLUSIONS The structured withdrawal program significantly reduces relapse rates, and offers an alternative and rapid means of successfully withdrawing medication. It is argued that the influential variable concerns the ability of the child to shift attribution for success from an external source (that is medication) to an internal focus (that is changes in themselves).

A United Kingdom Population-Based Study of Intellectual Capacities in Children With and Without Soiling, Daytime Wetting, and Bed-wetting

OBJECTIVE. The objective of this study was to examine differences in intellectual capacities between children with and without soiling, daytime wetting, and bed-wetting. METHODS. This study was based on a population of >6000 children (age range: 7 years 6 months to 9 years 3 months; median: 7 years 6 months) from the United Kingdom–based Avon Longitudinal Study of Parents and Children. Data on wetting and soiling were obtained from a questionnaire completed by parents. The Wechsler Intelligence Scale for Children–Third Edition was administered at a research clinic. RESULTS. Bed-wetting was associated with lower Wechsler Intelligence Scale for Children–Third Edition IQ scores compared with control subjects, particularly performance IQ. This difference remained after exclusion of children with an IQ of <70 and adjustment for gender, stressful life events, and sociodemographic background. There were fewer differences in IQ scores between children with and without soiling or daytime wetting. Co-occurring wetting and soiling were associated with lower IQ scores than isolated soiling, daytime wetting, or bed-wetting, but this was mostly attributable to an overrepresentation of children with an IQ of <70 in the co-occurrence group. CONCLUSIONS. It is hypothesized that the differences in intellectual capacities between children with and without bed-wetting are associated with maturational deficits of the central nervous system. There was less evidence for differences in intellectual capacities between children with and without soiling and daytime wetting. The central nervous system is involved to a lesser extent in soiling and daytime wetting, because peripheral influences from the bladder and gut play a greater role.

Exploring the differences between mono- and polysymptomatic nocturnal enuresis

Objective. Recently the heterogeneity of nocturnal enuresis has been manifest in the distinction between mono- and polysymptomatic forms, based on the absence or presence of bladder overactivity, respectively. Although this classification has important clinical implications, there is a lack of empirical work relating to associated symptom expression and psychological functioning. The aim of this study was to identify variables associated with the two forms of nocturnal enuresis by means of a large population survey. Material and methods. From a cohort of 11 021 parents surveyed as part of the Avon Longitudinal Study of Parents and Children when their children were aged 7½ years, 8242 questionnaires were returned, with 7935 children meeting the inclusion criteria. Parents were invited to complete a questionnaire containing items relating to bedwetting, toileting behaviour, day-time wetting, bowel functioning and psychological variables. Results. A total of 194 children met the Diagnostic and Statistical Manual of Mental Disorders-IV definition of nocturnal enuresis, of whom 133 (68.5%) were classified as monosymptomatic and 61 (31.5%) as polysymptomatic. Those with the polysymptomatic form were significantly more likely to have multiple episodes of bedwetting, to show signs (such as fidgeting) of needing to urinate during the day, to need a reminder to toilet during the day and to have day-time wetting and soiling. Conclusions. The proportion of mono- to polysymptomatic nocturnal enuresis was 2:1. Children with the polysymptomatic form had a number of associated bladder and bowel problems. Clinically it is important to distinguish between the two types of nocturnal enuresis in order to identify the most appropriate treatment intervention.