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Keywords:

  • Humans;
  • Absorbent Pads;
  • Adult;
  • Case-Control Studies;
  • Child;
  • Child, Preschool;
  • Desmopressin [therapeutic use];
  • Electrodes;
  • Enuresis [drug therapy; *prevention & control];
  • Nephrology [methods];
  • Randomized Controlled Trials;
  • Renal Agents [therapeutic use]

Abstract

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

Background

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.

Objectives

To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions.

Search strategy

We searched the Cochrane Incontinence Group specialised trials register (searched 22 November 2004) and the reference lists of relevant articles.

Selection criteria

All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods.

Data collection and analysis

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

Main results

Fifty five trials met the inclusion criteria, involving 3152 children of whom 2345 used an alarm. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods.

Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95% CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents.

Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (4/22 (18%) vs 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69). Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94).

Authors' conclusions

Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.

PLAIN LANGUAGE SUMMARY

Alarm interventions reduce night-time bed wetting in children during treatment, and are better in the long term than treatment with desmopressin or tricyclic drugs.

Night-time bedwetting is common in childhood, and can cause stigma, stress and inconvenience. Alarms take longer to reduce bedwetting than desmopressin, but their effects continue after treatment in half the children who use alarms. Overlearning (giving children extra fluids at bedtime after successfully becoming dry using an alarm) and dry bed training (getting children to go to the toilet repeatedly and changing their own sheets when they wet) may reduce the relapse rate. There are no serious side-effects, which can occur with drug treatment. However, children need more supervision and time from other family members at first. There was not enough evidence with which to compare alarms with other non-drug treatments. Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.


BACKGROUND

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

This is one of seven reviews of interventions for bedwetting, or non-organic nocturnal enuresis. The others focus on: desmopressin (Glazener 2002), tricyclics and related drugs (Glazener 2003a), other drugs (Glazener 2003b), simple behavioural training (Glazener 2004b), complex behavioural training (Glazener 2004b) and miscellaneous other therapies (eg complementary, in preparation). All seven are based on the work of Lister-Sharp and her colleagues at the Centre for Reviews and Dissemination at the University of York, UK (Lister-Sharp 1997). The current review is a further update of two previously published Cochrane reviews (Glazener 2001; Glazener 2003c). It concerns the use of alarms triggered by wetting (eg pad-and-bell alarms) to waken the child. It is restricted to children with monosymptomatic nocturnal enuresis who are treated with an alarm triggered by wetting, and includes other interventions if they are compared with such alarms or used in combination with them.

Nocturnal enuresis is the involuntary loss of urine at night, in the absence of organic (physical) disease such as urinary tract infection or detrusor overactivity, at an age when a child could reasonably be expected to be dry (by consensus, at a developmental age of five years) (WHO 1992; APA 1980). Although bedwetting in itself is pathologically benign and has a high rate of spontaneous remission, it may bring social and emotional stigma, stress and inconvenience to both the person with enuresis and their families (Fitzwater 1992). Children who wet the bed may experience parental disapproval, sibling teasing and repeated treatment failure which may lower self esteem (Warzak 1992). The children may also be at increased risk of emotional and physical abuse (Warzak 1992). Consequently, it is important that enuresis is properly managed (Moffatt 1994).

Although daytime wetting is a significant problem and is often associated with bedwetting, it is usually considered separately. It has been suggested that there are different aetiologies underlying monosymptomatic nocturnal enuresis and daytime wetting (Jarvelin 1989). If daytime symptoms are present, investigations to identify physical causes such as urinary tract dysfunction, congenital malformation and neurogenic disorders are usually necessary (Djurhuus 1992). An organic cause is more often found in children with daytime wetting; for example more structural abnormalities and functional disorders of the urinary tract are found in daytime wetters than controls (Jarvelin 1990).

