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Simple behavioural interventions for nocturnal enuresis in children

  1. Patrina HY Caldwell1,*,
  2. Gail Nankivell2,
  3. Premala Sureshkumar3

Editorial Group: Cochrane Incontinence Group

Published Online: 19 JUL 2013

Assessed as up-to-date: 15 DEC 2011

DOI: 10.1002/14651858.CD003637.pub3

How to Cite

Caldwell PHY, Nankivell G, Sureshkumar P. Simple behavioural interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003637. DOI: 10.1002/14651858.CD003637.pub3.

Author Information

  1. 1

    The Children's Hospital at Westmead Clinical School, University of Sydney, Discipline of Paediatrics and Child Health, Westmead, Australia

  2. 2

    The Children's Hospital at Westmead, Physiotherapy, Westmead, NSW, Australia

  3. 3

    Royal Alexandra Hospital for Children, Centre for Kidney Research, Parramatta, New South Wales, Australia

*Patrina HY Caldwell, Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead Clinical School, University of Sydney, Locked Bag 4001, Westmead, NSW, Australia. Patrinac@chw.edu.au.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 19 JUL 2013

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Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

This is one of seven reviews of interventions for bedwetting or nocturnal enuresis. The others focus on: desmopressin (Glazener 2004a), tricyclics and related drugs (Glazener 2004b), other drugs (Deshpande 2012), alarms (Glazener 2004d), complex behavioural and educational interventions (Glazener 2004e) and complementary and miscellaneous therapy (Huang 2011). This review is an update of previous updates by Glazener (Glazener 2002; Glazener 2004f) based on the original review by Lister-Sharp and her colleagues at the NHS Centre for Reviews and Dissemination at the University of York, UK (Lister-Sharp 1997).

With the promotion by the International Children's Continence Society (ICCS) of using standardised nomenclature in paediatric continence research (Neveus 2006) and the improved understanding about the pathophysiology of nocturnal enuresis, there has been an emphasis on classifying enuresis as either monosymptomatic or non-monosymptomatic. The ICCS has also defined initial and long term treatment success. Unfortunately, the older studies have usually not used these definitions (or were unclear about their definition of initial success). There were no studies that included a two-year follow-up; therefore, long term success could not be assessed.

 

Description of the condition

Nocturnal enuresis is the intermittent involuntary loss of urine at night, in the absence of physical disease, at an age when a child could reasonably be expected to be dry (by consensus, at a developmental age of five years) (APA 1980; Neveus 2006; WHO 1992). Nocturnal enuresis has a significant negative impact on the child's psychosocial well-being (Hagglof 1998; Von Gontard 2011a). Children with nocturnal enuresis usually do not have daytime bladder symptoms and are deemed to have monosymptomatic nocturnal enuresis (Neveus 2006). Between 10% to 28% of children who wet during sleep at night also have bladder problems during the day (including daytime wetting) (Forsythe 1974).These children are said to have non-monosymptomatic nocturnal enuresis (Neveus 2006). A total of 6.6% of children have combined daytime urinary incontinence and nocturnal enuresis (Sureshkumar 2009).

Although daytime urinary incontinence is a significant problem it is usually considered separately to nocturnal enuresis, as the aetiologies underlying the two conditions are thought to be different (Neveus 2006). Physical causes such as structural abnormalities and functional disorders of the urinary tract, including overactive bladder syndrome or urinary tract infections, are more often found in children who also have daytime wetting (Jarvelin 1990). If daytime symptoms are present, investigations to identify physical (organic) causes such as urinary tract dysfunction, congenital malformation and neurogenic disorders are usually necessary (Djurhuus 1992), with treatment initially focused on addressing the daytime urinary symptoms (Hjalmas 2004; Neveus 2006). Daytime urinary incontinence is considered in a separate review (Sureshkumar 2003).

 

Prevalences and causes

Nocturnal enuresis is common in children. Estimating its prevalence is difficult because there is variation in diagnostic criteria with very few studies using ICCS (International Children's Continence Society) definitions (De Jonge 1973; Krantz 1994; Neveus 2006). The generally quoted prevalence rates are 15% to 20% of five year olds, 7% of seven year olds, 5% of ten year olds, 2% to 3% of teenagers and 0.5% to 2% of adults, with a spontaneous remission rate of 14% until adolescence (Blackwell 1989; Bower 1996; Forsythe 1974; Hirasing 1997; Rutter 1973; Yeung 2004). The prevalence of nocturnal enuresis is higher amongst children in residential care (Morgan 1970).

Butler proposed the conceptual model that nocturnal enuresis occurs when there is poor arousal from sleep in response to a sensation of a full bladder with overactivity of bladder function or excessive overnight urine production, or both (Butler 2000). There are also many known risk factors for nocturnal enuresis including:

It is thought that these risk factors impact on sleep arousal, bladder function and overnight urine production.

 

Description of the intervention

Interventions used for treating nocturnal enuresis include pharmacological, behavioural (including alarm training), complementary and miscellaneous interventions. All of the following interventions are reviewed separately: alarms (Glazener 2004d), other complex behavioural and educational interventions (which require greater effort by the child and parents to achieve) such as dry bed training and full spectrum home training (Glazener 2004e), complementary and miscellaneous interventions such as acupuncture, homeopathy, chiropractic, spinal manipulation, functional magnetic stimulation, hypnosis and psychological therapies such as counselling and psychotherapy (Huang 2011), and pharmacological interventions such as desmopressin (Glazener 2004a), tricyclics and related drugs (Glazener 2004b) and drugs other than desmopressin and tricyclics (Glazener 2004c). Studies which compare more than one type of intervention are included in the reviews of each included intervention.

The current review is restricted to simple behavioural interventions which can be used by the child without great effort. These include fluid restriction, lifting, wakening, reward systems (e.g. star charts) and bladder training (e.g. retention control training). Other interventions were included only in this review if they were compared with simple interventions or used in combination with them.

 

How the intervention might work

 

1. Simple behavioural interventions

Behavioural interventions assume that the ability to remain dry at night is a learned response which can be achieved using psychological conditioning techniques if dryness has not arisen spontaneously. These include fluid restriction, lifting, wakening, reward systems (e.g. star charts) and bladder training (including retention control training).

 

Fluid restriction

Fluid restriction (deprivation) before bedtime is a method frequently used by parents (Shaffer 1977). Fluid restriction reduces the total overnight urine production which reduces the child's need to void overnight. However, fluid restriction (particularly during the day) may reduce the bladder volume (Sorotzkin 1984) and hence increase the chance of enuresis by reducing the ratio of bladder volume to overnight urine production. Even so, it might be useful to limit pre-bedtime fluid intake, particularly drinks with diuretic properties (Novello 1987).

 

Lifting

In 'lifting', carers pick up the child, while still asleep, from the bed to allow them to urinate in an appropriate place, reducing the likelihood of urinating in the bed. Usually lifting is done without a password. It has been argued that this practice is counterproductive as the child is encouraged to urinate without waking and is denied the opportunity to learn to recognise the sensation of a full bladder which may trigger arousal (Butler 1994). On the other hand, some suggest that lifting is effective, precluding the need for professional help (Shaffer 1977).

 

Scheduled wakening

Scheduled wakening involves waking the child to urinate during the night (Warzak 1994), reducing the likelihood of urinating during sleep. A scheduled waking programme may be used with the child being woken progressively earlier after dry nights until the interval between going to bed and scheduled waking is one hour. Older individuals may use an alarm clock (Blackwell 1989), mobile phones or other forms of alarms to wake themselves. Lifting with a password is another form of waking where the child is woken 1.5 to 2 hours after falling asleep and asked a password to check whether they are awake before being taken to the toilet.

 

Star charts and other reward systems

Star charts and other reward systems are behavioural interventions which use positive reinforcement to encourage a desired behaviour. The child is rewarded for attaining a goal, such as remaining dry all night or getting up to go to the toilet. These schemes should be negotiated with the child and family. The aim is to positively reinforce dry nights and to reduce the negative emphasis on wet beds. These are often the first type of treatments proposed (Stewart 1975). However, rewards for dry nights may be problematic because children may feel a failure if they try but cannot attain the goal despite trying their best (Blackwell 1989).

 

Bladder training and retention control training

Retention control training (a form of bladder training) aims to increase the bladder capacity by using exercises such as delaying urination for extended periods of time during the day or drinking extra fluids (Warzak 1994). Stream interruption exercises (pelvic floor muscle training, sphincter control exercises) are other forms of bladder training that are sometimes tried (Novello 1987).

 

2. Other behavioural interventions (only included in this review if used in comparison arms)

 

Enuresis alarms

Enuresis alarms consist of an alarm system which is triggered by micturition (Glazener 2004d). The first enuresis alarms were bed-based with the child sleeping on a pad or mat containing an electrical circuit. Urine coming into contact with the mat would cause an alarm to sound. The alarm is intended to train the child to recognise the sensation of having a full bladder and to either inhibit urination or waken to void (Forsythe 1989). There are now many different types of enuresis alarms, including body worn alarms with sensors placed in the child's underwear. Alarms are now either wired or wireless and stimuli range from noises (buzzer, various sounds, voice) to vibration and light.

 

Over-learning with alarm training

Over-learning is a reinforcement procedure which may be initiated after successful alarm treatment (e.g. after achievement of 14 consecutive dry nights). Extra drinks are given at bedtime to ensure that the bladder is full overnight causing the child to learn to wake to void. Alarm treatment is then continued until 14 consecutive dry nights are again achieved (Blackwell 1989; Young 1972).

