Simple behavioural interventions for nocturnal enuresis in children

  • Conclusions changed
  • Review
  • Intervention

Authors

  • Patrina HY Caldwell,

    Corresponding author
    1. The Children's Hospital at Westmead Clinical School, University of Sydney, Discipline of Paediatrics and Child Health, Westmead, 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.

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  • Gail Nankivell,

    1. The Children's Hospital at Westmead, Physiotherapy, Westmead, NSW, Australia
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  • Premala Sureshkumar

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

Background

Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15% to 20% of five year olds and up to 2% of adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs can be great. Behavioural interventions for treating bedwetting are defined as interventions that require a behaviour or action by the child which promotes night dryness and includes strategies which reward that behaviour. Behavioural interventions are further divided into:

(a) simple behavioural interventions - behaviours or actions that can be achieved by the child without great effort; and

(b) complex behavioural interventions - multiple behavioural interventions which require greater effort by the child and parents to achieve, including enuresis alarm therapy.

This review focuses on simple behavioural interventions.

Simple behavioural interventions are often used as a first attempt to improve nocturnal enuresis and include reward systems such as star charts given for dry nights, lifting or waking the children at night to urinate, retention control training to enlarge bladder capacity (bladder training) and fluid restriction. Other treatments such as medications, complementary and miscellaneous interventions such as acupuncture, complex behavioural interventions and enuresis alarm therapy are considered elsewhere.

Objectives

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.

Search methods

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 15 December 2011). The reference lists of relevant articles were also searched.

Selection criteria

All randomised or quasi-randomised trials of simple behavioural interventions for treating nocturnal enuresis in children up to the age of 16. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded.

Data collection and analysis

Two reviewers independently assessed the quality of the eligible trials and extracted data. Differences between reviewers were settled by discussion with a third reviewer.

Main results

Sixteen trials met the inclusion criteria, involving 1643 children of whom 865 received a simple behavioural intervention. Within each comparison, outcomes were mostly addressed by single trials, precluding meta-analysis. The only exception was bladder training versus enuresis alarm therapy which included two studies and demonstrated that alarm therapy was superior to bladder training.

In single small trials, rewards, lifting and waking and bladder training were each associated with significantly fewer wet nights, higher full response rates and lower relapse rates compared to controls. Simple behavioural interventions appeared to be less effective when compared with other known effective interventions (such as enuresis alarm therapy and drug therapies with imipramine and amitriptyline). However, the effect was not sustained at follow-up after completion of treatment for the drug therapies. Based on one small trial, cognitive therapy also appeared to be more effective than rewards. When one simple behavioural therapy was compared with another, there did not appear to be one therapy that was more effective than another.

Authors' conclusions

Simple behavioural methods may be superior to no active treatment but appear to be inferior to enuresis alarm therapy and some drug therapy (such as imipramine and amitriptyline). Simple behavioural therapies could be tried as first line treatment before considering enuresis alarm therapy or drug therapy, which may be more demanding and have adverse effects, although evidence supporting their efficacy is lacking.

摘要

背景

對於兒童夜間遺尿利用簡單行為學或是物理治療的介入性治療

遺尿(尿床)是一個令人窘迫的事情同時也會造成社交障礙,這樣的情形影響15∼20%的五歲孩童甚至有2%的年輕成人也被困擾著. 雖然有蠻高的機會能自然緩解,但是在社交,情緒,身心上付出的成本可能相當高. 治療尿床的簡單行為方法包括獎勵系統,如:用積分表的方式:獎勵沒有尿床的晚上,在晚上提醒或是喚醒小孩去解尿,儲尿控制訓練還增加膀胱儲尿容積(膀胱訓練)及限制液體的攝取.

目標

評估簡單行為學介入性治療,並且用此與其他治療方式比較對於夜間遺尿兒童的治療

搜尋策略

我們搜尋考科藍實證醫學團隊特殊的試驗紀錄(2005年11月22日)我們也搜尋前一版的回顧性文章之參考目錄.

選擇標準

所有兒童至16歲之夜間遺尿症用簡單行為學的介入性治療之隨機和半隨機的試驗. 排除針對日間遺尿的試驗.

資料收集與分析

由二位審查員分別評估這些合適的試驗及摘錄資料的品質。

主要結論

主要結論 有十三個試驗達到入選的標準,包括702位兒童,其中387位接受簡單行為學的治療。然而,每項對照及結果僅經由單一試驗提出,阻礙metaanalysis。在單一小型試驗中,獎勵系統(例如積分表)、夜晚提醒或喚醒孩童解尿相較於控制組下,與較少尿床、較高治癒率及較低復發率有顯著相關。沒有足夠證據去評估膀胱儲尿容積(膀胱訓練),無論是與控制組、不尿床訓練或使用鬧鈴輔助對照,或是與desmopressin比較。認知訓練與積分方式比較後,可能有較低的失敗率及復發率,但僅是根據一個小型試驗的發現。一個品質不佳的小型試驗指出,相較於amitriptyling的使用,一開始積分方式較少治療成功,但治療結束後,就不再有這樣的差異持續存在。另一項試驗指出impipramine的使用效果,比液體限制及無效的懲罰效果佳。

作者結論

簡單行為學治療方式對於一些小孩有效,但是需要更進一步的試驗, 尤其是與目前已知具有療效的方式進行比較,如:desmopressin,三環抗鬱藥及鬧鈴治療. 然而簡單行為學治療方式可以作為在考慮使用鬧鈴治療或是藥物之前的第一線治療,因為這些替代性治療可能會有需要更多的配合及副作用.

翻譯人

本摘要由中國醫藥大學附設醫院李明泓翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

尿床(夜間遺尿)是一個令人感到壓力大的狀況,尤其在年輕的兒童身上. 非疾病造成的不自主漏尿. 這可能造成社交上的問題,遭到兄弟姐妹的嘲笑,降低自尊. 這大約影響著15∼20%的五歲孩童甚至有2%的年輕成人也被困擾著. 簡單行為學治療方式幫助兒童控制尿床,其中包含:積分表及其他獎勵系統,液體限制或是提醒及喚醒方式. 在使用藥物或是鬧鈴治療之前,這些方式常被用來做為首先嘗試控制尿床的問題. 這份回顧性文章找了13個試驗其中包還有702位兒童. 每個治療方式大多數都只在單一的小試驗作研究, 證據的可靠性較低. 簡單行為治療方式相較於不進行治療似乎有較好的減少尿床次數成效,例如:獎勵不尿床的夜晚(用積分表)及提醒及喚醒方式. 然而,這些試驗未與已知具有療效的方式進行比較,例如:尿床鬧鈴及藥物如:desmopressin.另一方面,簡單行為學治療方式沒有任何副作用或是安全性的考量. 因此,在考慮藥物或是鬧鈴治療前,可以嘗試簡單行為學治療方式作為第一線治療. 這還是要更多的研究.

Résumé scientifique

Interventions comportementales simples dans l’énurésie nocturne chez l'enfant

Contexte

L’énurésie nocturne (incontinence urinaire nocturne) est une affection stressante et socialement déstabilisante qui touche entre 15 et 20 % des enfants âgés de cinq ans et jusqu’à 2 % des adultes. Bien que le taux de rémission spontanée soit élevé, les coûts sociaux, émotionnels et psychologiques peuvent être importants. Les interventions comportementales pour le traitement de l'incontinence urinaire nocturne sont des interventions exigeant un comportement ou une action de la part de l'enfant qui favorise les nuits sans incontinences et qui inclut des stratégies visant à récompenser ce comportement. Les interventions comportementales sont divisées en :

(a) interventions comportementales simples - comportements ou actions pouvant être obtenu(e)s de l'enfant sans lui demander beaucoup d'efforts ; et

(b) interventions comportementales complexes - interventions comportementales multiples exigeant un effort supplémentaire de l'enfant et des parents pour son accomplissement, notamment le traitement de l'énurésie à l'aide d'alarmes.

