WORKSHOP Nocturnal Enuresis

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WORKSHOPNocturnal Enuresis

• Dr Jonathan Evans
• Paediatric Nephrologist
• Nottingham

Prof Johan Vande Walle Paediatric
Nephrologist Ghent
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The Evidence
Evidence Based Medicine
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Randomised Controlled Trials

• NE
• Gets better over time
• Is variable week to week (usually start treatment
  when worst)
• Placebo effect
• Other treatments (fluid, bowels, charts etc)
• Therapist effect
• Only RCTs tell you if a given intervention is
  effective!

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Simple Behavioural Physical Interventions

• Star Charts with or without waking are better
  than no treatment (Grade B)
• Constipation management - may help if you are
  constipated (Grade D)
• No trials of restricting or increasing fluids
• Retention Control - insufficient evidence
• Conclusion
• remarkably little research on first line
  interventions
• star charts rewards alone (used properly) may
  be effective

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Enuresis alarms better than no treatment (Grade
A) - fewer wet nights during treatment - more
children get dry and stay dry
Alarm v Control wet on wet after
Abc Alarm Control Get Dry 68 1 Stay Dry
45 1
Odds Ratio - Wet
Odds Ratio ? 95 CI
13 studies n 552
5 studies n 162
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• Enuresis alarm overlearning is more effective
  than alarm alone (Grade B)
• Enuresis alarm dry bed training is more
  effective than alarm alone (Grade B/C)
• Insufficient evidence to support the use of
  enuresis alarm desmopressin over alarm alone
  (Grade B)
• More children get dry remain dry using alarm
  than desmopressin or imipramine (Grade B)

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Insufficient evidence to support the use of
enuresis alarm desmopressin over alarm alone
(Grade B)
Cochrane review wet on wet after
Gibb (n 207) wet on wet after
Odds Ratio - Wet
? dry nights per week DA v A
1 trial n 60
2 trials n 153
2 trials n 116
Gibb n 207
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• More children get dry remain dry using alarm
  than either desmopressin or imipramine (Grade B)

Desmopressin v Alarm wet on wet after
Imipramine v Alarm wet on wet after
Odds Ratio - Wet
3 studies n 243
1 study n 46
3 studies n 108
1 study n 24
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Adverse Prognostic Factors - Enuresis Alarm

• Definite (Grade B)
• psychosocial problems
• parent or child
• lack of concern in child
• infrequent wet nights
• multiple wettings / night
• Uncertain
• lack of arousability?
• nocturnal polyuria?
• bladder dysfunction?

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• Desmopressin, during treatment is better than no
  treatment (Grade A)
• less wet on treatment but limited evidence shows
  that benefit not sustained after withdrawal
• Nasal Oral desmopressin are probably equally
  effective (Grade C)
• Unclear data on dose - response curve
• Inconsistent trend in placebo controlled studies
• Is present in larger uncontrolled studies

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Desmopressin compared to placebo
20mcg
40mcg
60mcg
10 mcg
20 mcg
On treatment
After treatment
change in wet nights / week
11 trials n 813
6 trials n 424
2 trials n 164
2 trials n 54
1 trial n 22
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Desmopressin- good prognostic factors

• Definite
• older age
• normal / large bladder
• nocturnal polyuria
• wet early in night
• less frequent wetting
• Possible
• primary enuresis
• monosymptomatic
• Not known
• psycho-social factors

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Imipramine (Tricyclics)

• Imipramine, gives more dry nights during
  treatment than no treatment (Grade A)
• fewer wet on treatment but benefit not sustained
  (Grade A)
• Insufficient data on comparing with Desmopressin
  but crude data - similar improvement (Grade C)
• Fewer children get dry remain dry using
  imipramine than alarm (Grade B)
• Adverse effects are frequent and may be severe
• 17.3 per 100 children (8 studies, 480 children)
• neuropsychiatric 40, gastrointestinal 27, sleep
  disturbance 20
• fatal overdose, seizures arrythmias
  reported,incidence not known

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Anticholinergics

• Propanthiline is no better than placebo (Grade B)
• Insufficient evidence to conclude whether
  oxybutinin is better than placebo in PNE (without
  day wetting)
• 1 small RCTs did not show a difference to
  placebo
• 1 RCT concluded no difference but data inadequate
  to confirm this conclusion
• Oxybutinin may be beneficial in bedwetting
  children with detrusor overactivity(DO) (Grade
  D)
• Oxybutinin desmopressin may be better than
  oxybutinin alone in bedwetting children with DO

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Combination vs Desmopressin (vs Imipramine)
Desmopressin Oxybutinin

• Similar but more rapid response with
  combination in both MNE Non MNE

Non-monosymptomatic
monosymptomatic
Lee et al J Urol 2005
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Conclusions

• There are only a few treatments that work!
• Alarms are the only treatment with reliable
  evidence of persisting benefit
• Physiological assessments may refine your
  estimate of treatment success but by how much?
• A trial of medication may be the best predictor
  of response!
• Patient Carer choice is very important - if
  they dont want alarm it will not work!