By Will Boggs MD
NEW YORK (Reuters Health) - Enuresis alarms and desmopressin should remain the first treatment choices for nocturnal enuresis in children, according to an updated standardization document from the International Children's Continence Society.
"The enuresis alarm and desmopressin are still first-line choices. There has been no major breakthrough in enuresis treatment, i.e., no revolutionary new therapies," lead author Dr. Tryggve Neveus of Uppsala University, in Sweden, told Reuters Health by email.
Up to 10% of 7-year-olds experience enuresis, which, left untreated, can result in poor self-esteem, avoidance of social activities, and parental stress. Up to 1% of adults still wet their beds.
The new guidelines address the management and treatment of nocturnal enuresis, defined as bedwetting in a child aged 5 years or older, and update earlier guidelines from 2010 and 2012.
Initial evaluation should include a careful history; a physical examination focusing on general health and signs of occult spinal dysraphism; a voiding chart; and, if enuresis is secondary, if there are any daytime lower-urinary-tract symptoms, or if there are any relevant warning signs in the history, a urine dipstick.
Active treatment should begin by the age of 6 years, the authors report in the Journal of Pediatric Urology. Children who have daytime lower-urinary-tract symptoms in addition to their bedwetting should be instructed to establish a schedule of regular voiding, drink adequately, especially in the morning and at lunch, and adopt a good voiding posture with the thighs well supported.
"There is no evidence to support basic bladder advice (or urotherapy) as a first-line therapy in the child with monosymptomatic enuresis (this is a change from the previous document)," Dr. Neveus said. "This may be just a waste of time. If the child is old enough to be bothered by the enuresis, it should be actively treated with the alarm or desmopressin."
The enuresis alarm provides a strong arousal stimulus to the child and family when urine activates a detector located in the child's bed or clothing. This treatment is useful for frequent enuresis in a well-motivated child and family.
Enuresis alarms are less effective for children whose enuresis is infrequent or periodic and for children who wet the bed more than once per night, the authors write.
Desmopressin decreases nocturnal urine production to a level which can be accommodated within the bladder. Its efficacy (or lack thereof) will be evident immediately, so there is no justification for prolonging treatment beyond one or two weeks in a child who doesn't respond, according to the guidelines.
One of two strategies can be pursued for determining which treatment to use first. Desmopressin can be tried first in children who have nocturnal polyuria and normal daytime voided volumes, whereas enuresis alarms are reasonable choices for children whose nocturnal urine output is normal and maximum daytime voided volumes are low.
Combination therapy can be considered if both nocturnal polyuria and reduced maximum daytime voided volumes are present. A second strategy simply allows families to choose which therapy to use first after being informed about the pros and cons of both alternatives.
Regardless of strategy, if the first choice of therapy does not make the child dry, then the other alternative should be offered, and, if both fail as monotherapy, a combination of the two can be considered.
Children with enuresis who respond to neither treatment are best referred to a pediatrician or pediatric urologist, where they should undergo noninvasive urodynamic investigation with flowmetry and residual urine measurement.
Anticholinergics can be considered as second-line therapy in some children, and antidepressant therapy with imipramine can be used by specialists as a third-line alternative when other approaches have failed and/or are contraindicated.
"Although there is a substantial psychiatric comorbidity in enuretic children, the condition is almost never caused by psychiatric problems or 'immaturity' (there are still many healthcare providers stuck in the old Freudian notions)," Dr. Neveus said.
"The sleep of enuretic children is probably low-quality and may in itself impact the daytime functioning of the child," he said. "This is another reason to treat the disorder and not wait for it to remit spontaneously."
SOURCE: https://bit.ly/2GZz3Zc Journal of Pediatric Urology, online January 30, 2020.