La présente revue privilégie les interventions comportementales simples.

Elles sont couramment utilisées comme première tentative d'amélioration de l'énurésie nocturne et intègrent un système de récompenses, comme des tableaux permettant d'apposer des étoiles pour chaque nuit passée sans incontinence, le lever ou le réveil de l'enfant la nuit pour uriner, l'apprentissage du contrôle de la vessie afin d'accroître la capacité de la vessie (rééducation vésicale) et une diminution de la consommation de liquides. D'autres traitements, comme des médicaments, des interventions complémentaires et diverses, comme l'acupuncture, des interventions comportementales complexes et le traitement de l'énurésie à l'aide d'alarmes, sont envisagés dans les autres cas.

Objectifs

Déterminer les effets d'interventions comportementales simples chez l'enfant souffrant d'énurésie nocturne.

Les comparaisons suivantes ont été réalisées :
1. interventions comportementales simples versus absence d'un traitement actif ;
2. n'importe quel type d'intervention comportementale simple versus une autre méthode comportementale (une autre intervention comportementale simple, traitement de l'énurésie à l'aide d'alarmes ou interventions comportementales complexes) ;
3. interventions comportementales simples versus traitement médicamenteux seul (y compris des placebos) ou traitement médicamenteux combiné à d'autres interventions.

Stratégie de recherche documentaire

Nous avons effectué des recherches dans le registre spécialisé du groupe Cochrane sur l’incontinence qui contient des essais identifiés dans le registre Cochrane des essais contrôlés (CENTRAL), MEDLINE, MEDLINE in Process, ainsi que des recherches manuelles dans des revues et actes de conférence (recherches effectuées le 15 décembre 2011). Les listes bibliographiques d'articles pertinents ont également fait l’objet de recherches.

Critères de sélection

Tous les essais randomisés ou quasi randomisés portant sur des interventions comportementales simples dans le traitement de l'énurésie nocturne chez l'enfant jusqu'à l'âge de 16 ans. Les études qui incluaient des enfants souffrant d'incontinence urinaire diurne ou des enfants souffrant d'une affection organique étaient également incluses dans cette revue, à condition que l'étude examine l'énurésie nocturne. Nous avons exclu les essais portant exclusivement sur l'incontinence urinaire diurne et les essais réalisés auprès d'adultes souffrant d'énurésie nocturne.

Recueil et analyse des données

Deux relecteurs ont indépendamment évalué la qualité méthodologique des essais éligibles et extrait des données. Des discussions avec un troisième relecteur ont permis de régler tout désaccord entre les relecteurs.

Résultats principaux

Seize essais répondaient aux critères d'inclusion et impliquaient 1 643 enfants, dont 865 ont bénéficié d'une intervention comportementale simple. Dans chaque comparaison, les résultats étaient généralement examinés par des essais uniques, empêchant ainsi toute méta-analyse. La seule exception étant la comparaison de la rééducation vésicale à un traitement de l'énurésie à l'aide d'alarmes qui incluait deux études et démontrait que le traitement par alarmes était plus efficace que la rééducation vésicale.

Dans des essais uniques de petite taille, les récompenses, le lever et le réveil de l'enfant, ainsi que la rééducation vésicale, étaient tous associés à une diminution significative du nombre de nuits sans incontinences, une augmentation des taux de réponse maximums et une diminution des taux de rechute par rapport aux groupes témoins. Les interventions comportementales simples semblaient être moins efficaces par rapport à d'autres interventions efficaces connues (comme le traitement de l'énurésie à l'aide d'alarmes et les traitements médicamenteux par imipramine et amitriptyline). Toutefois, les effets n'étaient pas durables pendant le suivi une fois le traitement médicamenteux terminé. D'après un essai de petite taille, un traitement cognitif semblait également être plus efficace que les récompenses. Lors de la comparaison d'un traitement comportemental simple à un autre, il semblerait qu'il n'existe aucun traitement plus efficace qu'un autre.

Conclusions des auteurs

Les méthodes comportementales simples peuvent être supérieures à l'absence de traitement actif, mais elles semblent être moins efficaces que le traitement de l'énurésie à l'aide d'alarme et certains traitements médicamenteux (comme l'imipramine et l'amitriptyline). Il est recommandé de recourir à des thérapies comportementales simples comme traitements de première ligne avant d'envisager un traitement de l'énurésie à l'aide d'alarmes, qui peut être plus contraignant et présenter des effets indésirables, bien que les preuves concernant son efficacité soient insuffisantes.

Plain language summary

Simple treatments for bedwetting in children

Bedwetting (nocturnal enuresis) is the involuntary loss of urine at night without an underlying organic disease as the cause. It can result in issues of psychosocial well-being such as social problems, sibling teasing and lowered self esteem. It affects around 15% to 20% of five year olds and up to 2% of adults.

Simple behavioural strategies to help children gain control include star charts and other reward systems, fluid restriction, bladder training (including retention control training) and lifting or wakening. These are often used as a first attempt to control bedwetting and can be undertaken by families with less professional involvement.

The review found 16 trials which involved 1643 children. Most simple behavioural treatments were only studied in single small trials which makes the evidence less reliable. Simple treatments such as rewarding dry nights (e.g. with star charts), lifting and waking and bladder training appeared to be more effective than no treatment but they are not as effective when compared with other treatments known to work, such as enuresis alarm therapy and drug therapy. There does not appear to be one simple behavioural therapy that is more effective than another. On the other hand, simple treatments do not have any side effects or safety concerns. Therefore, simple methods could be tried as first line therapy before considering alarms or drugs for this common childhood condition.

Laički sažetak

Jednostavni postupci za noćno mokrenje kod djece

Noćno mokrenje je nekontrolirano otpuštanje mokraće tijekom noći, pri čemu ne postoji neka organska bolest kao uzročnik. Može uzrokovati različite psihosocijalne probleme kao što su problemi u društvu, zadirkivanje braće i sestara i manjak samopouzdanja. Pogađa oko 15-20% djece u dobi od 5 godina, i do 2% odraslih osoba.

Jednostavni bihevioralni postupci kojima se može pomoći djeci da postignu bolju kontrolu mjehura uključuju različite metode nagrađivanja, ograničavanje tekućine, vježbanje mjehura (uključujući vježbanje zadržavanja tekućine) te podizanje ili buđenje. Ti se postupci često koriste kao prvi pokušaji kontrole noćnog mokrenja i može ih provoditi obitelj bez pomoći zdravstvenih djelatnika.