 

Complex behavioural and educational interventions

Complex behavioural interventions include combinations of interventions and usually require greater effort by the child and parents or carers to achieve. These include Dry Bed Training and Full Spectrum Home Training (Glazener 2004e; Howe 1992).

 

Dry Bed Training

Dry Bed Training was initially developed in the early 1970s for use with people with learning disabilities (Azrin 1973). It aims to condition the child to wake to void. The original schedule involved an intensive training night, during which the person was woken every hour and taken to the toilet. If an accident occurred, 45 minutes of 'cleanliness training' (changing the bed) and 'positive practice' (practices of getting up and going to the toilet about nine times) was implemented. On subsequent nights, the individual was woken once and taken to the toilet, this nightly wakening occurring progressively earlier. Variants such as Modified Dry Bed Training forego the reprimands and positive practice elements (Butler 1988).

 

Full Spectrum Home Training

Full Spectrum Home Training (Houts 1983) combines enuresis alarm training, cleanliness training, retention control training and over-learning procedures.

 

3. Other managements for enuresis (only included in this review if used in comparison arms)

 

Psychotherapy

Since psychotherapists consider enuresis to be a symptom rather than a condition in itself, the emphasis of treatment is on the "child's inner emotional disturbance" (Mishne 1993). Consequently, the intervention is aimed at addressing underlying psychological causative factors and modifying the environment which produced the symptom (Mishne 1993). Psychotherapy may be used in the management of children who have psychological problems in addition to enuresis, to address problems directly related to psychopathology (Warzak 1994).

 

4. Drugs

Pharmacological interventions are used to reduce nocturnal enuresis by reducing overnight urine production (e.g. desmopressin), reducing bladder overactivity (e.g. oxybutynin) or by other mechanisms. Placebo drugs have been used to compare with other interventions to test their effectiveness. Drugs that have been compared with simple behavioural interventions include desmopressin (Glazener 2004a), tricyclic drugs (amitriptyline or imipramine) (Glazener 2004b), drugs other than desmopressin and tricyclics (e.g. oxybutynin) (Glazener 2004c) and placebo.

 

Why it is important to do this review

Nocturnal enuresis is common in children. Although nocturnal enuresis in itself is pathologically benign, it is socially and emotionally stigmatising and can affect the self esteem, peer relationships and educational opportunities of sufferers. It can be inconvenient and distressing to both the child and their family (Fitzwater 1992; Morison 1998; Redsell 2001; Theunis 2002; Warzak 1993). Although many different interventions have been tried for treating nocturnal enuresis, the relative effectiveness of each remains uncertain. Simple behavioural interventions are often the first interventions tried by parents or carers at home with minimal professional involvement. Therefore, it is important to identify effective interventions because successful treatment of nocturnal enuresis can result in improvement in health, self esteem and quality of life (Hagglof 1998).

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

To determine the effects of simple behavioural interventions in children with nocturnal enuresis.

The following comparisons were made:
1. simple behavioural interventions versus no active treatment;
2. any single type of simple behavioural intervention versus another behavioural method (another simple behavioural intervention, enuresis alarm therapy or complex behavioural interventions);
3. simple behavioural interventions versus drug treatment alone (including placebo drugs) or drug treatment in combination with other interventions.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Randomised or quasi-randomised trials of simple behavioural interventions compared with an appropriate comparison group for the treatment of nocturnal enuresis in children.

 

Types of participants

Children (as defined by the trialists, usually up to age 16) with nocturnal enuresis.

 

Types of interventions

Any trial which used a simple behavioural intervention in at least one arm of the study for treating nocturnal enuresis.

Comparisons were made with no active treatment, other behavioural interventions and drugs, either alone or in combination.

 

Types of outcome measures

 

Primary outcomes

  • mean number of wet nights per week at the end of treatment;
  • number of children failing to attain 14 consecutive dry nights by the end of treatment.

 

Secondary outcomes

  • mean number of wet nights per week at follow-up after treatment was stopped;
  • number of children failing to attain 14 consecutive dry nights during treatment or relapsing at follow-up after treatment was stopped, or both;
  • adverse events.

 

Search methods for identification of studies

We did not impose any language or other limits on the searches.

 

Electronic searches

This review has drawn on the search strategy developed for the Incontinence Review Group. Relevant trials were identified from the Group's Specialised Register of controlled trials which is described, along with the group search strategy, under the Incontinence Group's module in The Cochrane Library. The register contains trials identified from MEDLINE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL) and handsearching of journals and conference proceedings. The Incontinence Group Trials Register was searched using the Group's own keyword system. The search terms used were:
({design.cct*} OR {design.rct*})
AND
({topic.urine.enuresis*})
(All searches were of the keyword field of Reference Manager 12, Thomson Reuters).
Date of the most recent search of the register for this review: 15 December 2011.
Most of the trials in the Incontinence Group Specialised Register are also contained in CENTRAL.

 

Searching other resources

The reference list of a previous systematic review of enuresis treatments was searched (Lister-Sharp 1997). The reference lists of other relevant articles were also searched.

 

Data collection and analysis

The studies for this review were assessed using the methods described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

 

Selection of studies

The titles and where possible abstracts of all studies located by the searches were checked (PC,GN) to identify those likely to evaluate the effects of simple behavioural interventions for nocturnal enuresis. Full papers were then obtained and assessed to identify those which met the inclusion criteria. Studies were excluded if they were not randomised or quasi-randomised trials for children with nocturnal enuresis. Excluded studies are listed with reasons for their exclusion.

 

Data extraction and management

The data were extracted using a standard form. Included trial data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Where appropriate, the results were converted to the mean and standard deviation of the number of wet nights per week, or the number of children failing to achieve full response during treatment, defined as 14 consecutive dry nights at the end of the treatment period, or the number who did not achieve full response during treatment plus those who relapsed after stopping active treatment at follow-up (after completion of treatment). Where a mean value was reported with no standard deviation, we entered the data into 'Other Data Tables'.

 

Assessment of risk of bias in included studies

Standard risk of bias items according to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) were assessed for each study. These include:

  • adequate sequence generation;
  • allocation concealment;
  • blinding of study participants;
  • blinding of study personnel;
  • blinding of outcome assessors;
  • incomplete outcome data addressed;
  • free of selective reporting;
  • free of other bias (e.g. whether children who had daytime wetting or who had physical (organic) causes of their enuresis were specifically excluded, whether there were baseline differences between groups or whether there was a washout period in cross-over trials).

 

Measures of treatment effect

We intended, where possible, to calculate standardised effect sizes and 95% confidence intervals (CI): weighted mean differences (WMD) for pooled estimates or mean difference (MD) for comparing treatment effects where outcomes were continuous variables and risk ratios (RR) where they were dichotomous. A fixed-effect model was to be used for calculation of summary estimates and 95% CI. However, we could not perform pooled estimates due to insufficient trials for each intervention.

 

Unit of analysis issues

The unit of allocation was individual patients. Cross-over trials were only included if the design was evaluated to be appropriate for the question being investigated. Otherwise, data from the first arm of cross-over trials was to be used like parallel group data.

 

Dealing with missing data

When intention-to-treat analysis was not mentioned in the paper, or if some participants were not analysed in the group to which they were randomised, we looked for sufficient information to restore them to the correct group. If participants could not be analysed in their allocated groups, we documented it in the 'Risk of bias' table and in the 'Risk of bias' section of the text.

Where there were missing outcome data in the included studies, the primary analysis used the number of participants with available data as the denominator (that is 'available case' analysis). We also attempted to contact the authors regarding missing data. Standard deviations were obtained from standard errors, confidence intervals, t values or P values that related to the differences between means in two groups, according to the Cochrane Handbook for Systematic Reviews of Interventions Section 7.7.3.3

 

Assessment of heterogeneity

Differences between trials were further investigated if statistically significant heterogeneity was found at the 10% significance level using the Chi2 test or assessment of the I2 statistic to quantify the degree of heterogeneity (Higgins 2011). We also applied visual inspection of the results. A fixed-effect model was used if there was little or no heterogeneity and a random-effects model was used when there was statistically significant heterogeneity.

 

Assessment of reporting biases

We planned to investigate the possibility of publication bias and related biases if any meta-analyses were performed that involved 10 or more studies. However, this did not occur due to insufficient studies for meta-analyses.  

The methods that would be used for this are described below:

  1. if there are 10 or more studies in an analysis, a funnel plot is produced;
  2. we would perform a visual assessment of funnel plot asymmetry.

Statistical tests for funnel plot asymmetry are: for continuous outcomes using mean differences, the test proposed by Egger (Egger 1997); and for dichotomous outcomes using odds ratios or risk ratios, the tests proposed by either Harbord et al (Harbord 2006) or Peters et al (Peters 2006). 

If evidence for funnel plot asymmetry was found, exploratory analyses would then be performed to investigate the possible causes (see Handbook section 10.4.4).  These could include comparison of fixed-effect and random-effects estimates, comparison of treatment effects of small and large studies, or studies at low- and high-risk of bias, or investigation of the effects of methods to correct for publication bias. 

 

Data synthesis

Meta-analysis would have been performed according to the recommendations of theCochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) had there been a sufficient number of trials for each comparison. We planned to use a fixed-effect model. If there was substantial heterogeneity, assuming treatment effects differed between trials, we planned to use the random-effects model to produce an overall summary estimate.