PREVALENCES AND CAUSES

Nocturnal enuresis is a complaint that affects many families. Estimating the prevalence of monosymptomatic nocturnal enuresis is difficult, however, because there is variation in methods of diagnosis and definitions (de Jonge 1973; Krantz 1994). About 13-19% of boys and 9-16% of girls at age five wet the bed at least once per month (Devlin 1991; Feehan 1990; Rutter 1973; Verhulst 1985). Although enuresis shows a steady decline with age, 2-3% still wet regularly during the late teens and early adulthood (Forsythe 1974). The incidence of nocturnal enuresis is particularly high amongst children in residential care (Morgan 1970). Without treatment, about 15% of bedwetting children become dry each year (Forsythe 1974). However, it is not possible to predict which children will become dry spontaneously (Doleys 1977).

The causes of monosymptomatic nocturnal enuresis are unclear (Lister-Sharp 1997). Genetic (Bakwin 1971; Bakwin 1973; APA 1980; Eiberg 1995), physiological (Djurhuus 1992; Norgaard 1993) and psychological (Shaffer 1977; Rutter 1973; Devlin 1991; Moffatt 1989) factors, as well as delay in maturation of the mechanism for bladder control (Jarvelin 1989; Koff 1995), have been suggested. Other factors which may contribute to bedwetting include: constipation, sleep apnoea and upper airway obstructive symptoms (Maizels 1993); and diet and mild caffeine drinks with diuretic effects (eg cola) (Blackwell 1989).

INTERVENTIONS

Pharmacological, psychological/behavioural and a variety of 'unconventional' interventions are commonly used for people who wet the bed.

  • Pharmacological interventions include desmopressin (Glazener 2002), tricyclic drugs (amitriptyline, dothiepin, doxepin, trimipramine, clomipramine, desipramine, imipramine, lofepramine, nortriptyline and protriptyline, Glazener 2003a), drugs related to the tricyclics (viloxazine, desipramine, mianserin and maprotiline, Glazener 2003a), and a variety of other drugs (eg amphetamine, diazepam and oxybutynin, Glazener 2003b). These are discussed in separate reviews as indicated.

  • Behavioural interventions include simple methods (eg star charts, reward systems, overlearning, retention control training, urine stream interruption exercises, lifting and scheduled wakening, Glazener 2004b), and complex (multidimensional) behavioural methods (eg dry bed training, full spectrum home training, Glazener 2004a).

  • Other interventions include psychotherapy, surgery, fluid deprivation and complementary therapies (review in preparation).

ENURESIS ALARMS

Enuresis alarms consist of some kind of alarm which is activated by micturition. The first enuresis alarms were bed-based, the child sleeping on a pad or mat containing an electrical circuit (Mowrer 1938). Urine, coming into contact with this would complete the circuit causing a bell to ring. Historically, some alarms worked by giving an electric stimulus or shock to the children's skin. The alarm is intended to change the meaning of the sensation of having a full bladder from a signal to urinate to a signal to inhibit urination and waken (Forsythe 1989). There are now many variations: the alarm may be a bell, buzzer, a visual signal such as a light or it may vibrate. There are also many different tones and intensities, and the alarm may be set to operate only intermittently or after an interval. In 'mini-alarm' systems, the sensor is placed in pants, producing a discrete, portable system ('body-worn' alarm).

OVERLEARNING

An over-learning procedure may be initiated after successful alarm treatment (eg achievement of 14 consecutive dry nights). Extra drinks are given at bed-time to cause additional stress to the detrusor muscles in the bladder. Alarm treatment is then continued until 14 consecutive dry nights are once again achieved (Blackwell 1989).

OTHER BEHAVIOURAL INTERVENTIONS

These include:

  • Lifting

Lifting involves taking the child to the toilet during the night to empty their bladder, usually before the time that bedwetting is expected, without necessarily waking the child.

  • Waking

This intervention involves waking the child to allow them to get up and urinate (Warzak 1994). 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 to wake themselves (Blackwell 1989). However, the use of an alarm clock in this circumstance is not included as an alarm triggered by bedwetting as defined in this review.

  • Reward systems (eg star chart)

Systems to reward the child for dry nights are often used as first line treatment. For example, the child might receive a star for every dry night, and a reward after a preset number of stars have been earned.

  • Retention control training

This is an attempt to increase the functional bladder capacity using exercises such as delaying urination for extended periods of time or drinking increased fluids (Warzak 1994).

  • Stop-start training

Stream interruption exercises (pelvic floor muscle training) have also been used (Novello 1987).

