Educational article
Evaluation and treatment of nonmonosymptomatic nocturnal enuresis: A standardization document from the International Children's Continence Society

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Abstract

Purpose

This document represents the consensus guidelines recommended by the ICCS on how to evaluate and treat children with nonmonosymptomatic nocturnal enuresis (NMNE). The document is intended to be clinically useful in primary, secondary and tertiary care.

Materials and methods

Discussions were held by the board of the ICCS and a committee was appointed to draft this document. The document was then made available to the members of the society on the web site. The comments were vetted and amendments were made as necessary to the document.

Results

The main scope of the document is the treatment of NMNE with drugs other than desmopressin-based therapy. Guidelines on the assessment, and nonpharmacologic and pharmacologic management of children with NMNE are presented.

Conclusions

The text should be regarded as an expert statement, not a formal systematic review of evidence-based medicine. It so happens that the evidence behind much of what we do in the care of enuretic children is quite weak. We do, however, intend to present what evidence there is, and to give preference to this rather than to experience-based medicine, whenever possible.

Section snippets

Scope of the document

This document represents the guidelines recommended by the ICCS on how to evaluate and treat children with nonmonosymptomatic nocturnal enuresis (NMNE). NMNE throughout the text will be taken to mean “enuresis in children with any other lower urinary tract symptoms and with a history of bladder dysfunction”, in accordance with the updated ICCS terminology [1], which will be consistently adhered to. The document is intended to be clinically useful in primary, secondary and tertiary care. The

Background

It is well known that nocturnal enuresis is a common disorder among children. It has been documented that 15–30% of enuretic children can experience daytime incontinence [2], [3], [4], [5]. It is likely that many more children suffer from subtle issues regarding bladder emptying, voiding postponement, and urgency and frequency than are actually documented in these publications. We are not going to address the role of polyuria in this monograph since it is well covered in the prior document on

Enuresis

Enuresis means wetting in discrete portions while asleep in a child who has passed his or her fifth birthday. The word nocturnal may be added for extra clarity, but it should be emphasized that the previous definition of enuresis denoting “an urodynamically normal, complete emptying of the bladder” [12] (Nørgaard et al., 1998) is no longer valid, since this would require ambulatory cystometric investigations before being able to use the correct terminology. Thus, bedwetting is properly called

Prevalence

Enuresis is a common problem among children and adolescents. If a wetting frequency of more than one “wet night” per month is taken into account, the prevalence of nocturnal enuresis is above 10% among 6 year olds [14], around 5% among 10 year olds [15], [16], and 0.5–1% among teenagers and young adults [17]. The only epidemiological study analyzing children with NMNE is the British Alspac Study. Of 8242 7½-year-old children, 15.5% wet the bed in total and 2.6% had a frequency of 2 or more wet

Etiology

According to the ICCS definitions, NMNE consists of two different disorders: nocturnal enuresis and lower urinary tract dysfunction (LUTD) identical to those with daytime urinary incontinence (except daytime wetting does not occur). The main etiological factors in NE are: (1) polyuria, (2) an arousal disturbance during sleep and (3) lack of inhibition of the micturition reflex. These developmental disturbances are genetically based and can be modulated by environmental factors [20]. The

Comorbidity

Comorbidity is defined as the co-existence of two or more disorders at the same time or sequentially. Children with elimination disorders have increased rates of comorbid behavioral or psychological disorders according to standardized classification systems such as the ICD-10 and the DSM-IV. Of possible combined bowel and bladder dysfunction, children with fecal incontinence (formerly encopresis) have the highest rates of comorbid behavioral disorders: 30–50% of all children have clinically

Evaluation

Evaluation of the child with NMNE should follow the guidelines outlined in the documents prepared in for the treatment of monosymptomatic nocturnal enuresis and functional bladder problems [6], [24].

The first step in any diagnostic and therapeutic process is to create a good relationship with both the child and his/her parent(s). One should inquire and talk about all relevant facts and signs and symptoms openly.

Treatment

In NMNE, it is advisable to follow a sequence of steps.

  • 1.

    Treat any constipation (or fecal incontinence) first, as effective treatment of bowel problems can lead to spontaneous remission of daytime incontinence [25], [26].

  • 2.

    Treat the underlying LUTD symptoms first, as effective treatment of an overactive bladder (or postponement, dysfunctional voiding) can lead to cessation of nocturnal enuresis.

  • 3.

    If comorbid behavioral disorders are present, these often require specific additional treatments (such as

Urotherapy

Urotherapy is a comprehensive term defined as a “type of training which makes use of cortical control of the bladder, teaching children to recognize and employ conscious command over their lower urinary tract”. A major part of therapy for incontinence in children is non-pharmacological and nonsurgical. Its main ingredients are information about normal lower urinary tract function and the specific dysfunction in the child, instruction about what to do about it, and support and encouragement to

Alarm treatment

Alarm treatment for nocturnal enuresis is another type of CBT. It works in conjunction with positive reinforcement, as well as aversive, negative experiences, and has been shown to be highly effective after it was introduced by Mowrer and Mowrer in 1938.

It is the most effective form of treatment of nocturnal enuresis with the best long-term results (grade I level of evidence according to several reviews and meta-analyses). Houts et al. [34] compiled a systematic review and meta-analysis of 78

Non-desmopressin treatment of NMNE

The treatment of NMNE is a complex process that involves aggressive therapy for daytime issues prior to achieving success at nighttime. In this section we will discuss non-cognitive modalities to treat associated bladder problems in conjunction with enuresis. In some cases medications have been used for primary nocturnal enuresis as the initial treatment modality. In other cases some medications have never been used for nocturnal enuresis on a regular basis but are used commonly for the

Advanced urotherapy

Standard noninterventional urotherapy was discussed above, describing behavioral modification and cognitive therapy as ‘first-line’ or ‘basic’ urotherapy. Treatments other than pharmacological and behavioral ones, for lower urinary tract symptoms associated or not with nocturnal enuresis, are generally adopted when the former fails to provide a satisfactory result. Despite an adequate work-up a core of 20–40% of the children with LUTD (with or without NE) at long-term follow-up are resistant to

Conclusions

The management of the child with NMNE involves a two-pronged approach, which calls for the management and identification of the underlying daytime functional bladder problem and the subsequent treatment of the nocturnal enuresis. It is critical to treat the daytime issues first and in many cases it should not even be attempted to treat the nocturnal problems, since the failure rate is high and there is a likelihood that the patient and parents will become frustrated. It is imperative for the

Conflict of interest

Israel Franco is a paid consultant to Allergan, producer of botulinum toxin A. He is also a consultant to Astellas Pharmaceuticals, maker of solifenacin.

The other authors declare no conflict of interests.

Funding

None.

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