Cochrane sustavni pregled u literaturi je pronašao 16 kliničkih istraživanja s ukupno 1643 djece. Najjednostavnijim postupcima bilo je posvećeno samo po jedno malo kliničko istraživanje, zbog čega su ti dokazi manje pouzdani. Jednostavni postupci kao što je nagrađivanje djece za suhu noć (primjerice, izrada ploče na koju se stavljaju zvjezdice za noć bez mokrenja), podizanje i buđenje djece te vježbanje mjehura čine se učinkovitijima nego izostanak bilo kakvih postupaka, ali nisu jednako učinkoviti kao drugi postupci za koje se već zna da učinkovito djeluju – kao što su alarm za noćno mokrenje i lijekovi. Čini se da ne postoji jedna jednostavna bihevioralna terapija koja je učinkovitija od neke druge. S druge strane, jednostavni postupci za noćno mokrenje nemaju nikakvih neželjenih učinaka i sigurni su za primjenu. Stoga se jednostavni postupci trebaju pokušati kao prva linija terapije za noćno mokrenje, prije nego se razmotri kupnja alarma za noćno mokrenje ili uzimanje lijekova za ovo često stanje kod djece.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Livia Puljak
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Résumé simplifié

Traitements simples contre l'incontinence urinaire nocturne chez l'enfant

L'incontinence urinaire nocturne (énurésie nocturne) se caractérise par la perte involontaire d'urine pendant la nuit, non-causée par une maladie organique sous-jacente, susceptible de provoquer des problèmes de bien-être psychosocial, comme des problèmes sociaux, des taquineries de la part des frères et sœurs et une mauvaise estime de soi. Elle touche environ 15 à 20 % des enfants âgés de cinq ans et jusqu'à 2 % des adultes.

Des stratégies comportementales simples pour aider les enfants à contrôler leur vessie incluent des tableaux composés d'étoiles et d'autres systèmes de récompenses, une diminution de la consommation de liquides, une rééducation vésicale (notamment apprendre à contrôler sa vessie) et le lever ou le réveil de l'enfant. Elles sont souvent utilisées comme première tentative pour contrôler l'incontinence urinaire nocturne et les familles peuvent les appliquer, ce qui limite l'intervention de professionnels.

La présente revue a identifié 16 essais impliquant 1 643 enfants. La plupart des traitements comportementaux simples étaient uniquement étudiés dans des essais uniques de petite taille, ce qui altère la fiabilité des preuves. Les traitements simples, comme l'attribution de récompenses pour les nuits sans incontinences (par ex. : des tableaux composés d'étoiles), le lever et le réveil de l'enfant et la rééducation vésicale, semblaient être plus efficaces que l'absence de traitement, mais ils ne sont pas aussi efficaces comparés à d'autres traitements ayant une efficacité reconnue, comme un traitement de l'énurésie à l'aide d'alarmes et un traitement médicamenteux. Il semblerait qu'il n'existe aucun traitement comportemental simple qui soit plus efficace qu'un autre. En revanche, les traitements simples ne présentent aucun effet secondaire ou danger en termes de sécurité. Par conséquent, ces méthodes simples peuvent être tentées comme traitement de première ligne avant d'envisager l'utilisation d'alarmes ou de médicaments contre cette affection infantile courante.

Notes de traduction

Traduit par: French Cochrane Centre 4th September, 2013
Traduction financée par: Pour la France : Minist�re de la Sant�. Pour le Canada : Instituts de recherche en sant� du Canada, minist�re de la Sant� du Qu�bec, Fonds de recherche de Qu�bec-Sant� et Institut national d'excellence en sant� et en services sociaux.

Background

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

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

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

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.

Figure 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).

Figure 2.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 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

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

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

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

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 treatment2 Mean Difference (IV, Fixed, 95% CI)Totals not selected
1.1 Bladder training vs control (wait list + reward)1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
1.2 Reward vs control (wait list)1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
2 Number not achieving 14 consecutive dry nights (failed) on treatment4 Risk 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 control1287Risk Ratio (M-H, Fixed, 95% CI)0.79 [0.68, 0.92]
2.5 Lifting (with password) vs control1284Risk Ratio (M-H, Fixed, 95% CI)0.92 [0.81, 1.05]
3 Mean wet nights after completion of treatment0 Mean Difference (IV, Fixed, 95% CI)Totals not selected
4 Number failed or relapsed after completion of treatment1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
4.1 Reward + lifting vs control (play)1 Risk 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
Analysis 1.1.

Comparison 1 Simple behavioural intervention vs control, Outcome 1 Mean wet nights on treatment.

Analysis 1.2.

Comparison 1 Simple behavioural intervention vs control, Outcome 2 Number not achieving 14 consecutive dry nights (failed) on treatment.

Analysis 1.4.

Comparison 1 Simple behavioural intervention vs control, Outcome 4 Number failed or relapsed after completion of treatment.

Analysis 1.5.

Comparison 1 Simple behavioural intervention vs control, Outcome 5 Mean wet nights on treatment (no SDs).

Mean wet nights on treatment (no SDs)
StudyBehaviouralControl
Waking + reward vs control (wait list)
Baker 1969Mean wet nights per week 3.1; N = 10Mean wet nights per week 5.9; N = 10
Bladder training vs control (wait list)
Harris 1977Mean wet nights per week 2.6; N = 9Mean wet nights per week 5; N = 9
Comparison 2. Simple behavioural intervention vs another behavioural intervention
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Mean wet nights on treatment3 Mean Difference (IV, Fixed, 95% CI)Totals not selected
1.1 Bladder training vs Dry Bed Training (complex intervention)1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
1.2 Bladder training vs alarm1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
1.3 Reward vs cognitive therapy1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
1.4 Reward vs alarm1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
1.5 Waking vs alarm (continuous signal)1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
1.6 Waking vs alarm (twin signal)1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
2 Number not achieving 14 consecutive dry nights (failed) on treatment8 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
2.1 Bladder training vs alarm280Risk Ratio (M-H, Fixed, 95% CI)2.73 [1.75, 4.26]
2.2 Bladder training + alarm vs alarm alone133Risk Ratio (M-H, Fixed, 95% CI)1.77 [0.50, 6.23]
2.3 Bladder training + bladder volume alarm vs alarm alone140Risk 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 alarm139Risk Ratio (M-H, Fixed, 95% CI)1.9 [0.99, 3.66]
2.6 Reward vs cognitive therapy140Risk Ratio (M-H, Fixed, 95% CI)2.8 [1.24, 6.30]
2.7 Waking linked to wetting vs waking at set time1125Risk 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 password1283Risk Ratio (M-H, Fixed, 95% CI)0.86 [0.74, 1.02]
2.11 Lifting (without password) vs reward1286Risk Ratio (M-H, Fixed, 95% CI)0.93 [0.78, 1.10]
2.12 Lifting (with password) vs reward1283Risk Ratio (M-H, Fixed, 95% CI)1.07 [0.92, 1.25]
3 Mean wet nights after completion of treatment1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
3.1 Bladder training vs alarm1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
3.2 Bladder training vs Dry Bed Training (complex intervention with alarm)1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
4 Number failed or relapsed after completion of treatment3 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
4.1 Bladder training + alarm vs alarm alone1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
4.2 Reward vs alarm1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
4.3 Reward vs cognitive therapy1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
4.4 Waking linked to wetting vs waking at set time1 Risk 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
Analysis 2.1.

Comparison 2 Simple behavioural intervention vs another behavioural intervention, Outcome 1 Mean wet nights on treatment.

Analysis 2.2.

Comparison 2 Simple behavioural intervention vs another behavioural intervention, Outcome 2 Number not achieving 14 consecutive dry nights (failed) on treatment.

Analysis 2.3.

Comparison 2 Simple behavioural intervention vs another behavioural intervention, Outcome 3 Mean wet nights after completion of treatment.

Analysis 2.4.

Comparison 2 Simple behavioural intervention vs another behavioural intervention, Outcome 4 Number failed or relapsed after completion of treatment.

Analysis 2.5.

Comparison 2 Simple behavioural intervention vs another behavioural intervention, Outcome 5 Mean wet nights on treatment (no SDs).