  • Dry bed training

Dry bed training was initially developed in the early 1970s for use with people with learning disabilities (Azrin 1973). The original schedule involved an intensive training night, during which the patient was woken every hour and taken to the toilet. If an accident occurred, 45 minutes of 'cleanliness training' (changing the bed) and 'positive practice' (child practices 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. The wakening might or might not be triggered by an alarm.

Other (miscellaneous) interventions in the current review include: cognitive therapy, psychotherapy, counseling, education/information systems, restricted diet and shaming. These are described in the Table of Included Studies.

The wide variety of treatments for nocturnal enuresis indicates the lack of consensus as to which is the best. Provided that a sufficient number of adequate quality have been conducted, the most reliable evidence is likely to come from consideration of all well-designed randomised controlled trials. Hence, there is a need for an easily accessible, periodically updated, comprehensive systematic review of such studies which will not only help to identify optimal practice, but also highlight gaps in the evidence base.

OBJECTIVES

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

To determine the effects of alarms for the treatment of children with nocturnal enuresis.

The following hypotheses were tested:

  • 1.
    alarms are better than no active treatment/non-functioning alarms
  • 2.
    one type of alarm is better than another one
  • 3.
    alarm treatment alone is better than a behavioural intervention alone
  • 4.
    alarm treatment alone is better than alarm treatment supplemented by a behavioural method
  • 5.
    alarm treatment alone is better than a drug treatment alone or better than alarm treatment supplemented by a drug
  • 6.
    alarm treatment alone is better than treatments other than behavioural or drugs

CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

Types of studies

Randomised or quasi-randomised trials of alarm interventions for the treatment of non-organic nocturnal enuresis.

Types of participants

Children (as defined by the trialists, usually up to age 16) suffering from nocturnal enuresis. Trials which included children suffering from daytime enuresis or where some children may have had an organic cause contributing to their enuresis were only included if the primary problem was nocturnal enuresis.

Types of intervention

Any trial which used an alarm in at least one arm of the study.

Comparisons were made with no active treatment, behavioural interventions and drugs (either alone or in combination with alarms) and any other treatments not already specified.

Types of outcome measures

The outcomes considered in this review were:

  • change in the mean number of wet nights per week during treatment;

  • number of participants failing to attain 14 consecutive dry nights;

  • mean number of wet nights per week when participants were followed up after treatment had ceased;

  • number failing to attain 14 consecutive dry nights or subsequently relapsing; and

  • adverse events

Timing of relapse and follow up was as defined by the trialists.

SEARCH METHODS FOR IDENTIFICATION OF STUDIES

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

See: Incontinence Group methods used in reviews.

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 under the Incontinence Group's details in The Cochrane Library. The register contains trials identified from MEDLINE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL) and hand searching of journals and conference proceedings. Date of the most recent search of the register for this review: 22 November 2004.

The trials in the Incontinence Group's specialised register are also contained in the Cochrane Central Register of Controlled Trials (CENTRAL). The terms used to search the Incontinence Group trials register are given below:

(TOPIC.URINE.ENURESIS*)

AND

({DESIGN.CCT*} OR {DESIGN.RCT*})

(All searches were of the keyword field of Reference Manager 9.5 N, ISI ResearchSoft).

The reviewers also searched the reference lists of relevant articles. No language or other restrictions were imposed on any of these searches.

METHODS OF THE REVIEW

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

The studies for this review were assessed using the methods of the Cochrane Collaboration (Deeks 2003).

Identification of primary studies

The titles and where possible abstracts of all studies located by the searches were checked to identify those likely to be evaluations of the effects of interventions for nocturnal enuresis. Full papers were then obtained and assessed to identify those which met the inclusion criteria.

Quality assessment

A range of both general and more specific quality issues were noted, including:

  • the level of concealment of random allocation in the trials (A=adequate method of concealment of allocation to groups, B=unclear, C=quasi-randomised, Deeks 2003);

  • whether data to assess the comparability of groups at baseline were given, including baseline levels of wetting;

  • use of a 'wash-out' period if a crossover design was employed;

  • intention-to-treat analysis;

  • whether outcomes were clearly defined;

  • blinding;

  • a follow-up of at least three months or provision of follow-up data;

  • whether useful data (eg means and standard deviations) were presented;

  • whether children with daytime wetting were specifically excluded;

  • whether children who had physical (organic) causes for their enuresis were specifically excluded.