 

Subgroup analysis and investigation of heterogeneity

If there was heterogeneity, we planned to investigate it using subgroup analysis restricted to primary outcomes and sensitivity analysis. However, subgroup analysis was unable to be performed in this review due to the limited number of trials. If there was evidence of statistical or clinical heterogeneity or other risk of bias, data could be analysed using random-effects and fixed-effect models.

 

Sensitivity analysis

Where appropriate, the possible effects of missing data could have been explored in a sensitivity analysis (e.g. assuming the 'worst' and 'best' case scenarios for all participants with missing outcome data).

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Description of studies

 

Results of the search

The flow of literature through the assessment process is shown in the PRISMA flowchart (Figure 1). The literature search produced a total of 451 abstracts and titles which were screened.Of these, 62 full text articles were assessed which identified 20 reports of 16 studies of simple behavioural interventions for treating nocturnal enuresis which were included in this review.

 FigureFigure 1. PRISMA study flow diagram

The current review is an update of a previously published review update (Glazener 2004f). There were three new trials (five reports of three studies) (Bryant 2003; Van Dommelen 2009; Van Hoeck 2007) included in this update. Two other studies are awaiting further information from authors (Rodriguez 1984; Unuvar 2005).

 

Included studies

Most interventions were addressed by either single trials, single arms in multi-intervention trials or had data for a particular outcome in only a single trial. Some trials combined two simple behavioural interventions (waking or lifting and reward (Baker 1969; Fava 1981)) or simple behavioural interventions with placebo in one arm (fluid restriction, avoiding punishment and placebo (Bhatia 1990); waking and placebo (Fournier 1987); waking, reward and placebo (Mehrotra 1980)). Two studies used a combination of bladder training with enuresis alarm (Fielding 1980) or bladder volume alarm (Pretlow 1999) and compared them with enuresis alarm monotherapy. These studies were included as they assessed the additive effects of the bladder training to enuresis alarm training.

There were only a limited number of interventions where it was possible to combine the data (Bennett 1985; Van Hoeck 2007 for bladder training vs alarm and Ronen 1995; Van Dommelen 2009 for rewards vs control). However, due to the heterogeneity of the rewards and control interventions in the latter studies, these results need to be viewed with caution.

 

Simple behavioural interventions

These included:

 

Active comparison interventions

These included:

 

'Untreated' control groups

These were allocated to:

 

Excluded studies

Forty reports of 39 studies were excluded from this review. Twenty-three studies did not include a simple behavioural intervention in one arm (Bak 2007; But 2006; Chertin 2007; Evans 2007; Jiang 1996; Jodorkovsky 2003; Li 1996; Li 2002; Ma 2007; Naitoh 2005; Ozden 2008; Reed 1994; Renjing 2004; Seabrook 2005; Tuygun 2007; Van Hoeck 2008; Van Kampen 2009; Vasconcelos 2006; Wang 1994; Wang 1999; Wang 2007; Xiao 1997; Yamanishi 1988); 13 were not randomised controlled trials (Bouchard 1981; Creer 1975; Dong 1998; Hagglund 1965; Jiang 1996; Kawauchi 1998b; Lebedev 1995; Li 1996; Paschalis 1972; Terakye 1997; Vasconcelos 2007; Wang 1994; Wang 1999) of which four also did not include a simple behaviour intervention; one was not about nocturnal enuresis (Kroll 2006); one focused on voiding dysfunction in children with no outcomes for nocturnal enuresis given (Ayan 2007) and two were conducted amongst adults with special needs (Barker 1979; Hanson 1988). One study was not able to be completed (Cohen 2006) and serious methodological flaws were identified in two other studies. In one, the groups were not comparable at baseline and children were switched between groups (Doleys 1977). In the second, recruitment to the random-waking arm stopped during the trial (because of lack of success) and in the other arms of the trial children were switched between treatments according to initial response (McConaghy 1969). Therefore, these two studies were also excluded as the data were unreliable. All excluded studies are listed with reasons for exclusion in the Characteristics of excluded studies table.

 

Risk of bias in included studies

Most included trials either had high risks of bias or had insufficient information to judge the level of risk of bias. Trial sizes were generally small, with only one large trial with a sample size of 570 (Van Dommelen 2009): all the other trials had fewer than 150 participants and 10 trials had fewer than 100 participants (Figure 2; Figure 3).

 FigureFigure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 3. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

 

Allocation

 

Random sequence generation (selection bias)

Of the 16 included trials, only one used adequate sequence generation (Bryant 2003). Twelve did not provide details of the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups. Three studies were at high risk of bias due to quasi-randomised methods of sequence generation (alternation allocation (Pretlow 1999); assigned in chronological order (Ronen 1995); and sequence generated by rule on computer based on gender (Van Dommelen 2009)). Therefore, these had high risk of bias (Figure 2; Figure 3).

 

Allocation concealment (selection bias)

Of the 16 included studies, there was only one study that had adequate allocation concealment (Bryant 2003). Twelve did not describe the method used to conceal the allocation sequence in sufficient detail to determine whether the intervention allocations could have been foreseen in advance of, or during, enrolment. In three trials there was high risk of selection bias due to inadequate allocation concealment: in one trial, although allocation was by means of stratification based on age and sex, children who dropped out were replaced by the next child referred to the clinic (Turner 1970); one study was quasi-randomised (alternation allocation) (Pretlow 1999) and one study assigned interventions in chronological order (Ronen 1995) (Figure 2; Figure 3).

 

Blinding

Blinding of participants and outcome assessors (who were usually the parents) was not possible for most of the simple behavioural interventions, although in studies involving drugs as a comparison intervention some blinding was achieved for the drug arms of the trial with the use of placebo drugs (Fournier 1987; Turner 1970; Van Hoeck 2007). There was only one study that had adequate blinding of study personnel (Fournier 1987). There was no blinding of the study personnel in four of the studies (Bennett 1985; Bhatia 1990; Bryant 2003; Ronen 1995) and in the other 11 studies, blinding of the study personnel was not mentioned (Figure 2; Figure 3).

 

Incomplete outcome data

Most studies (12) had high risk of attrition bias: two studies replaced drop-outs with new study participants (Bennett 1985; Turner 1970). In one study the total numbers of participants did not add up (El-Anany 1999) and the remaining nine studies had high attrition rates (which were often differential between interventions) and incomplete reporting of outcome data. In one study, the total number of participants at follow-up was not mentioned (Harris 1977); therefore, we were unable to determine whether there was any attrition bias. Only three studies had a low risk of attrition bias as they reported the outcomes of all participants randomised (Fava 1981; Mehrotra 1980; Pretlow 1999) (Figure 2; Figure 3).

Five studies used intention-to-treat analysis (El-Anany 1999; Fava 1981; Mehrotra 1980; Pretlow 1999; Van Hoeck 2007) and one study used an imputation method to deal with the high loss to follow up (Van Dommelen 2009). There was reporting bias in the remaining 10 studies where participants who dropped out were excluded in outcome analysis (Figure 2; Figure 3).

 

Selective reporting

Most studies did not state prespecified primary outcomes. In six trials there were high risks of reporting bias because of incomplete reporting of important and expected outcomes of interest (Bryant 2003; Fournier 1987; Hamano 2000; Ronen 1995; Turner 1970; Van Dommelen 2009). There was only one study where all prespecified and expected outcomes were reported (Mehrotra 1980).

 

Other potential sources of bias

As organic causes of wetting and the presence of daytime wetting can impact on treatment outcomes for nocturnal enuresis, we assessed whether these two characteristics were specifically excluded in included trials. Thirteen of the trials in the review specifically excluded children with organic causes for their bedwetting (Baker 1969; Bhatia 1990; Bryant 2003; El-Anany 1999; Fielding 1980; Fournier 1987; Hamano 2000; Harris 1977; Pretlow 1999; Ronen 1995; Turner 1970; Van Dommelen 2009; Van Hoeck 2007). The remaining three trials did not mention whether organic causes were excluded. In addition, six trials specifically excluded children with daytime wetting (Bennett 1985; Hamano 2000; Harris 1977; Pretlow 1999; Van Dommelen 2009; Van Hoeck 2007). One further trial included children with day and night wetting in a parallel study but data from these participants were excluded from this review (Fielding 1980). Children with daytime wetting were included in two trials (Bhatia 1990; Bryant 2003) and the other seven trials did not mention whether daytime wetting was excluded.

Baseline wetting was measured in nine trials, although in two of these trials there was evidence that the groups were not comparable at baseline (Harris 1977; Pretlow 1999). In the remaining seven trials baseline comparison of measurements of wetting for individual interventions were not reported (Baker 1969; Bhatia 1990; Fava 1981; Mehrotra 1980; Turner 1970; Van Dommelen 2009; Van Hoeck 2007).

 

Effects of interventions

The 16 trials included 1643 children, of whom 845 received a simple behavioural intervention. However, these interventions were so disparate that only bladder training compared with alarm training could be combined for meta-analysis.

 

1. Simple behavioural interventions compared with no active treatment (waiting list controls, play therapy)

See Comparisons 1.1. 1.2, 1.4, Other Data Tables 1.5

Six trials compared simple behavioural interventions with control management. The simple behavioural interventions were:

The control conditions included waiting list controls and play therapy. The interventions, control conditions and reported outcomes were so variable that they could not be combined.