Mean wet nights on treatment (no SDs)
StudyBehavioural int.Other behavioural
Bladder training + alarm vs alarm alone
Fielding 1980Mean wet nights per week 1.5; N = 16Mean wet nights per week 0.6; N = 17
Waking + reward vs alarm
Baker 1969Mean wet nights 3.1; N = 10Mean wet nights 1.8; N = 10
Waking vs alarm
Fournier 1987Mean wet nights per week 3.3; N = 8Mean wet nights per week 2.5; N = 8
Bladder training vs alarm
Bryant 2003Mean wet nights per week 4.0; N = 37Mean wet nights per week 3.0; N = 34
Bladder training vs bladder training + alarm
Bryant 2003Mean wet nights per week 4.0; N = 37Mean wet nights per week 4.3; N = 45
Comparison 3. Simple behavioural intervention vs drug intervention
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Mean wet nights on treatment2 Mean Difference (IV, Fixed, 95% CI)Totals not selected
1.1 Waking vs placebo1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
1.2 Bladder training vs desmopressin1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
2 Number not achieving 14 consecutive dry nights (failed) on treatment4 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
2.1 Waking vs placebo1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.2 Waking + reward + placebo vs amitriptyline1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.3 Waking + reward + placebo vs waking + reward + amitriptyline1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.4 Bladder training vs desmopressin1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.5 Bladder training + placebo vs oxybutynin1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.6 Bladder training + placebo vs placebo1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.7 Bladder training + placebo vs Bladder training + oxybutynin1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
3 Mean wet nights after completion of treatment0 Mean Difference (IV, Fixed, 95% CI)Totals not selected
4 Number failed or relapsed after completion of treatment3 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
4.1 Waking + reward + placebo vs amitriptyline1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
4.2 Waking + reward + placebo vs waking + reward + amitriptyline1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
4.3 Fluid restriction and avoidance of punishment vs imipramine1 Risk 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 + imipramine1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
4.5 Bladder training vs desmopressin1 Risk 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
Analysis 3.1.

Comparison 3 Simple behavioural intervention vs drug intervention, Outcome 1 Mean wet nights on treatment.

Analysis 3.2.

Comparison 3 Simple behavioural intervention vs drug intervention, Outcome 2 Number not achieving 14 consecutive dry nights (failed) on treatment.

Analysis 3.4.

Comparison 3 Simple behavioural intervention vs drug intervention, Outcome 4 Number failed or relapsed after completion of treatment.

Analysis 3.5.

Comparison 3 Simple behavioural intervention vs drug intervention, Outcome 5 Mean wet nights on treatment (no SDs).

Mean wet nights on treatment (no SDs)
StudyBehaviouralDrug
Waking vs placebo
Fournier 1987Mean wet nights per week 3.3; N = 8Mean wet nights per week 5; N = 8
Waking vs imipramine
Fournier 1987Mean wet nights per week 3.3; N = 8Mean wet nights per week 1.9; N = 8
Waking vs alarm + imipramine
Fournier 1987Mean wet nights per week 3.3; N = 8Mean wet nights per week 1; N = 8

What's new

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

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

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

None known.

Sources of support

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

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.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Baker 1969

MethodsRCT
Systematic baseline measure of wetting: no
Organic causes excluded: yes
Daytime wetting excluded: not mentioned
ParticipantsNumber of children (boys): 30 (20)
Inclusion criteria: recruited from newspaper advertisement, primary (26) and secondary (4) enuresis
Age median 8 years, range 6 to 12
Baseline wetting: half wetting every night
InterventionsA: (10) alarm
B: (10) wake up using alarm clock, and star chart
C: (10) waiting list control
Duration of treatment: 10 weeks, or 50 wet episodes
OutcomesMean number of wet nights per week in last 3 weeks of treatment: A: 1.8; B: 3.1; C: 5.9 (no SDs)
Minor behavioural adverse events, self limiting
NotesWaiting list controls subsequently given an intervention, results not presented separately
No SDs given
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskEnuretics were randomly assigned to each of the three experimental conditions
Allocation concealment (selection bias)Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Participant
High riskBlinding not possible
Blinding (performance bias and detection bias)
Study personnel
Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding not possible. Outcome assessors were parents
Incomplete outcome data (attrition bias)
All outcomes
High riskThree patients excluded because they did not complete treatment
Selective reporting (reporting bias)Unclear riskNot mentioned
Other biasUnclear risk

Adverse events mentioned

Systematic baseline measure of wetting: no
Organic causes excluded: yes
Daytime wetting excluded: not mentioned

Bennett 1985

MethodsRCT
Systematic baseline measure of wetting: yes
Organic causes excluded: not mentioned
Daytime wetting excluded: yes if only negligible
ParticipantsNumber of children (boys): 40 (25)
Dropouts: 32 (A: 9; B: 11; C: 10; D: 3)
Inclusion criteria: primary nocturnal enuresis, referred to enuresis service by general practitioner, negligible daytime wetting
Exclusion criteria: encopresis, previous behavioural intervention, gross psychopathology
Age mean 8.5 years (SD 3.2) range 5 to 12
Baseline wetting: dry nights, boys 3/14; girls 2.4/14; A: 3.7/14 (SD 3.1); B: 2.8/14 (2.9); C: 2.7/14 (2.3); D: 1.9/14 (2.1)
InterventionsA: (9) alarm (bell and pad)
B: (12) stop-start training (sphincter muscle exercises, bladder training)
C: (10) Dry Bed Training including alarm
D: (9) waiting list control (used star chart after first dry night)
Duration of treatment: 10 weeks
OutcomesMean dry nights in last 2 weeks of 12 weeks treatment: A: 12 (SD 3.9); B: 7.5 (5.2); C: 11.2 (3.6); D: 3.7 (3.0)
Number achieving 14 dry nights:
A: 4/9; B: 2/12; C: 5/10; D: 0/9
Mean dry nights at follow-up:
A: 12.3 (3.1); B: 7.1 (5.8); C: 9.3 (5.3); (D treated after 12 weeks)
Adverse events: not mentioned
NotesAll children were given star charts after their first dry night
High dropout rate
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskEligible children were randomly assigned to one of four treatments
Allocation concealment (selection bias)High riskHigh dropout replaced by others
Blinding (performance bias and detection bias)
Participant
High riskBlinding not possible
Blinding (performance bias and detection bias)
Study personnel
High riskNo blinding
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding not possible
Incomplete outcome data (attrition bias)
All outcomes
High riskHigh dropout
Selective reporting (reporting bias)Unclear riskNot mentioned
Other biasUnclear risk

Side effects not mentioned

Systematic baseline measure of wetting: yes
Organic causes excluded: not mentioned
Daytime wetting excluded: yes if only negligible

Bhatia 1990

MethodsRCT (matched on age and sex)
Systematic baseline measure of wetting: no
Organic causes excluded: yes
Daytime wetting excluded: no
Participants

Number of children (boys): 60 (39)
Dropouts: 22 due to irregular follow-up
Inclusion criteria: nocturnal enuresis (52), diurnal enuresis (24), daytime wetting (6); behaviour problems
Setting: Child Guidance Clinic, New Delhi

Age: 4 to 12 years

Although baseline data were provided for all participants, individual baseline data for each treatment group were not provided.