However, none of these criteria were used to include or exclude trials.

Data extraction

The data were extracted using a standard form, independently by two reviewers.

Data analysis

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 cure during treatment, defined as 14 consecutive dry nights, or the number who were not cured during treatment plus those who relapsed after stopping active treatment (to allow for possible differences in initial 'success' rates). Where a mean value was reported with no standard deviation, we entered the data into 'Other Data Tables'.

We intended, where possible, to calculate standardised effect sizes and 95% confidence intervals (CI): weighted mean differences (WMD) where outcomes were continuous variables and relative risks (RR) where they were binary. A fixed effect model was used to calculate the pooled estimates and the 95% CIs (Berlin 1989). The weighted mean differences were weighted by the inverse of the variance, and given as differences in number of wet nights per week. Negative values indicate fewer wet nights in the group on the left of the metaview.

Differences between trials were further investigated when statistically significant heterogeneity was apparent either at the 10% probability level, using the chi squared test or assessment of the I-squared statistic (Higgins 2003), or from visual inspection of the results. If there was no obvious reason for the heterogeneity, or it persisted despite the removal of outlying trials, a random effects model was used.

Data from crossover trials were treated as if coming from parallel groups. A sensitivity analysis excluding crossovers would have been performed to check whether their inclusion biased the results. However, only one was found.

In general, dropouts were not taken into account and data were presented as given in the trial reports. However, if there were evidence of differential dropouts from the groups which may have been caused by adverse effects of the interventions, the data were recalculated as if the dropouts were failures.

DESCRIPTION OF STUDIES

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

Eighty three studies were identified as including an alarm intervention. Thirty were excluded, the majority because they were not randomised controlled trials. Three of these 30 were RCTs which included an adult population (Azrin 1973; Crisp 1984; Hanson 1988) and one other was excluded because children were switched between groups (McConaghy 1969). One of these trials was an 'included study' in a previous version of this review (Hanson 1988). Details are given in the Table of Excluded Studies.

Fifty five randomised controlled trials were included in the review (see Table of Included Studies). They were described in 51 reports (three reports each described two trials (Bollard 1981a; Bollard 1981b; Butler 1990a; Butler 1990b; Geffken 1986a; Geffken 1986b), and one described three trials (Lovibond 1964a; Lovibond 1964b; Lovibond 1964c)). One study (reported here as two separate trials) divided children into two groups according to their baseline maximal functional bladder capacity, large or small (Geffken 1986a; Geffken 1986b).

Trials with methodological flaws

Two included trials failed to provide reliable data, one because groups were combined and results reported only as medians for the combined groups (Azrin 1974) and the other because children who dropped out from the alarm groups (due to inability to use the alarm or family disruption) were replaced by other children resulting in non-randomised groups and unreliable data (Turner 1970).

Types of interventions

The trials all included an alarm which activated a bell or buzzer when triggered by wetting. In the majority, this was the standard bed-pad-and-bell but variations included body-worn alarms (Butler 1990a) and electric shock alarms (Elinder 1985; Hojsgaard 1979; Lovibond 1964a; McKendry 1975; Netley 1984).

Numbers of children

In total, 3152 children were studied, of whom 2345 received an alarm intervention either alone or in combination with another treatment. In general, sample sizes were small, ranging from 14 to 222 with an average of about 57 participants per trial.

Duration of treatment

Duration of treatment varied amongst the trials: alarms were used for between 2 and 8 weeks in 16 trials, 8 to 12 weeks in 17 trials, and for more than 8 weeks in 22 trials. However, children usually stopped earlier than the maximum allowed duration of treatment if they became dry.