Bladder training (compared with controls) was associated with fewer mean wet nights at the end of treatment (MD -1.90, 95% CI -3.67 to -0.13,  Analysis 1.1.1) in one trial but there was no difference in number not achieving 14 dry nights at the end of treatment (RR 0.85, 95% CI 0.63 to 1.15,  Analysis 1.2.1) (Bennett 1985). However, in this study some of the controls were given star charts if they achieved a dry night while on the waiting list and the star chart reward may have confounded the comparison (Bennett 1985). In Harris 1977 bladder training was also associated with lower absolute mean wet nights at the end of treatment compared with controls, but no test of significance could be applied as SDs were not given ( Analysis 1.5.2).

Rewards were associated with significantly lower mean wet nights (MD -4.63, 95% CI -6.41 to -2.85,  Analysis 1.1.2) (Ronen 1995) and number not achieving 14 dry nights at the end of treatment (RR 0.84, 95% CI 0.73 to 0.95,  Analysis 1.2.3) (Ronen 1995; Van Dommelen 2009) compared with control, although the rewards and control interventions were quite heterogeneous between the two studies.

Lifting without a password (RR 0.79, 95% CI 0.68 to 0.92,  Analysis 1.2.4) resulted in fewer children not achieving 14 dry nights at the end of treatment compared with controls. However, there was no statistically significant difference for lifting with a password compared with controls (RR 0.92, 95% CI 0.81 to 1.05,  Analysis 1.2.5) (Van Dommelen 2009).

Rewards plus lifting resulted in fewer children not achieving 14 dry nights at the end of treatment (RR 0.22, 95% CI 0.06 to 0.78,  Analysis 1.2.2), and also fewer failing or relapsing after treatment stopped (RR 0.22, 95% CI 0.06 to 0.78,  Analysis 1.4.1) (Fava 1981), compared with controls. Rewards plus waking were also associated with fewer wet nights at the end of treatment compared with controls (Baker 1969), but no test of significance could be applied as SDs were not given ( Analysis 1.5.1).

Overall, simple behavioural interventions appeared to be more effective than control management.

 

2. Simple behavioural interventions compared with other behavioural interventions

See Comparisons 2.1. 2.2, 2.3, 2.4, Other Data Tables 2.5

Eleven trials compared simple behavioural interventions with another behavioural intervention. The simple behavioural interventions studied were:

Comparison interventions were:

Bladder training was not as effective as enuresis alarm therapy based on fewer wet nights at the end of treatment with alarms (MD 2.25, 95% CI 0.30 to 4.20,  Analysis 2.1.2) (Bennett 1985), fewer children not achieving 14 dry nights at the end of treatment with alarms (RR 2.73, 95% CI 1.75 to 4.26,  Analysis 2.2.1)(Bennett 1985; Van Hoeck 2007) and fewer wet nights after completion of treatment with alarms (MD 2.60, 95% CI 0.67 to 4.53,  Analysis 2.3.1)(Bennett 1985). The Bryant 2003 trial also reported fewer wet nights at the end of treatment with alarm therapy, but no test of significance could be applied as SDs were not given. Bladder training did not provide any additional benefit to alarm therapy: there was no statistically significant difference in numbers of children not achieving 14 dry nights at the end of treatment for bladder training combined with enuresis alarm therapy (RR 1.77, 95% CI 0.50 to 6.23,  Analysis 2.2.2) (Fielding 1980) or bladder volume alarm (RR 0.89, 95% CI 0.43 to 1.83,  Analysis 2.2.3) (Pretlow 1999) but the trials were small and the confidence intervals were wide. Therefore, alarm training does appear to be more effective than bladder training, with no apparent additional benefits for bladder training when added to enuresis or bladder volume alarm therapy.

When reward treatment was compared with cognitive therapy, there was no statistically significant difference in mean wet nights at the end of treatment (MD 0.77, 95% CI -0.29 to 1.83,  Analysis 2.1.3). However, the numbers not achieving 14 dry nights at the end of treatment (RR 2.80, 95% CI 1.24 to 6.30,  Analysis 2.2.6) and the number failed or relapsed after completion of treatment was lower (better) for cognitive therapy compared to rewards alone (RR 3.43, 95% CI 1.11 to 10.59,  Analysis 2.4.3) (Ronen 1995) suggesting that cognitive therapy may be superior to rewards.

When reward treatment was compared with enuresis alarm therapy (Ronen 1995), no statistically significant difference in mean wet nights at the end of treatment was demonstrated (MD 0.70, 95% CI -0.65 to 2.05,  Analysis 2.1.4). When reward plus waking was compared with enuresis alarm therapy, there appeared to be no difference in the total mean wet nights at the completion of treatment ( Analysis 2.5.2) (Baker 1969) although no test of significance could be applied as SDs were not given. When reward treatment was compared with lifting with a password (RR 1.07, 95% CI 0.92 to 1.25,  Analysis 2.2.12) or lifting without a password (RR 0.93, 95% CI 0.78 to 1.10,  Analysis 2.2.11) there was no statistically significant difference in numbers not achieving 14 dry nights (Van Dommelen 2009).

When random waking was compared with enuresis alarm therapy using a continuous signal (conventional) alarm, there was no difference in mean wet nights (MD 0.33, 95% CI -1.23 to 1.89,  Analysis 2.1.5) (Turner 1970) and  Analysis 2.5.3 (Fournier 1987) where no test of significance could be applied as SDs were not given), and number not achieving 14 dry nights at the end of treatment (RR 1.17, 95% CI 0.88 to 1.55,  Analysis 2.2.8) (Turner 1970). Similarly, when random waking was compared with enuresis alarm therapy using a twin signal alarm, there was no difference in mean wet nights (MD -0.35, 95% CI -1.84 to 1.14,  Analysis 2.1.6) or number not achieving 14 dry nights at the end of treatment (RR 1.08, 95% CI 0.85 to 1.37,  Analysis 2.2.9) (Turner 1970). When waking at set times was compared with waking linked to expected time of wetting there was no difference in the number not achieving 14 dry nights at the end of treatment (RR 0.79, 95% CI 0.50 to 1.22,  Analysis 2.2.7) or the number failed or relapsed after completion of treatment (RR 1.06, 95% CI 0.79 to 1.44,  Analysis 2.4.4) (El-Anany 1999). When lifting without a password was compared with lifting with a password there was no difference in number not achieving 14 dry nights at the end of treatment (RR 0.86, 95% CI 0.74 to 1.02,  Analysis 2.2.10) (Van Dommelen 2009).

When bladder training was compared with dry bed training (Bennett 1985), there were no statistically significant differences in mean wet nights at the end of treatment (MD 1.85, 95% CI 0.00 to 3.70,  Analysis 2.1.1), numbers not achieving 14 dry nights (RR 1.67, 95% CI 0.85 to 3.26,  Analysis 2.2.4) or mean wet nights after completion of treatment (MD 1.10, 95% CI -1.22 to 3.42,  Analysis 2.3.2).

 

3. Simple behavioral interventions compared with drug interventions

See Comparison 3.1. 3.2, 3.3, 3.4, Other Data Tables 3.5

Six trials compared a simple behavioural intervention with a drug or placebo. The trials were all small, with at most 60 children per arm. The simple behavioural interventions studied were:

Comparison drug interventions were:

When bladder training plus placebo drug was compared with a placebo drug alone (Van Hoeck 2007), there was no difference in number not achieving 14 dry nights at the end of treatment (RR 0.97, 95% CI 0.88 to 1.06,  Analysis 3.2.6). When bladder training plus placebo was compared with oxybutynin (Van Hoeck 2007), there was no difference in number not achieving 14 dry nights at the end of treatment (RR 1.11, 95% CI 0.95 to 1.30,  Analysis 3.2.5). When bladder training plus placebo was compared with bladder training plus oxybutynin (Van Hoeck 2007), there was no difference in number not achieving 14 dry nights at the end of treatment (RR 1.07, 95% CI 0.93 to 1.23,  Analysis 3.2.7).

When bladder training was compared with desmopressin (Hamano 2000), there was no difference in mean wet nights (MD -0.10, 95% CI -0.40 to 0.20,  Analysis 3.1.2) and number not achieving 14 dry nights (RR 1.25, 95% CI 0.97 to 1.62,  Analysis 3.2.4) at the end of treatment. Nor was there a difference after treatment stopped, largely because most children who were cured while using desmopressin relapsed once the drug was stopped (number failed or relapsed after completion of treatment (RR 0.92, 95% CI 0.81 to 1.05,  Analysis 3.4.5)).

When waking was compared with placebo (Turner 1970), there was no difference in mean wet nights (MD -0.99, 95% CI -2.54 to 0.56,  Analysis 3.1.1), and number not achieving 14 dry nights (RR 1.22, 95% CI 0.91 to 1.64,  Analysis 3.2.1) at the end of treatment. In another study (Fournier 1987) the numbers were too small to determine whether waking was superior to placebo ( Analysis 3.5.1) and no test of significance could be applied as SDs were not given.