InterventionsA: (20) placebo and simple behavioural intervention (restrict fluids, avoid punishment)
B: (20) imipramine 10 mg (age 3-6 years); 25 mg (> 6 years), doubled after 2 weeks if no improvement, stopped 4 weeks after cure
C: (20) imipramine and simple behavioural intervention
Duration of treatment: 6 weeks
Follow-up: 6 months
Outcomes

Number not achieving 14 dry nights or relapsing afterwards: A: 16/20, B: 8/20, C: 2/20

Adverse events: not mentioned

NotesHigh dropout rate due to inadequate follow-up
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskCases were divided randomly into three groups
Allocation concealment (selection bias)Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Participant
High riskBlinding not possible for arm 2
Blinding (performance bias and detection bias)
Study personnel
High riskNo blinding
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding not possible for arm 2
Incomplete outcome data (attrition bias)
All outcomes
High riskHigh dropout, patients with irregular follow-up were excluded
Selective reporting (reporting bias)Unclear riskNot mentioned
Other biasUnclear risk

Adverse events not mentioned

Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: No

Bryant 2003

MethodsRCT
Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: no
Participants

Number of children (boys): 116 (86)
Dropouts: 55
Inclusion criteria: children presenting to community continence clinic with nocturnal enuresis
Exclusion criteria: developmental disability, voiding dysfunction, UTI, urinary tract abnormalities
Setting: community continence clinic in Sydney, Australia

Age: 5 to 14 years
Baseline wetting (number of wet nights per 28 nights): A: 26, B: 25, C: 24.

InterventionsA: (34) body worn alarm
B: (37) bladder training
C: (45) body worn alarm and bladder training
Duration of treatment: unknown
Follow-up: at 16 weeks, 24 weeks and 52 weeks.
Outcomes

Wet nights per 28 nights:

At 16 weeks: A: 12, B: 16, C: 17

At 26 weeks: A: 9, B: 16, C: 10

At 52 weeks: A: 9, B: 4, C: 8

Notes

Author contacted, additional information provided. Duration of treatment variable. Number achieving 14 consecutive dry nights was not given

Other outcomes assessed were: mean net wet pull-up weight, diurnal average/maximum void

Adverse events not mentioned

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskComputer random number generated (contact with author)
Allocation concealment (selection bias)Low riskCentral allocation (contact with author)
Blinding (performance bias and detection bias)
Participant
High riskParticipants not blinded
Blinding (performance bias and detection bias)
Study personnel
High riskNo blinding (contact with author)
Blinding (performance bias and detection bias)
Outcome assessor
High riskNo blinding
Incomplete outcome data (attrition bias)
All outcomes
High riskHigh dropouts, outcomes not reported
Selective reporting (reporting bias)High riskNot all outcomes mentioned
Other biasHigh risk

Adverse events not mentioned

Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: no

El-Anany 1999

MethodsRCT
Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: not mentioned
ParticipantsNumber of children (boys): 125 (78), A: 70 (46); B: 55 (32)
Dropouts: 64 within 1 month (groups not specified)
Inclusion criteria: baseline at least 3 wet nights per week
Exclusion criteria: age < 7 years; secondary enuresis; polysymptomatic; urinary, structural or clinical neurological abnormalities
Age: A: 13.23 years (SD 3.75) range 7 to 21; B: 12.49 years (SD 3.62) range 7 to 19
Baseline wetting: A: 5.24 years (SD 1.22) range 3 to 7; B: 5.13 years (SD 1.17) range 3.7
InterventionsA: (70) alarm clock set while still expected to be dry before usual time of wetting
B: (55) alarm clock set for 2 to 3 hours after falling asleep
Both groups, fluid restriction for 2 hours before bed
Duration of treatment 4 months
OutcomesSuccess at first: A: 54/70; B: 34/55
Success at 3 months: A: 46/70; B: 31/55
Success at 6 months follow-up: A: 41/70; B: 29/55
Failure or relapse at 6 months: A: 42/70; B: 31/55
Adverse events: none
Notes64 subjects stopped using the alarm clock within the first month, but results presented as intention-to-treat, including all participants
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskPatients were randomly enrolled into two treatment groups
Allocation concealment (selection bias)Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Participant
High riskBlinding not possible
Blinding (performance bias and detection bias)
Study personnel
Unclear riskBlinding not mentioned
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding not possible
Incomplete outcome data (attrition bias)
All outcomes
High riskDropout rate and number did not add up
Selective reporting (reporting bias)Unclear riskNot mentioned
Other biasLow risk

Adverse events mentioned

Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: not mentioned

Study used intention-to-treat analysis

Fava 1981

MethodsRCT
Systematic baseline measure of wetting: no
Organic causes excluded: not mentioned
Daytime wetting excluded: not mentioned
ParticipantsNumber of children (boys): 20 (A: 6; B: not given)
Dropouts: 0
Inclusion criteria: primary enuresis
Exclusion criteria: secondary enuresis
Age: A mean 8 years ± 1.66; B not given
InterventionsA: (10) behaviour modification (stars for dry nights and rewards; if no improvement after 15 nights, subjects also lifted at nights to void)
B: (10) unstructured play therapy
Duration of treatment: 3 months, follow-up at 1 year
OutcomesCured (14 consecutive dry nights): A: 8/10 (of whom 2 needed night lifting); B: 1/10
Failed or relapsed at 1 year: A: 2/10; B: 9/10
Adverse events: not mentioned
NotesNo baseline information about control group
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskPatients were randomly assigned to two groups
Allocation concealment (selection bias)Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Participant
High riskNot possible to blind
Blinding (performance bias and detection bias)
Study personnel
Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Outcome assessor
High riskNot possible to blind
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo loss to follow up, all patients follow-up data provided
Selective reporting (reporting bias)Unclear riskNot mentioned
Other biasUnclear risk

Adverse events not mentioned

Systematic baseline measure of wetting: no
Organic causes excluded: not mentioned
Daytime wetting excluded: not mentioned

Fielding 1980

MethodsRCT
Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: yes (study included day and night wetting in a parallel design, which was excluded in this review)
ParticipantsNumber of children (boys): 45 (6 lost at baseline) (30)
Dropouts: 11
Inclusion criteria: age 5 to 15; no urinary tract infection; no evidence of organic pathology; not treated within previous 12 months; no daytime wetting
Age range: 5 years 2 months to 13 years 10 months
Baseline wetting: mean number of wet nights in 4 weeks: A: 23.5; B: 24.7
InterventionsA: (16) bladder training and alarm
B: (17) alarm alone
Duration of treatment: retention control training 4 weeks and alarm 14 weeks
Follow-up after 3, 6 and 12 months
OutcomesMean number of wet nights in 3rd month of alarm: A: 6.2; B: 2.3
Number achieving 14 consecutive dry nights: A: 11/16; B: 14/17
Number (%) relapsing after 3 months: A: 3 (28); B: 4 (29)
after 6 months: A: 3 (28); B: 5 (36)
after 12 months: A: 4 (36); B: 8 (57)
Adverse events: not mentioned
Notes

Although dropouts mentioned, outcome analysis excluded those who dropped out
Parallel study specifically includes diurnal wetters (results not given here)
No blinding
Not reported if comparable groups
No SDs given

As data given for first month of treatment before alarms were introduced in group A, outcomes between retention control (without alarm) can be compared with alarm monotherapy where mean wetting frequency was 5.8 per week 6 for retention control training and 1.3 per week for alarm training

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskPatients were randomly allocated to treatment
Allocation concealment (selection bias)Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Participant
High riskBlinding not possible
Blinding (performance bias and detection bias)
Study personnel
Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding not possible
Incomplete outcome data (attrition bias)
All outcomes
High riskHigh number of dropouts were mentioned but analysis excluded dropouts
Selective reporting (reporting bias)Unclear riskNot mentioned
Other biasHigh riskAs group A (retention control) also had alarm training after 4 weeks, the treatment outcomes after 4 weeks from group A likely to be confounded