Baseline wetting, organic causes and daytime wetting

In 14 trials, there was no period of baseline recording of wetting before beginning the trial. In seven trials, authors failed to report that children with a possible organic cause for their bedwetting were excluded. In one of these seven, neither of these measures of quality (baseline wetting or exclusion of organic causes) were recorded (Forrester 1964). Of the seven trials where organic causes were not specifically excluded, two included some children with daytime wetting (Caceres 1982; Moffatt 1987), three failed to record information about daytime wetting (Forrester 1964; Houts 1986; van Londen 1993) and only two explicitly excluded children whose primary problem was daytime wetting (Bennett 1985; Lynch 1984). However, no trials included children with known organic causes.

In 18 trials, children with diurnal (daytime as well as nighttime) wetting were specifically excluded. Six trials included at least some children with daytime wetting (Bradbury 1995; Caceres 1982; Gibb 2004; McKendry 1975; Moffatt 1987; Taylor 1975) although in three, organic causes were specifically excluded (Bradbury 1995; McKendry 1975; Taylor 1975). Another included diurnal wetting 'only if negligible' (Bennett 1985). One trial included some children who also had encopresis (Taylor 1975). The remaining trials did not mention daytime wetting.

Follow up

Of the 55 included studies, only 28 trials provided follow-up data about wet nights or relapse rates after the end of trial treatment. In some trials follow up was not possible because children were given alternative (non-randomised) treatments.

Settings

The children were recruited in different settings. In six trials, they were identified from the community by advertising in the media; in 17 they were recruited in hospital or community outpatient clinics; in four both methods were used; three trials were in residential institutions (Jehu 1977) or amongst children with special needs (Kennedy 1968; Sloop 1973); and in 22 the setting was not specified.

Ages of children

Most trials required children to be at least five years old at entry, but in six trials a few younger children were included (Azrin 1974; Azrin 1978; Jehu 1977; Taylor 1975; Wright 1974; Young 1972).

Previous treatment

In three trials, children were only included if they had not previously had treatment for their enuresis (Butler 1990a; Faraj 1999; Sloop 1973); in another four, all the children had failed with previous treatment (Butler 1990b; Caceres 1982; Gibb 2004; Scholander 1968); in a further 16 trials some children had received previous treatment (Bollard 1982a; Bradbury 1995; Butler 1988; Elinder 1985; Fielding 1980; Jehu 1977; Leebeek 2001; Longstaffe 2000; Motavalli 1994; Nawaz 2002; Rodriguez 2001; Sukhai 1989; Tobias 2001; Wagner 1982; Wille 1986; Young 1972); the remainder did not provide this information.

METHODOLOGICAL QUALITY

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

Of the 55 included trials, eight reported concealment of allocation to groups which was probably adequate (eg by use of sealed opaque envelopes or remote computer allocation, rated as A: Azrin 1974; Bradbury 1995; Leebeek 2001; Longstaffe 2000; Moffatt 1987; Motavalli 1994; Scholander 1968; Sukhai 1989); 39 trials did not provide adequate detail for this to be assessed (rated as B); and seven used methods where allocation definitely was not adequately concealed (ie quasi-randomised such as alternate numbers, rated as C: Butler 1990a; Butler 1990b; Kennedy 1968; Ronen 1992; Taylor 1975; Wagner 1985; Werry 1965). In one further trial, although the initial randomisation was classed as A and stratified by age and sex, there were differential dropouts from the groups and they were non-systematically replaced resulting in unreliable groups (Turner 1970).

Crossover trials

There was one double-blind cross over trial (Sukhai 1989). An alarm in both arms of the trial was supplemented by desmopressin or placebo for two weeks, crossing over to the alternative arm after a two-week washout period. Follow-up information could therefore not be given separately for each regimen.

Dropouts

Only three trials reported that there were no dropouts (Scholander 1968; Sukhai 1989; Wagner 1985). Where the drop-out rates in treatment and comparison groups were similar and no reasons were given, or where children randomised were found ineligible or did not attend for initial monitoring, analyses were conducted according to actual results reported, excluding drop-outs. There were 27 such trials, in which dropouts did not seem to be affected by group of allocation (Bennett 1985; Bollard 1981a; Butler 1988; Butler 1990a; Butler 1990b; Elinder 1985; Faraj 1999; Fielding 1980; Forrester 1964; Fournier 1987; Geffken 1986a; Geffken 1986b; Houts 1986; Jehu 1977; Kolvin 1972; Lovibond 1964a; Lynch 1984; Moffatt 1987; Netley 1984; Rodriguez 2001; Ronen 1992; Wagner 1982; Werry 1965; Wright 1974). In one other trial, the number of dropouts was unclear because each was replaced with a subsequent child seen in the clinic (Taylor 1975) but as this did not seem to be affected by the intervention allocated, the data have been used as reported.