When waking plus reward plus placebo drug was compared with amitriptyline (Mehrotra 1980), amitriptyline appeared to be more effective with lower numbers not achieving 14 dry nights at the end of treatment (RR 2.83, 95% CI 1.42 to 5.67,  Analysis 3.2.2). However, there was no significant difference in the number who failed or relapsed after completion of treatment (RR 1.50, 95% CI 0.90 to 2.49,  Analysis 3.4.1). When waking plus reward plus placebo was compared with waking plus reward plus amitriptyline, the addition of amitriptyline was just superior to the behavioural therapy alone, with a lower number not achieving 14 dry nights at the end of treatment (RR 1.55, 95% CI 1.00 to 2.39,  Analysis 3.2.3). However, the number who failed or relapsed after completion of treatment (RR 1.00, 95% CI 0.70 to 1.43,  Analysis 3.4.2) was not statistically different. This suggests that the amitriptyline may be effective during treatment but has no sustained effect after stopping treatment .

When random waking was compared with imipramine, or imipramine combined with alarm therapy, although the mean number of wet nights was lower for imipramine or imipramine combined with alarm therapy ( Analysis 3.5.2 and  Analysis 3.5.3, respectively), the numbers were small and no test of significance could be applied as SDs were not given (Fournier 1987).

When fluid restriction and avoidance of punishment was compared to imipramine (either alone or in combination with fluid restriction and avoidance of punishment), the addition of imipramine appears to be superior with lower numbers of those who failed or relapsed after completion of treatment (RR 2.00, 95% CI 1.12 to 3.57,  Analysis 3.4.3 and RR 8.00, 95% CI 2.11 to 30.34,  Analysis 3.4.4, respectively) (Bhatia 1990). Therefore, the tricyclic antidepressants imipramine and amitriptyline alone or in combination with simple behavioural interventions appeared to be superior to simple behavioural interventions alone.

 

Adverse effects

There were no reported adverse effects directly caused by simple behavioural interventions. Eight trials mentioned adverse events but only five specifically mentioned adverse events for individual interventions (Baker 1969; El-Anany 1999; Hamano 2000; Mehrotra 1980; Van Hoeck 2008). The main adverse events, leading to the high dropout rate, were: failure of the treatment because it was too demanding of the children or their families (Pretlow 1999); because it led to family strife (Pretlow 1999; Turner 1970); or emotional problems (Baker 1969); or simply because it did not work (Bennett 1985; El-Anany 1999; Fournier 1987; McConaghy 1969; Pretlow 1999). Adverse events caused by the comparison intervention were mentioned (for example, headaches with oxybutynin (Van Hoeck 2007), nasal discomfort with desmopressin (Fournier 1987; Hamano 2000) and drowsiness with amitriptyline (Mehrotra 1980)). The remaining eight trials failed to report whether adverse events occurred or not (Bennett 1985; Bhatia 1990; Bryant 2003; Fava 1981; Fielding 1980; Harris 1977; Ronen 1995; Van Dommelen 2009).

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Summary of main results

 

Comparison with no active treatment

Simple behavioural interventions generally appeared to be more effective than no active treatment. Rewards for dry nights with or without lifting or waking appeared to be more effective (Baker 1969; Fava 1981; Ronen 1995; Van Dommelen 2009), but each finding was based on single, small trials. Bladder training (retention control training) also appeared to be more effective than no active treatment, although the studies were too small and of low methodological quality to provide useful information (Baker 1969; Bennett 1985; Harris 1977). These interventions are widely used by families as first line treatment. The role of lifting is more controversial because of concerns that it encourages the child to pass urine whilst asleep, thus preventing their learning to wake to the sensation of a full bladder, even if there may be more instances of dry nights. In one study, lifting without a password (but not lifting with a password) was superior to no active treatment (Van Dommelen 2009). One explanation for the failure of lifting with a password (compared with the success of lifting without a password) may be related to increased tiredness in the child caused by their trying to remember the password which may affect their treatment response.

 

Comparison with other behavioural interventions

Enuresis alarm therapy was more effective than bladder training (retention control training) for treating nocturnal enuresis (Bennett 1985; Bryant 2003; Van Hoeck 2007), with no additional benefit when bladder training was combined with alarm therapy (Fielding 1980; Pretlow 1999). Cognitive therapy also appeared to be more effective than rewards in one small trial (Ronen 1995). In the other studies of behavioural interventions, no single behavioural intervention was more effective than any other behavioural intervention, with no differences between alarm therapy and rewards, lifting or waking or combination of rewards and waking, or between rewards and various forms of lifting or waking or between bladder training and dry bed training.

 

Comparison with drugs

Four of the six trials which included a drug arm were conducted over 20 years ago (Bhatia 1990; Fournier 1987; Mehrotra 1980; Turner 1970) before the recognition of the effectiveness of desmopressin (Glazener 2004a), tricyclic drugs (Glazener 2004b) and enuresis alarms (Glazener 2004d) for treating nocturnal enuresis.

The tricyclics amitriptyline and imipramine were compared with simple behavioural therapies and appeared to be more effective than simple behavioural therapies such as waking, lifting, rewards, fluid restriction or avoidance of punishment, either alone or in combination (Bhatia 1990; Fournier 1987; Mehrotra 1980).

There was no difference demonstrated between bladder training and desmopressin (Hamano 2000), oxybutynin or placebo, either alone or in combination with bladder training (Van Hoeck 2007).

Although the tricyclics appeared to be more effective than some simple behavioural therapies, the potential adverse effects of the tricyclics needs to be considered. The main problems with many of the simple behavioural interventions were the high dropout and non-compliance rates as families found themdifficult and found the waking at night to attend to the child disruptive and stressful.

 

Overall completeness and applicability of evidence

This review included 16 trials comparing various simple behavioural strategies for treating nocturnal enuresis, involving 1643 participants. Simple behavioural therapies are generally more effective than no treatment but inferior to proven effective treatments such as alarm training and tricyclics. As most trials are small and of poor methodological quality, care needs to be taken with interpretation of the results.

 

Quality of the evidence

The methodological quality of the 16 included trials was low. Of the nine trials which reported means of continuous outcomes, five failed to provide SDs (Baker 1969; Bryant 2003; Fielding 1980; Fournier 1987; Harris 1977). The sample sizes were small for most studies. The only combination of interventions that could be meta-analysed was bladder training versus enuresis alarm therapy. In the other comparisons outcomes were reported for single trials only, precluding meta-analysis. The confidence intervals are wide and this is likely to obscure or overestimate treatment effects. Only ten of the 16 studies gave information about the follow-up results after the intervention was finished (Bennett 1985; Bhatia 1990; Bryant 2003; El-Anany 1999; Fava 1981; Fielding 1980; Hamano 2000; Mehrotra 1980; Ronen 1995; Van Dommelen 2009).

Most included trials either had high risks of bias or had insufficient information to judge the level of risk. Thirteen of the 16 trials did not provide information about the method used to generate the allocation sequence, blinding was usually not possible for simple behavioural therapies, most studies had high attrition rates, with 10 of the studies not using intention-to-treat analysis or imputation methods to deal with the high loss to follow up.

Other potential biases included not providing adequate baseline or background information about the participants, inclusion of children with organic causes of wetting or daytime urinary incontinence (who may respond differently to the interventions) and failure to report details of adverse reactions.

 

Potential biases in the review process

Many of the studies did not provide adequate detail to allow the reviewers to assess the adequacy of the quality of the study. Therefore, subjective judgement was sometimes made by the reviewers based on the scant information provided.

As there was no clear definition of what is a "simple behavioural intervention" for treating nocturnal enuresis, the reviewers had to make a subjective judgement. It could be argued that some of the included interventions should be classified as a complex behavioural intervention.

 

Agreements and disagreements with other studies or reviews

The results of this study are consistent with the other reviews of nocturnal enuresis, showing superiority of proven effective treatments such as enuresis alarm therapy and tricyclic antidepressants over simple behavioural therapies. However, there was no difference found between desmopressin and simple behavioural therapies: this may have been caused by the inclusion of only one small, low quality study of desmopressin versus bladder training (a simple behavioural therapy which did not appear to be effective when compared with other active treatments).

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

 

Implications for practice

Simple behavioural interventions are commonly used by families for treating nocturnal enuresis. However, other proven effective therapies such as enuresis alarm therapy and tricyclic antidepressants were found to be more effective than simple behavioural interventions. Although desmopressin had been proven to be an effective treatment for nocturnal enuresis in other reviews, there were limited trials comparing desmopressin with simple behavioural therapies. The findings from this review should be interpreted cautiously due to the poor quality and small sizes of the trials. Nevertheless, rewards, bladder training and lifting or waking could initially be tried as such methods are safe and are better than doing nothing. However, they require a high level of parental involvement which can sometimes be stressful. Their main benefit may be to encourage a positive attitude to dry nights rather than blame and punishment for wetting.

 
Implications for research

These tentative findings need to be tested in rigorous trials against other proven methods such as desmopressin (Glazener 2004a), tricyclics (Glazener 2004b) and alarms (Glazener 2004d) or as an adjunct to these other therapies. Future trials should clearly distinguish children with monosymptomatic nocturnal enuresis and those with non-monosymptomatic nocturnal enuresis and exclude physical (organic) causes of wetting. There needs to be adequate assessment of baseline wetting and change in wetting for each intervention.

The difficulty in comparing interventions is exacerbated by the lack of uniformity in outcome measures used. In our view, these should include: the mean number of wet nights at the completion of treatment and at follow-up after the end of treatment (at six months and two years, consistent with ICCS definitions); the number failing to achieve 14 consecutive dry nights at the end of the treatment period; adverse events; acceptability of treatment; compliance; and relapse rates after treatment has stopped. Economic analysis of costs both to the health service and families should be included.