Fournier 1987

MethodsRCT (double-blind)
Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: not mentioned
Differences in baseline severity of wetting - MANOVA used
ParticipantsNumber of children (boys): 64 (47) completed the study
5 extra children dropped out
Inclusion criteria: no treatment in past 3 months
Mean age: 8 years 5 months
Baseline wetting: mean number of wet nights in week 2: A: 5.3; B: 6; C: 4.5; D: 4.2; E: 4.5
InterventionsA: (8) imipramine
B: (8) alarm
C: (8) placebo
D: (8) random awakening
E: (8) alarm and imipramine
F: (8) alarm + placebo
G: (8) random awakening and placebo
H: (8) imipramine and random awakening
Duration of treatment: 6 weeks
Follow-up 3 months but some children continued on treatments
Outcomes

Mean number of wet nights per week:
A: 1.9; B: 2.5; C: 5; D: 3.3
E: 1
No results for F, G or H

Adverse events: 4 boys dropped out because of side effects or non-compliance, but adverse events by individual interventions not specifically mentioned

Notes

Parallel groups
4 boys dropped out because of side effects or non-compliance, 1 girl with UTI
No SDs given

For random waking, parents were instructed to wake the child to void any time before midnight

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskRandom assignment to one of the two treatment groups
Allocation concealment (selection bias)Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Participant
High riskBlinding not possible for some treatments
Blinding (performance bias and detection bias)
Study personnel
Low riskMentioned "double blind"
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding not possible for some treatments
Incomplete outcome data (attrition bias)
All outcomes
High riskNo details of dropouts
Selective reporting (reporting bias)High riskNot all outcomes reported
Other biasUnclear risk

Adverse events not mentioned

Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: not mentioned

Hamano 2000

MethodsRCT (method not given)
Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: yes
Follow-up 2 weeks
ParticipantsNumber of children (boys): 114 (88)
Dropouts: 18 (not wet or poor compliance)
Inclusion criteria: primary monosymptomatic nocturnal enuresis, at least 4 times a week
Exclusion criteria: neurological or physical abnormalities, UTI
Age 5 to 15 years; A: 9.2; B: 9.4
Baseline wetting (SD) A: 6.8 (0.7); B: 6.7 (0.9)
InterventionsA: (54) DDAVP intranasally, 5 mcg increasing to 20 mcg if no response, decreasing when strongly responding
B: (60) bladder training; holding voiding once a day to increase bladder capacity
Duration 12 weeks
OutcomesMean wet nights/week: A: 6.8 (SD 0.76); B: 6.7 (SD 0.87)
Number not achieving 14 dry nights A: 33/54; B: 46/60
Relapsing after cure: A: 17; B: 5
Failed or relapsing after trial: A: 50/54; B: 51/60
Side effects: adverse events infrequent: A: 2/54 (nasal discomfort); B: 0/60
NotesResults presented according to functional bladder capacity but merged here
Short follow-up
Groups comparable at baseline
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot mentioned
Allocation concealment (selection bias)Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Participant
High riskBlinding not possible
Blinding (performance bias and detection bias)
Study personnel
Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding not possible
Incomplete outcome data (attrition bias)
All outcomes
High riskNot all outcomes reported
Selective reporting (reporting bias)High riskNot all outcomes reported
Other biasLow riskSystematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: yes

Harris 1977

MethodsRCT
Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: yes
ParticipantsNumber of children (boys): 18 (12); A: 9 (5); B: 9 (7)
Inclusion criteria: recruited from newspaper advertisement; at least 1 wet night per week
Exclusion criteria: daytime wetting; mental deficiency; urinary infection; diabetes; anatomical defects; current medication for enuresis
Mean age: A: 9.2 years; B: 8.8 years; range 5 to 13
Half of subjects had previously taken medication but discontinued because it was ineffective or because of side effects.
Baseline wetting: mean number of wet nights per week: A: 3.2; B: 5
InterventionsA: (9) bladder training in a camp or treatment program followed by parental training
B: (9) waiting list control
Duration of treatment: A, stage 1 (camp): 5 days; stage 2 (home): 30 days
Follow-up: 9 weeks
OutcomesMean number of wet nights per week: A: 2.6; B: 5.0, but no differences within groups over time
Follow-up, mean wet nights: A: 3.9, which was not significantly different from pre- or post-treatment measures (F = 1.68, df = 2, 16)
Significant main effect of intervention was on bladder capacity in experimental group A
Adverse events: not mentioned
NotesNo blinding
Comparability of groups not reported, but appeared to be different
Unclear if intention-to-treat
Short follow-up
Inappropriate control
No SDs given
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"...randomly assigned"
Allocation concealment (selection bias)Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Participant
High riskBlinding not possible
Blinding (performance bias and detection bias)
Study personnel
Unclear riskBlinding not mentioned
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding not possible
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo mention of number of participants at follow-up
Selective reporting (reporting bias)Unclear riskVery little information given
Other biasLow riskSystematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: yes

Mehrotra 1980

MethodsRCT (stratified by age, sex and socioeconomic status)
Systematic baseline measure of wetting: no
Organic causes excluded: not mentioned
Daytime wetting excluded: not mentioned
Participants

Number of children: 60
Dropouts: 0
Inclusion criteria: children attending outpatients for enuresis

Baseline data not provided for individual interventions

InterventionsA: (20) placebo tablets (B complex) and behavioural intervention (waking and lifting 2 hours after bedtime, stars and rewards for dry nights)
B: (20) amitriptyline (10 mg ages 3-6, 25 mg over 6 years; dose doubled if no improvement after 3 weeks)
C: (20) amitriptyline and behavioural intervention
Duration: 5 weeks
Follow-up: 4 to 5 months
OutcomesFailed (i.e. not cured): A: 17/20; B: 6/20; C: 11/20
Failed or relapsed at follow-up: A: 15/20; B: 10/20; C: 15/20
Adverse events: 2 drowsy with amitriptyline (B or C)
NotesParallel groups
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Divided equally into three groups randomly"
Allocation concealment (selection bias)Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Participant
High riskNot possible to blind
Blinding (performance bias and detection bias)
Study personnel
Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Outcome assessor
High riskNot possible to blind
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo loss to follow up
Selective reporting (reporting bias)Low riskAll outcomes reported
Other biasHigh risk

Adverse events mentioned

Systematic baseline measure of wetting: no
Organic causes excluded: not mentioned
Daytime wetting excluded: not mentioned

Pretlow 1999

MethodsRCT (alternate allocation)
Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: yes
ParticipantsNumber of children: 40
Dropouts (failures) A: 9; B: 8
Inclusion criteria: non-organic monosymptomatic nocturnal enuresis, at least 1 time/week in previous year
Exclusion criteria: daytime wetting, other medical or psychological pathology, other enuresis treatment
Baseline comparisons: Mean age: A: 10.7 years; B: 9.6 years
% dry nights: A: 33.7%; B: 9.3%
Number of wet nights: A: 1.85; B: 2.5
Recruited from responders to newspaper advertisement
InterventionsA: (20) volume alarm triggered at 80% of average daytime volume
B (20) volume alarm triggered at 80% of average enuretic volume and retention control training
Alarm not triggered by actual wetting
OutcomesCured: A: 11/20: B: 12/20
Time to achieve cure: A: 10.5 months; B: 7.2 months
Increase in full bladder capacity: A: from 132 cc to 223 (69%); B: 128 to 228 (78%)
Adverse events: failure or non-compliance mentioned, but adverse events by individual interventions not specifically mentioned
Notes

