Complex behavioural and educational interventions for nocturnal enuresis in children
Editorial Group: Cochrane Incontinence Group
Published Online: 26 JAN 2004
Assessed as up-to-date: 19 MAR 2008
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Glazener CMA, Evans JHC, Peto RE. Complex behavioural and educational interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004668. DOI: 10.1002/14651858.CD004668.
- Publication Status: New search for studies and content updated (no change to conclusions)
- Published Online: 26 JAN 2004
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 young adults.
To assess the effects of complex behavioural and educational interventions on nocturnal enuresis in children, and to compare them with other interventions.
We searched the Cochrane Incontinence Group Specialised Trials Register (searched 20 March 2008) and the reference lists of relevant articles.
All randomised or quasi-randomised trials of complex behavioural or educational interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and physical behavioural methods, alarms, desmopressin, tricyclic antidepressants, and miscellaneous other interventions.
Data collection and analysis
Two review authors independently assessed the quality of the eligible trials, and extracted data.
Eighteen trials involving 1174 children were identified which included a complex or educational intervention for nocturnal enuresis. The trials were mostly small and some had methodological problems including the use of a quasi-randomised method of concealment of allocation in three trials and baseline differences between the groups in another three.
A complex intervention (such as dry bed training (DBT) or full spectrum home training (FSHT)) including an alarm was better than no-treatment control groups (for example the relative risk (RR) for failure or relapse after stopping DBT was 0.25; 95% CI 0.16 to 0.39) but there was not enough evidence about the effects of complex interventions alone if an alarm was not used. A complex intervention on its own was not as good as an alarm on its own or the intervention supplemented by an alarm (e.g. RR for failure or relapse after DBT alone versus DBT plus alarm was 2.81; 95% CI 1.80 to 4.38). On the other hand, a complex intervention supplemented by a bed alarm might reduce the relapse rate compared with the alarm on its own (e.g. RR for failure or relapse after DBT plus alarm versus alarm alone was 0.5; 95% CI 0.31 to 0.80).
There was not enough evidence to judge whether providing educational information about enuresis was effective, irrespective of method of delivery. There was some evidence that direct contact between families and therapists enhanced the effect of a complex intervention, and that increased contact and support enhanced a package of simple behavioural interventions, but these were addressed only in single trials and the results would need to be confirmed by further randomised controlled trials, in particular the effect on use of resources.
Although DBT and FSHT were better than no treatment when used in combination with an alarm, there was insufficient evidence to support their use without an alarm. An alarm on its own was also better than DBT on its own, but there was some evidence that combining an alarm with DBT was better than an alarm on its own, suggesting that DBT may augment the effect of an alarm. There was also some evidence that direct contact with a therapist might enhance the effects of an intervention.
Plain language summary
Complex behavioural and educational interventions for bedwetting (nocturnal enuresis) in children
Night-time bedwetting is common in childhood, and can cause stigma, stress and inconvenience. Bed alarms are the treatments which currently appear to work best in the long term. Complex interventions such as dry bed training can also be tried. This involves, as well as using an alarm to wake the child after he or she has wet the bed, getting them to go to the toilet repeatedly and changing their own sheets. The review found 18 trials in 1174 children who had received this sort of training or another treatment. Although an alarm on its own was better than the dry bed training on its own, there was some evidence that using them together might reduce the relapse rate after stopping alarm treatment, and without the adverse effects of drug treatment. However, both using an alarm and dry bed training needs time and effort from the child and family. There was not enough research comparing complex interventions with other techniques.
夜間遺尿(尿床)會導致社交障礙與壓力的狀態，有15% – 20%的五歲孩童, 2%的成人受其影響,
所有探討(兒童夜間遺尿)複合行為治療或教育治療的隨機或半隨機試驗皆納入評估, 排除只分析白天尿床的研究。比較的治療包括沒有接受治療的族群, 單純或物理性的行為治療, 鬧鐘, desmopressin, 三環抗鬱劑或其他。
18個試驗共計1174名兒童被納入夜間遺尿的複合(行為)治療或教育治療中。大部分試驗的樣本數都不多, 而且研究設計方法上也出現問題, 如其中三個試驗使用半隨機方法中的隱藏配給(concealment of allocation); 在另外三個試驗中, 也出現試驗組與對照組之間使用基準差異(baseline differences)的狀況。 複合式治療(例如無尿床單訓練(dry bed training)或全方位居家訓練(full spectrum home training)如鬧鐘), 它的治療效果優於控制組 (例如停止DBT治療之後, 夜尿復發的相對危險性(relative risk)為0.25, 95%信賴區間0.16至0.39)。沒有確實證據顯示如果沒有使用鬧鐘, 複合式治療的效果依然。 如果單純使用複合式治療, 結果顯示其療效並沒有比鬧鐘合併複合式治療的效果來得優越 (例如, 使用DBT vs DBT加上警示器的失敗或復發率之相對風險值(relative risk)為2.81, 95%信賴區間為1.80至4.38)。另外, 如果使用鬧鐘, 合併複合式治療的夜尿復發率比較低(例如, 使用鬧鐘加上DBT vs 只有鬧鐘, 它們的失敗或復發RR值為0.5, 95%信賴區間為0.31至0.80)。 無論衛教的方法為何, 都沒有足夠證據顯示衛教是治療夜間遺尿的一種有效方式。如果家屬與治療師之間直接聯繫, 可以增加複合式治療的效果；增加家屬與治療師之間的聯繫和支持, 也可以達到單純行為治療的治療效果。但是這些試驗的樣本數都較少, 需要透過隨機控制試驗(randomised controlled trials)來證實這樣的結論, 特別是證實所使用何種方式的治療效果。
雖然DBT和FSHT在跟鬧鐘配合的情況下, 治療效果優於對照組, 但是卻沒有足夠證據顯示如果在沒有鬧鐘的情況下它們也有同樣的治療效果。單獨使用鬧鐘的治療效果也優於單獨使用DBT, 但是證據顯示鬧鐘合併DBT治療效果優於單獨使用DBT, 這樣的結果可能暗示DBT可以作為鬧鐘的輔助治療。有些證據顯示, 加強家屬與治療師的聯繫可以增加治療效果。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。
複合式治療與鬧鐘並用可以減少夜間尿床的次數, 但是這需要時間也需要孩童跟家屬一併努力。兒童族群中, 夜間遺尿是常見的問題, 讓家屬跟孩童倍感羞恥、壓力與不便。床邊警示器(鬧鐘)是目前認為最有療效的長期治療方法, 也可以嘗試複合式治療如DBT, 包括在他們還沒有尿床之前用鬧鐘把他們叫醒, 讓他們重複上廁所與換床單。這次的回顧也發現鬧鐘合併這些訓練使用可以減少夜尿的復發, 也沒有藥物的副作用, 但這需要時間和努力。目前並沒有研究是在探討復合式療法與其他治療技術之間的差別。