Not all interventions are suitable for all children. Further research is needed to determine which interventions are appropriate for which groups and why. It should include formal testing to identify pre-treatment factors which might determine or modify treatment effects. Important factors include age, presence of daytime wetting and family circumstances. It is important to be able to compare interventions in different populations (e.g. in primary care) and for different purposes (e.g. a short-term measure to cover nights away from home), in order to inform choice of treatment.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

This review was based on an updated review by Cathryn Glazener from the University of Aberdeen and Jonathan Evans from Nottingham University Hospitals NHS Trust, UK (Glazener 2004f). Their review was based on one originally written by the NHS Centre for Reviews and Dissemination, University of York, UK. The original authors were Deborah Lister-Sharp, Susan O'Meara, Matthew Bradley and Trevor A Sheldon. It is published as: A Systematic Review of the Effectiveness of Interventions for Managing Childhood Nocturnal Enuresis, CRD Report 11, NHS Centre for Reviews and Dissemination, University of York (Lister-Sharp 1997). The York reviewers obtained information from a variety of sources, including organisations, manufacturers and individuals. These are listed in the NHS Centre for Reviews and Dissemination Report (Lister-Sharp 1997), and we acknowledge their contribution to this review.

We would like to thank Prof Cathryn Glazener, Sheila Wallace, June Cody and Dr Imran Omar from the Cochrane Incontinence Review Group, Aberdeen, UK, for their tireless help and advice in conducting this update. We would also like to thank Prof Herman Cohen from Schneider Children's Hospital, Israel, and Ms Charmaine Bryant for feedback about their studies.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
Download statistical data

 
Comparison 1. Simple behavioural intervention vs control

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mean wet nights on treatment2Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Bladder training vs control (wait list + reward)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Reward vs control (wait list)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Number not achieving 14 consecutive dry nights (failed) on treatment4Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    2.1 Bladder training vs control (wait list + reward)
121Risk Ratio (M-H, Fixed, 95% CI)0.85 [0.63, 1.15]

    2.2 Reward + lifting vs control (play)
120Risk Ratio (M-H, Fixed, 95% CI)0.22 [0.06, 0.78]

    2.3 Reward vs control (wait list)
2325Risk Ratio (M-H, Fixed, 95% CI)0.84 [0.73, 0.95]

    2.4 Lifting (without password) vs control
1287Risk Ratio (M-H, Fixed, 95% CI)0.79 [0.68, 0.92]

    2.5 Lifting (with password) vs control
1284Risk Ratio (M-H, Fixed, 95% CI)0.92 [0.81, 1.05]

3 Mean wet nights after completion of treatment0Mean Difference (IV, Fixed, 95% CI)Totals not selected

 4 Number failed or relapsed after completion of treatment1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    4.1 Reward + lifting vs control (play)
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Mean wet nights on treatment (no SDs)Other dataNo numeric data

    5.1 Waking + reward vs control (wait list)
Other dataNo numeric data

    5.2 Bladder training vs control (wait list)
Other dataNo numeric data

 
Comparison 2. Simple behavioural intervention vs another behavioural intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mean wet nights on treatment3Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Bladder training vs Dry Bed Training (complex intervention)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Bladder training vs alarm
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.3 Reward vs cognitive therapy
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.4 Reward vs alarm
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.5 Waking vs alarm (continuous signal)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.6 Waking vs alarm (twin signal)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Number not achieving 14 consecutive dry nights (failed) on treatment8Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    2.1 Bladder training vs alarm
280Risk Ratio (M-H, Fixed, 95% CI)2.73 [1.75, 4.26]

    2.2 Bladder training + alarm vs alarm alone
133Risk Ratio (M-H, Fixed, 95% CI)1.77 [0.50, 6.23]

    2.3 Bladder training + bladder volume alarm vs alarm alone
140Risk Ratio (M-H, Fixed, 95% CI)0.89 [0.43, 1.83]

    2.4 Bladder training vs Dry Bed Training (complex intervention)
122Risk Ratio (M-H, Fixed, 95% CI)1.67 [0.85, 3.26]

    2.5 Reward vs alarm
139Risk Ratio (M-H, Fixed, 95% CI)1.9 [0.99, 3.66]

    2.6 Reward vs cognitive therapy
140Risk Ratio (M-H, Fixed, 95% CI)2.8 [1.24, 6.30]

    2.7 Waking linked to wetting vs waking at set time
1125Risk Ratio (M-H, Fixed, 95% CI)0.79 [0.50, 1.22]

    2.8 Waking vs alarm (continuous signal)
130Risk Ratio (M-H, Fixed, 95% CI)1.17 [0.88, 1.55]

    2.9 Waking vs alarm (twin signal)
130Risk Ratio (M-H, Fixed, 95% CI)1.08 [0.85, 1.37]

    2.10 Lifting (without password) vs lifting with password
1283Risk Ratio (M-H, Fixed, 95% CI)0.86 [0.74, 1.02]

    2.11 Lifting (without password) vs reward
1286Risk Ratio (M-H, Fixed, 95% CI)0.93 [0.78, 1.10]

    2.12 Lifting (with password) vs reward
1283Risk Ratio (M-H, Fixed, 95% CI)1.07 [0.92, 1.25]

 3 Mean wet nights after completion of treatment1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 Bladder training vs alarm
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 Bladder training vs Dry Bed Training (complex intervention with alarm)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Number failed or relapsed after completion of treatment3Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    4.1 Bladder training + alarm vs alarm alone
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 Reward vs alarm
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.3 Reward vs cognitive therapy
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.4 Waking linked to wetting vs waking at set time
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Mean wet nights on treatment (no SDs)Other dataNo numeric data

    5.1 Bladder training + alarm vs alarm alone
Other dataNo numeric data

    5.2 Waking + reward vs alarm
Other dataNo numeric data

    5.3 Waking vs alarm
Other dataNo numeric data

    5.4 Bladder training vs alarm
Other dataNo numeric data

    5.5 Bladder training vs bladder training + alarm
Other dataNo numeric data

 
Comparison 3. Simple behavioural intervention vs drug intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mean wet nights on treatment2Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Waking vs placebo
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Bladder training vs desmopressin
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Number not achieving 14 consecutive dry nights (failed) on treatment4Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Waking vs placebo
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 Waking + reward + placebo vs amitriptyline
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.3 Waking + reward + placebo vs waking + reward + amitriptyline
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.4 Bladder training vs desmopressin
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.5 Bladder training + placebo vs oxybutynin
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.6 Bladder training + placebo vs placebo
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.7 Bladder training + placebo vs Bladder training + oxybutynin
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

3 Mean wet nights after completion of treatment0Mean Difference (IV, Fixed, 95% CI)Totals not selected

 4 Number failed or relapsed after completion of treatment3Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    4.1 Waking + reward + placebo vs amitriptyline
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 Waking + reward + placebo vs waking + reward + amitriptyline
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.3 Fluid restriction and avoidance of punishment vs imipramine
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.4 Fluid restriction and avoidance of punishment vs fluid restriction and avoidance of punishment + imipramine
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.5 Bladder training vs desmopressin
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Mean wet nights on treatment (no SDs)Other dataNo numeric data

    5.1 Waking vs placebo
Other dataNo numeric data

    5.2 Waking vs imipramine
Other dataNo numeric data

    5.3 Waking vs alarm + imipramine
Other dataNo numeric data

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Last assessed as up-to-date: 15 December 2011.


DateEventDescription

17 July 2013New citation required and conclusions have changedAdded 3 new trials Bryant 2003; Van Dommelen 2009; Van Hoeck 2007

17 July 2013New search has been performedAdded 3 new trials Bryant 2003; Van Dommelen 2009; Van Hoeck 2007



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Protocol first published: Issue 2, 2002
Review first published: Issue 2, 2002


DateEventDescription

23 November 2010AmendedUpdate

10 October 2008AmendedConverted to new review format.

22 November 2005New search has been performedMinor Update Issue 2 2006. The review was updated again: one extra study was excluded (Hagglund 1965) but the conclusions were unchanged.

19 February 2004New citation required and conclusions have changedSubstantive Update Issue 2 2004. One new trial was added (Bhatia 1990) and two previously included trials were excluded due to protocol violations resulting in unreliable data. The Bhatia trial provided some information that imipramine was better than a simple behavioural intervention.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

The reviewers (PC and GN) independently assessed the studies identified by the updated searches and extracted data from the included studies. PC, GN and PS also reviewed the included studies from the previous review (Glazener 2004f) and PS and PC updated the characteristics of excluded study table and the risk of bias tables. PC and PS analysed the data and PC wrote the updated review.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Internal sources

  • No sources of support supplied

 

External sources

  • National Institute for Health Research (NIHR), UK.
    The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Incontinence Group