Ultrasound monitor used to measure bladder volume during sleep
Data given for individual patients

Baseline differences between groups: group B younger and enuresis more severe during baseline monitoring

Poor response due to: 1, parents refused to help child; 1, child did not use instrument consistently; 1, parent failed to use instrument properly; 2, family strife
Dropouts due to: 3, parents' sleep disturbed; 3, family break-up; 5, child schedule too busy; 2, parent schedule too busy; 2, child didn't like retention control exercises; 2, technology too complicated

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskDivided into two groups, did not mention randomisation
Allocation concealment (selection bias)High riskAlternate allocation
Blinding (performance bias and detection bias)
Participant
High riskBlinding not possible
Blinding (performance bias and detection bias)
Study personnel
Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding not possible
Incomplete outcome data (attrition bias)
All outcomes
Low riskHigh withdrawal rate, but accounted for in intention-to-treat analysis
Selective reporting (reporting bias)Unclear riskNot mentioned
Other biasHigh risk

Two groups were not comparable at baseline as group 1 was less severe

 

Ronen 1995

MethodsRCT (assigned chronologically in order of application)
Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: not mentioned
ParticipantsNumber of children (boys): 77 (39)
Dropouts: 23 (A: 2; B: 4; C: 6; D: 11)
Inclusion criteria: children attending a community mental health clinic with primary enuresis
Exclusion criteria: medical or developmental problems; age < 5 years
Age: mean 10.05 (SD 2.28)
Baseline wetting: mean wet nights in 3 weeks (SD): A: 19.8 (1.73); B: 19.8 (2.14); C: 18.9 (2.21); D: 18 (8.72)
InterventionsA: (20) cognitive and behavioural self-control education therapy counselling
B: (19) alarm (bell and pad)
C: (20) token economy (star chart and rewards)
D: (18) control (waiting list for 3 months)
Duration: 18 weeks
Follow-up at 6 months
OutcomesCured (3 consecutive dry weeks): A: 15/20; B: 12/19; C: 6/20; D: 0/18
Failed (intention-to-treat, including dropouts as failures): A: 5/20; B: 7/19; C: 14/20; D: 18/18
Number of wet nights in 3 weeks at end of treatment: A: N = 18; mean 1.03, (SD 2.15); B: N = 15; 1.23 (SD 5.28); C: N = 14; 3.33 (SD 5.8); D: N = 16; 17.22 (SD 9)
Actual failure or relapse after 6 months (excluding dropouts): A: 3/18; B: 9/15; C: 8/14
Adverse events: not mentioned
Notes

A (cognitive treatment) had lowest dropout, highest success and lowest relapse compared with B, C or D

Ronen 1992 and Ronen 1995 are both the same trial

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskAssigned by chronological order
Allocation concealment (selection bias)High riskNo concealment
Blinding (performance bias and detection bias)
Participant
High riskBlinding not possible
Blinding (performance bias and detection bias)
Study personnel
High riskNo blinding
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding not possible
Incomplete outcome data (attrition bias)
All outcomes
High riskNumber of participants at the end of treatment less than at baseline.
Selective reporting (reporting bias)High riskThe study only reported results they thought were "reliable and trustworthy"
Other biasHigh riskImbalance in dropouts between interventions

Turner 1970

MethodsRCT (stratified by age (4 to 7 years and 7 to 15 years) and sex (12:8 M:F))
Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: not mentioned
Participants

Number of children (boys): 115 (80)
Dropouts: 39 of 81 allocated to an alarm (A, B or C), due to failure to use equipment properly, disruption or domestic problems. 1/32 from D or E
Inclusion criteria: primary (103) and secondary (12) enuresis
Exclusion criteria: organic pathology; adverse home conditions; bedwetting < 3 times/week; previous alarm treatment
Age mean 7.5 years (SD 2.6)

Baseline data not provided for individual interventions

InterventionsA: (15) alarm, continuous signal
B: (15) alarm, twin signal
C: (12) alarm, intermittent twin signal (after first 2 weeks, alarm sometimes disconnected)
D: (15) random wakening
E: (17) placebo tablet
Duration: 4 weeks for D and E only: if no success, withdrawn from study for alternative treatment
Mean duration: A: 6.8 weeks; B: 6.2 weeks; C: 10.2 weeks
OutcomesFailed at 4 weeks: A: 12/15; B: 13/15; D: 14/15; E: 13/17
Mean wet nights per week at 4 weeks: A: 2.9 (SD 2.27); B: 3.58 (2.07); D: 3.23 (2.09); E: 4.22 (2.37)
Failure at end of treatment: A: 3/15; B: 4/15; C: 1/12
Longterm failure at 3 years: A+B combined: 13/20; C: 3/11
Adverse events: non-compliance, failure or family disruption caused high dropout but adverse events by individual interventions not specifically mentioned
Notes

Dropouts replaced by next child referred to the clinic. Some failures treated with methedrine. Trial unable to reach required sample size of 20 subjects per group during 5 year recruitment period
Therefore unreliable trial
Adverse events caused high dropout rate in alarm groups due to unable to use the equipment or family disruption or strife
Data therefore not useable

Random waking - parents given a chart of when the child should be woken each night, with the times varying randomly

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot mentioned
Allocation concealment (selection bias)High risk"Allocated at random... within 2 age bands"
Blinding (performance bias and detection bias)
Participant
High riskBlinding not possible
Blinding (performance bias and detection bias)
Study personnel
Unclear riskBlinding not mentioned
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding not mentioned
Incomplete outcome data (attrition bias)
All outcomes
High risk115 children enrolled, but data only available for 74 patients
Selective reporting (reporting bias)High riskLarge number of dropouts, those with poor compliance to treatment replaced
Other biasHigh risk

When treatment had to be stopped due to poor parental cooperation, the vacancy was filled by the next child referred to the clinic

There were differential compliance rates between groups with higher non-compliance rates in the alarm conditioning groups (39/81) compared with the control (placebo + random waking) groups (1/34)

Van Dommelen 2009

MethodsRCT
Systematic baseline measure of wetting: yes
Organic causes excluded: yes
Daytime wetting excluded: yes, unless deemed an accident
Participants

Number of children (boys): 570 (342)
Dropouts: 140
Inclusion criteria: children 4 to 5 years of age with MNE for 2 or more wet nights in the past 3 months who have had no previous treatment with alarm or pharmacology and no underlying pathology for nocturnal enuresis
Exclusion criteria: daytime wetting, non-Dutch readers, underlying pathology or wetting less than 2 nights per week

Setting: community (children recruited from magazine, Internet and during standard preventative visit to health care professionals)
Age: 4 to 5 years
Baseline wetting: not known

Interventions

A: (140) lifting with a password
B: (143) lifting (without a password)
C: (143) star chart reward

D: (144) control (diary)

Duration of treatment: 6 months or until 14 consecutive dry nights
Follow-up: 3 years

Outcomes

Predicted number achieving 14 consecutive dry nights at 6 months and 3 years using a multivariate imputation technique were reported (absolute number achieving 14 consecutive dry nights at 6 months and 3 years were also given)

Using MICE at 6 months: A: 27% (140), B: 37% (143), C: 32% (143), D: 21% (144)

at 3 years: A: 78% (140), B: 78% (143), C: 76% (143), D: 69% (144)

Initial planned outcome was 14 consecutive dry nights with intervention and an additional 14 consecutive dry nights without intervention. However, researchers adapted outcome continence criteria according to what parents did (to 14 consecutive dry nights with intervention only).