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

The original protocol of this review included physical interventions. There were no physical interventions identified in the previous versions of this review and we identified two studies of physical interventions in the updated search (But 2006; Reed 1993) which we felt were more suitable to the complementary and miscellaneous intervention review as these studies are quite distinct from the other simple behavioural interventions. Therefore, the authors have decided to exclude physical interventions from this review and from the title of this review.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
  22. References to other published versions of this review
Baker 1969 {published data only}
Bennett 1985 {published data only}
  • Bennett GA, Walkden VJ, Curtis RH, Burns LE, Rees J, Gosling JA, et al. Pad-and-buzzer training, dry-bed training, and stop-start training in the treatment of primary nocturnal enuresis. Behavioural Psychotherapist 1985;13:309-19.
Bhatia 1990 {published data only}
  • Bhatia MS, Dhar NK, Rai S, Malik SC. Enuresis: an analysis of 82 cases. Indian Journal of Medical Sciences 1990;44(12):337-42. [MEDLINE: 91231332]
Bryant 2003 {published data only}
  • Bryant C, Fairbrother G. Baseline results: randomised trial of bladder training vs enuresis alarm vs bladder training plus enuresis alarm among children with nocturnal enuresis (Abstract 12.09 PP). Proceedings of the joint meeting of the International Children's Continence Society (ICCS) and the Asia-Pacific Association of Pediatric Urology (APAPU), 2002 Dec 10-13, Hong Kong. 2002:80.
  • Bryant C, Fairbrother G. Randomised trial of bladder training vs enuresis alarm vs combined interventions in the management of nocturnal enuresis in children (Abstract). Conference unknown 2003. [: SR-INCONT34172]
El-Anany 1999 {published data only}
Fava 1981 {published data only}
  • Fava GA, Cracco L, Facco L. Positive reinforcement and enuresis. Italian Journal of Psychology 1981;8(2):149-52.
Fielding 1980 {published data only}
Fournier 1987 {published data only}
Hamano 2000 {published data only}
  • Hamano S, Yamanishi T, Igarashi T, Ito H, Murakami S. Functional bladder capacity as predictor of response to desmopressin and retention control training in monosymptomatic nocturnal enuresis. European Urology 2000;37(6):718-22. [MEDLINE: 20291060]
Harris 1977 {published data only}
Mehrotra 1980 {published data only}
  • Mehrotra SN, Liu L, Srivastava JR, Singh SB. Evaluation of various methods in treatment of enuresis. Indian Pediatrics 1980;17(6):519-22. [MEDLINE: 81166737]
  • Singh SB, Nigam A, Liu L, Mehrotra SN, Srivastava JR. Medical psychological and combined therapy in the cases of enuresis: a comparative study. Indian Journal of Clinical Psychology 1980;7:99-102.
Pretlow 1999 {published and unpublished data}
Ronen 1995 {published data only}
  • Ronen T, Rahav G, Wozner Y. Self-control and enuresis. Journal of Cognitive Psychotherapy: An International Quarterly 1995;9:249-58.
  • Ronen T, Wozner Y, Rahav G. Cognitive intervention in enuresis. Child & Family Behaviour Therapy 1992;14(2):1-14.
Turner 1970 {published data only}
Van Dommelen 2009 {published data only}
  • Van Dommelen P, Kamphuis M, Van Leerdam FJ, De Wilde JA, Rijpstra A, Campagne AE, et al. The short- and long-term effects of simple behavioral interventions for nocturnal enuresis in young children: a randomized controlled trial. Journal of Pediatrics 2009;154(5):662-6.
Van Hoeck 2007 {published and unpublished data}
  • Van Hoeck K, Bael A, Hirche H, Lax H, Van Gool J, Trouet D. Increasing functional bladder capacity in monosymptomatic nocturnal enuresis? A randomized controlled trial in 149 pre-pubertal children (Abstract number 545 (P)). Pediatric Nephrology 2007;22:1546.
  • Van Hoeck KJ, Bael A, Van Dessel E, Van Renthergem D, Bernaerts K, Vandermaelen V, et al. Do holding exercises or antimuscarinics increase maximum voided volume in monosymptomatic nocturnal enuresis? A randomized controlled trial in children. Journal of Urology 2007;178(5):2132-6.

References to studies excluded from this review

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
  22. References to other published versions of this review
Ayan 2007 {published data only}
  • Ayan S, Topsakal K, Gokce G, Gultekin EY. Efficacy of combined anticholinergic treatment and behavioral modification as a first line treatment for nonneurogenic and nonanatomical voiding dysfunction in children: a randomized controlled trial. Journal of Urology 2007;177(6):2325-9.
Bak 2007 {published data only}
  • Bak M, Serdaroglu E, Bicilioglu Y. Comparing desmopressin, alarm and combined treatments in nocturnal enuretic children (Abstract number 531 (P)). Pediatric Nephrology 2007;22:1542.
Barker 1979 {published data only}
Bouchard 1981 {published data only}
  • Bouchard M-A, Joly J, Cardinal J-F. Diurnal urinary retention in the treatment of enuresis: Comparison of univariate and multivariate analyses [Rétention urinaire diurne dans le traitement de l'énurésie: comparaison des analyses univariées et multivariées]. Canadian Journal of Behavioural Science 1981;13(1):53-64.
But 2006 {published data only}
  • But I, Varda NM. Functional magnetic stimulation: A new method for the treatment of girls with primary nocturnal enuresis?. Journal of Pediatric Urology 2006;2(5):415-8.
Chertin 2007 {published data only}
  • Chertin B, Koulikov D, Abu-Arafeh W, Mor Y, Shenfeld OZ, Farkas A. Treatment of nocturnal enuresis in children with attention deficit hyperactivity disorder. Journal of Urology 2007;178(4 Pt 2):1744-7.
Cohen 2006 {published data only}
  • Cohen HA. Treatment of enuresis nocturna by circular muscle exercise (Paula Method). http://clinicaltrials.gov/ct2/show/NCT00404638 2006.
Creer 1975 {published data only}
  • Creer TL, Davis MH. Using a staggered-wakening procedure with enuretic children in an institutional setting. Journal of Behavioural Therapy and Experimental Psychiatry 1975;6:23-5.
Doleys 1977 {published data only}
  • Doleys DM, Ciminero AR, Tollinson JW, Williams CL, Wells KC. Dry-bed training and retention control training: A comparison. Behaviour Therapy 1977;8(4):541-8.
  • Williams CL, Doleys DM, Ciminero AR. A two year follow-up of enuretic children treated with dry-bed training. Journal of Behavior Therapy & Experimental Psychiatry 1978;9(3):285-6.
Dong 1998 {published data only}
  • Dong WZ, Sun JH, Bi DC, Hao YH. Impulse direct current therapy for 45 cases with enuresis. Chinese Journal of Physical Therapy 1998;21(4):248.
Evans 2007 {published data only}
  • Evans J, Lottmann H. "Desmopressin response in the treatment of primary nocturnal enuresis in the United Kingdom" DRIP UK: an open-label, randomised comparative study of oral desmopressin versus enuresis alarm (Abstract number 225). Proceedings of the 37th Annual Meeting of the International Continence Society (ICS), 20-24 Aug, Rotterdam, the Netherlands. 2007.
Hagglund 1965 {published data only}
  • Hagglund TB. Enuretic children treated with fluid restriction or forced drinking. Annales Paediatriae Fenniae 1965;11:84-90.
Hanson 1988 {published data only}
Jiang 1996 {published data only}
  • Jiang HEXI. Cake-separated moxibustion for 108 cases of enuresis due to deficiency of the kidney-qi. Shanghai Zhenjiu Zazhi [Shanghai Journal of Acupuncture and Moxibustion)] 1996;15(2):16-7.
Jodorkovsky 2003 {published data only}
  • Jodorkovsky R. Treatment of primary nocturnal enuresis with hand therapy: A randomized, double-blind, placebo-controlled trial. Medical Acupuncture 2003;14(2):28-31.
Kawauchi 1998b {published data only}
  • Kawauchi A, Imada N, Tanaka Y, Yamao Y, Watanabe H. Effects of systematic treatment based on overnight simultaneous monitoring of electroencephalography and cystometry. European Urology 1998;33 Suppl 3:58-61.
Kroll 2006 {published data only}
  • Kroll P, Jankowski A, Makowiak J. The comparative study on selective alpha1-blocker and behavioural therapy in the treatment of discoordinated voiding in children. Przeglad Lekarski 2006;63(Suppl 3):226-8.
Lebedev 1995 {published data only}
  • Lebedev VA. The treatment of neurogenic bladder dysfunction with enuresis in children using the SKENAR apparatus (self-controlled energy-neuroadaptive regulator). Voprosy Kurortologii, Fizioterapii i Lechebnoi Fizicheskoi Kultury 1995;Jul-Aug(4):25-6.
Li 1996 {published data only}
  • Li W, Xu YZ. Analysis of the effectiveness of catgut implantation at acupoint for enuresis. Shanghai Zhenjiu Zazhi [Shanghai Journal of Acupuncture and Moxibustion] 1996;15(4):23.
Li 2002 {published data only}
  • Li Z-H. Clinical research on the treatment of enuresis with electroacupuncture plus TDP irradiation. Shanghai Zhenjiu Zazhi [Shanghai Journal of Acupuncture and Moxibustion] 2002;21(4):28-9.
Ma 2007 {published data only}
  • Ma J, Zhang Y-W, Wu H, Jiang F, Jin X-M. A randomized controlled clinical trial for treatment of children with primary nocturnal enuresis. Zhonghua Er Ke Za Zhi [Chinese Journal of Pediatrics] 2007;45(3):167-71.
McConaghy 1969 {published data only}
  • McConaghy N. A controlled trial of imipramine, amphetamine, pad-and-bell conditioning and random awakening in the treatment of nocturnal enuresis. Medical Journal of Australia 1969;2(5):237-9. [MEDLINE: 69296582]
Naitoh 2005 {published data only}
  • Naitoh Y, Kawauchi A, Yamao Y, Seki H, Soh J, Yoneda K, et al. Combination therapy with alarm and drugs for monosymptomatic nocturnal enuresis not superior to alarm monotherapy. Urology 2005;66(3):632-5.
Ozden 2008 {published data only}
  • Ozden C, Ozdal OL, Aktas BK, Ozelci A, Altinova S, Memis A. The efficacy of the addition of short-term desmopressin to alarm therapy in the treatment of primary nocturnal enuresis. International Urology & Nephrology 2008;40(3):583-6.
Paschalis 1972 {published data only}
  • Paschalis AP, Kimmel HD, Kimmel E. Further study of diurnal instrumental conditioning in the treatment of enuresis nocturna. Journal of Behavior Therapy & Experimental Psychiatry 1972;3:253-6.
Reed 1994 {published data only}
  • Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary noctural enuretic children (Abstract). Proceedings of the National Conference on Chiropractic & Pediatrics. 1993:64-82.
Renjing 2004 {published data only}
  • Renjing L. Therapy of children with nocturnal enuresis using tuina. Chinesische Medizin 2004;19(2):63-9.
Seabrook 2005 {published data only}
  • Seabrook JA, Gorodzinsky F, Freedman S. Treatment of primary nocturnal enuresis: A randomized clinical trial comparing hypnotherapy and alarm therapy. Paediatrics & Child Health 2005;10(10):609-10.
Terakye 1997 {published data only}
  • Terakye G, Buldukoglu K. Childhood enuresis: application of Orem's Self-Care Practice Model to home visits in Turkey. Journal of Pediatric Nursing 1997;12(3):193-7. [MEDLINE: 97342228]
Tuygun 2007 {published data only}
  • Tuygun C, Eroglu M, Bakirtas H, Gucuk A, Zengin K, Imamoglu A. Is second-line enuretic alarm therapy after unsuccessful pharmacotherapy superior to first-line therapy in the treatment of monosymptomatic nocturnal enuresis?. Urologia Internationalis 2007;78:260-3.
Van Hoeck 2008 {published data only}
  • Van Hoeck KJ, Bael A, Lax H, Hirche H, Bernaerts K, Vandermaelen V, et al. Improving the cure rate of alarm treatment for monosymptomatic nocturnal enuresis by increasing bladder capacity--a randomized controlled trial in children. Journal of Urology 2008;179(3):1122-1126; discussion 1126-7.
Van Kampen 2009 {published data only}
  • Van Kampen M, Lemkens H, Deschamps A, Bogaert G, Geraerts I. Influence of pelvic floor muscle exercises on full spectrum therapy for nocturnal enuresis. Journal of Urology 2009;182(4 Suppl):2067-71.
Vasconcelos 2006 {published data only}
  • Vasconcelos M, Lima E, Caiafa L, Noronha A, Cangussu R, Gomes S, et al. Voiding dysfunction in children. Pelvic-floor exercises or biofeedback therapy: a randomized study. Pediatric Nephrology 2006;21(12):1858-64.
Vasconcelos 2007 {published data only}
  • Vasconcelos M, Lima E, Oliveira E, Filqueiras M, Vasconcelos R, Colozimo E. Predicting factors of success of a training program in children with dysfunctional elimination syndrome (DES): a multivariate analysis (Abstract number 540 (P)). Pediatric Nephrology 2007;22:1545.
Wang 1994 {published data only}
  • Wang J-X, Liu F, Wei J. Clinical observation on 32 cases of functional enuresis treated with acupuncture at Baihui (Gv 20). World Journal of Acupuncture-Moxibustion 1994;4(4):5-8.
Wang 1999 {published data only}
  • Wang JR, Zhang BF. Comparative study on treatment of nocturnal enuresis by needle-embedding, acupuncture, and catgut-embedding. Zhongguo Zhen Jiu [Chinese acupuncture & moxibustion] 1999;19:608.
Wang 2007 {published data only}
  • Wang QL, Xu H, Bi YI, Cao Q, Ruan SS. A randomized control trial (RCT) study of biofeedback and DDAVP in children with primary nocturnal enuresis (Abstract number 484 (P)). Pediatric Nephrology 2007;22:1531.
Xiao 1997 {published data only}
  • Xiao LF. 42 cases of enuresis treated by point injection therapy. Shanghai Zhenjiu Zazhi 1997;16(1):22.
Yamanishi 1988 {published data only}
  • Yamanishi T, Igarashi T, Murakami S, Murayama N, Kamura K, Yasuda K, et al. A comparative study of the effects of drug therapy and bladder training therapy (Japanese). Urologic Transactions 1988;34(1):102-6. [MEDLINE: 88238207]