Adverse events: not mentioned

NotesDue to large loss to follow up, MICE (imputation method) was used to handle missing data
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskComputer database used but assignment does not appear to be random (sequence generated by rule on computer based on gender)
Allocation concealment (selection bias)Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Participant
High riskNot possible to blind
Blinding (performance bias and detection bias)
Study personnel
Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Outcome assessor
High riskNot possible to blind
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskHigh loss to follow up reported without reasons given, however, use of MICE (imputation method) to address attrition
Selective reporting (reporting bias)High riskThe researchers adapted the outcome incontinence criteria according to what the parents did rather than the prespecified outcomes
Other biasHigh riskThere were differential dropouts between the groups, with large loss to follow up

Van Hoeck 2007

  1. a

    Alarm = enuresis alarm triggered by wetting; Bladder Training = increasing fluid intake and delaying urination for increasing periods of time to expand bladder capacity; DDAVP = desmopressin; MICE = multivariate imputation by chained equation; MNE = monosymptomatic nocturnal enuresis; Random Wakening = wakening the child to urinate at random times; RCT = randomised controlled trial; SD = standard deviation; UTI = urinary tract infection; Volume Alarm = alarm triggered by ultrasound measurement of bladder volume, triggered at prespecified volume before wetting occurs;

MethodsRCT
Systematic baseline measure of wetting: no
Organic causes excluded: yes
Daytime wetting excluded: yes
Participants

Number of children (boys): 149 (108)
Dropouts: 8
Inclusion criteria: 5 years or older with at least 14 wet nights in 28 days
Exclusion criteria: anatomical or functional incontinence, previous treatment in the last 3 months with alarm, desmopressin or anticholinergic, puberty beyond Tanner stage 1

Setting: Referral to author's institution (University Hospital, Antwerp, Belgium)
Age: 5.9 to 12.7 years, with median 7.5 years
Baseline wetting: no baseline number of wet nights measured

Interventions

A: (29) holding exercises + placebo
B: (30) holding exercises + oxybutynin
C: (30) placebo

D: (30) oxybutynin

E: (30) alarm
Duration of treatment: 12 weeks
Follow-up: at end of treatment (12 weeks)

Outcomes

One wet night or less in last 28 nights was considered full response:

A: 1/29 (3%), B: 3/30 (10%), C: 0/30 (0%), D: 4/30 (13%), E: 22/30 (73%)

Adverse events mentioned: headache with oxybutynin

Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNo information given. Randomisation stratified by hospital referred, gender, age, pubertal stage, family history of MNE, previous treatment and bladder capacity.
Allocation concealment (selection bias)Unclear riskNot mentioned
Blinding (performance bias and detection bias)
Participant
High riskBlinding only for medication, not for holding exercises or alarm
Blinding (performance bias and detection bias)
Study personnel
Unclear riskBlinding not mentioned
Blinding (performance bias and detection bias)
Outcome assessor
High riskBlinding only for medication, not for holding exercises or alarm
Incomplete outcome data (attrition bias)
All outcomes
High risk8 dropouts, 7 were due to poor response
Selective reporting (reporting bias)Unclear riskNot mentioned
Other biasHigh risk

Adverse events mentioned

Systematic baseline measure of wetting: no
Organic causes excluded: yes
Daytime wetting excluded: yes

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
  1. a

    CCT = controlled clinical trial; CT = cleanliness training; PP = positive practice; RCT = randomised controlled trial

Ayan 2007Intervention: did not look at outcomes for nocturnal enuresis
Bak 2007Intervention: only looking at subset
Barker 1979Participants: adult residents with special needs (not children)
Bouchard 1981Study design: not RCT
But 2006Intervention: not simple behavioural therapy, functional magnetic stimulation
Chertin 2007Intervention: not simple behavioural therapy, alarm versus desmopressin
Cohen 2006Contact with author, study was not completed, no data available
Creer 1975Study design: not RCT
Doleys 1977Intervention: Dry bed training versus Retention control training
Excluded because children moved from B to A, therefore data unreliable
Dong 1998Study design: not RCT
Intervention: traditional Chinese medicine (herbs) for children with enuresis, not simple behavioural therapy
Evans 2007Intervention: not simple behavioural therapy, desmopressin versus alarm
Hagglund 1965Study design: not RCT ('divided into three groups without selection')
Hanson 1988Participants: adult residents with mental retardation (aged 13 to 29)
Jiang 1996

Study design: not RCT

Intervention: not simple behavioural therapy, complimentary and miscellaneous interventions for nocturnal enuresis

Jodorkovsky 2003Intervention: not simple behavioural therapy, complimentary and miscellaneous interventions for nocturnal enuresis
Kawauchi 1998bStudy design: not RCT
Kroll 2006

Participants: not nocturnal enuresis

Intervention: comparing alpha 1 blockers and behavioural therapy to treat detrusor-sphincter discoordination

Lebedev 1995Study design: not RCT
Participants: children with neurogenic bladder dysfunction
Li 1996Study design: not RCT
Intervention: not simple behavioural therapy, complimentary and miscellaneous interventions for nocturnal enuresis
Li 2002Intervention: not simple behavioural therapy, complimentary and miscellaneous interventions for nocturnal enuresis
Ma 2007Intervention: not simple behavioural therapy, complex behaviour and education
McConaghy 1969Interventions: imipramine, amphetamine, pad-and-bell conditioning and random awakening
Excluded because children were moved between trial arms, data therefore unreliable
Naitoh 2005Intervention: not simple behavioural therapy
Ozden 2008Intervention: not simple behavioural therapy
Paschalis 1972Study design: not RCT
Reed 1994Intervention: not simple behavioural therapy - chiropractic treatment
Renjing 2004Intervention: not simple behavioural therapy, complimentary and miscellaneous interventions for nocturnal enuresis
Seabrook 2005Intervention: not simple behavioural therapy, complimentary and miscellaneous interventions for nocturnal enuresis
Terakye 1997Study design: not RCT (children allocated according to 'settlement places')
Tuygun 2007Intervention: not simple behavioural therapy
Van Hoeck 2008Intervention: not simple behavioural therapy - alarm therapy
Van Kampen 2009Intervention: not simple behavioural therapy, complex behaviour and education
Vasconcelos 2006Intervention: not simple behavioural therapy, complex behaviour and education
Vasconcelos 2007Study design: not RCT
Wang 1994Study design: not RCT
Intervention: not simple behavioural therapy, complimentary and miscellaneous interventions for nocturnal enuresis
Wang 1999Study design: not RCT
Intervention: Not simple behavioural therapy, complimentary and miscellaneous interventions for nocturnal enuresis
Wang 2007Intervention: not simple behavioural therapy, complex behaviour and education
Xiao 1997Intervention: not simple behavioural therapy, complimentary and miscellaneous interventions for nocturnal enuresis
Yamanishi 1988Study design: not RCT

Characteristics of studies awaiting assessment [ordered by study ID]

Rodriguez 1984

MethodsAwaiting response from author
ParticipantsAwaiting response from author
InterventionsComparative efficacy between three procedures for the treatment of enuresis (Kimmel behavioural approach, pharmacological and mixed techniques)
OutcomesAwaiting results
NotesNumbers do not add up. Author contacted. Awaiting response

Unuvar 2005

MethodsAwaiting author response
ParticipantsAwaiting author response
InterventionsDesmopressin vs conditioning therapies (alarm clock or enuresis alarm)
OutcomesAwaiting author response
NotesAwaiting response from authors as we were unsure whether conditioning therapy involves alarm clock or enuresis alarm Therefore, unsure if it is a simple therapy or alarm training

Ancillary