References to studies awaiting assessment

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
  22. References to other published versions of this review
Rodriguez 1984 {published data only (unpublished sought but not used)}
  • Rodriguez J, Parraga J, Leon JM. Comparative efficacy between three procedures for the treatment of enuresis (Kimmel behavioural approach, pharmacological and mixed techniques). Análisis y Modificación de Conducta 1983;9(20):111-31. [: SRINCONT29667]
Unuvar 2005 {published data only (unpublished sought but not used)}
  • Unuvar T, Sonmez F. The role of urine osmolality and ions in the pathogenesis of primary enuresis nocturna and in the prediction of responses to desmopressin and conditioning therapies. International Urology & Nephrology 2005;37(4):751-7.

Additional references

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
  22. References to other published versions of this review
APA 1980
  • American Psychiatric Association. Functional enuresis. Diagnostic and Statistical Manual of Mental Disorders. 3rd Edition. American Psychiatric Association, 1980.
Azrin 1973
Bakwin 1971
Bakwin 1973
  • Bakwin H. The genetics of enuresis. In: Kolvin I, MacKeith RC, Meadow SR editor(s). Bladder control and enuresis. London: William Heinemann Medical Books, 1973.
Blackwell 1989
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Bower 1996
Brooks 2003
Butler 1988
  • Butler RJ, Brewin CR, Forsythe WI. A comparison of two approaches to the treatment of nocturnal enuresis and the prediction of effectiveness using pre-treatment variables. Journal of Child Psychology & Psychiatry & Allied Disciplines 1988;29(4):501-9. [MEDLINE: 89109292]
Butler 1994
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Butler 2000
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Creighton 1990
De Jonge 1973
  • De Jonge GA. Section II: Epidemiology of enuresis: Chapter 4 - Epidemiology of enuresis: A survey of the literature. In: Kolvin I, MacKeith RC, Meadow SR editor(s). Bladder control and enuresis. London: William Heinemann Medical Books, 1973:39-46.
Deshpande 2012
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Forsythe 1989
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Glazener 2004b
  • Glazener CMA, Evans JHC, Peto R. Tricyclic and related drugs for nocturnal enuresis in children. Cochrane Database of Systematic Reviews 2003, Issue 3. [DOI: 10.1002/14651858.CD002117]
Glazener 2004c
Glazener 2004d
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Glazener 2004e
  • Glazener CMA, Evans JHC, Peto RE. Complex behavioural and educational interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews 2004, Issue 1. [DOI: 10.1002/14651858.CD004668]
Hagglof 1998
  • Hagglof B, Andren O, Bergstrom E. Self-esteem in children with nocturnal enuresis and urinary incontinence: improvement of self-esteem after treatment. European Urology 1998;33(Suppl 3):16-9. [DOI: 10.1159/000052236]
Harbord 2006
Higgins 2011
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org. [: www.cochrane-handbook.org.]
Hirasing 1997
Hjalmas 2004
Houts 1983
Howe 1992
Huang 2011
Jarvelin 1989
  • Jarvelin MR. Developmental history and neurological findings in enuretic children. Developmental Medicine and Child Neurology 1989;31(6):728-36. [MEDLINE: 90092792]
Jarvelin 1990
  • Jarvelin MR, Huttunen NP, Seppanen J, Seppanen U, Moilanen I. Screening of urinary tract abnormalities among day and nightwetting children. Scandinavian Journal of Urology and Nephrology 1990;24(3):181-9. [MEDLINE: 91047829]
Jura 2011
Kawauchi 1998a
Koff 1995
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Krantz 1994
  • Krantz I, Jylkas E, Ahlberg BM, Wedel H. On the epidemiology of nocturnal enuresis-a critical review of methods used in descriptive epidemiological studies on nocturnal enuresis. Scandinavian Journal of Urology and Nephrology 1994;163(Suppl):75-82. [MEDLINE: 95183925]
Maizels 1993
  • Maizels M, Gandhi K, Keating B, Rosenbaum D. Diagnosis and treatment for children who cannot control urination. Current Problems in Pediatrics 1993;23(10):402-50. [MEDLINE: 94116304]
Mishne 1993
  • Mishne JM. Primary nocturnal enuresis: a psychodynamic clinical perspective. Child and Adolescent Social Work Journal 1993;10(6):469-95.
Moffatt 1989
Morgan 1970
  • Morgan R. The treatment of enuresis amongst child clients of a social services department. British Journal of Social Work 1970;9(2):217-31.
Morison 1998
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References to other published versions of this review

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
  22. References to other published versions of this review
Glazener 2002
Glazener 2004f
  • Glazener CMA, Evans JHC. Simple behavioural and physical interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews 2004, Issue 2. [DOI: 10.1002/14651858.CD003637.pub2]
Lister-Sharp 1997
  • Lister-Sharp D, O'Meara S, Bradley M, Sheldon TA. A systematic review of the effectiveness of interventions for managing childhood nocturnal enuresis, CRD Report 11. York: NHS Centre for Reviews and Dissemination, University of York, 1997.