However, where reasons for drop-out were reported as clearly related to the treatment group (eg unacceptability of the particular treatment, adverse effects) they were included as failures. There were three trials which reported such differential dropouts from the groups, probably caused by adverse effects of the interventions. In the first two, data were reported as if the dropouts were failures (Bollard 1981b; McKendry 1975). In the other, children were differentially withdrawn from treatment, making the groups unreliable: data were not used from this study (Turner 1970).

Dropouts were usually due to: children not being sufficiently enuretic at baseline assessment or found not to be eligible in other ways for the trial; failure to attend for monitoring or follow up; receiving the wrong intervention; non-compliance or difficulty with using the equipment; family disruption; failure of the treatment; and in the case of the alarms which delivered electric shocks, the parents or the child being unwilling to experience the shocks (Elinder 1985; Lovibond 1964a; McKendry 1975; Netley 1984).

Statistical reporting

Eighteen trials reported continuous data but failed to provide measures of dispersion such as SDs (Azrin 1978; Baker 1969; Bollard 1981a; Bollard 1981b; Bollard 1982a; Butler 1988; Butler 1990a; Butler 1990b; Danquah 1975; Fielding 1980; Finley 1973; Fournier 1987; Jehu 1977; Kolvin 1972; Leebeek 2001; Wagner 1982; Wagner 1985; Wright 1974). These data were entered into Other Data Tables.

RESULTS

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

1. ALARMS COMPARED WITH PLACEBO / NO TREATMENT CONTROL (Comparison 01, Other Data Tables 01)

Seventeen trials compared an alarm with a no-treatment control group. The controls were:

The types of alarms were:

  • two trials used a delayed-alarm (Lynch 1984; Wagner 1985);

  • one included an unsupervised alarm group (Bollard 1981a);

  • two used an electric shock to the children's skin, the Uristop device (Elinder 1985; Hojsgaard 1979); and

  • all remaining trials used a pad-and buzzer type of alarm to wake the children when wetting occurred.

During treatment

Nine trials provided data about wet nights during treatment. On average, there were over three fewer wet nights per week using the standard alarm, compared to no-treatment controls (eg WMD -3.34, 95% CI -4.14 to -2.55 in the four trials which reported SDs, Comparison 01.01.01) (Bennett 1985; Lynch 1984; Nawaz 2002; Ronen 1992); and in 6/6 trials where SDs were not reported (Other Data Tables 01.02.01) (Baker 1969; Bollard 1981a; Bollard 1981b; Jehu 1977; Wagner 1982; Wagner 1985). In 13 trials, the relative risk of failure was less in the alarm groups of all the trials (107/316, 34% did not achieve 14 dry nights versus 250/260, 96% in no-treatment controls, RR 0.38, 95% CI 0.33 to 0.45, Comparison 01.03.01) (Bennett 1985; Bollard 1981a; Bollard 1981b; Houts 1986; Jehu 1977; Lynch 1984; Moffatt 1987; Nawaz 2002; Ronen 1992; Sacks 1974; Sloop 1973; Wagner 1982; Wagner 1985; Werry 1965).

There was significant heterogeneity (P<0.00001). After exclusion of two trials which involved children in residential homes (Jehu 1977) or with learning disabilities (Sloop 1973) and a further three trials which used quasi-randomised methods of allocation to groups (Ronen 1992; Wagner 1985; Werry 1965) the heterogeneity was reduced but still significant (P=0.013) while the RR for failure remained similar in favour of alarm treatment (RR 0.36, 95% CI 0.29 to 0.44). The remaining heterogeneity may have been due to differences in types or effectiveness of the alarms used (as the children in all the control groups had a similar failure rate of over 90%) or differences between types of children for example in baseline severity of wetting. It is more likely, however, that the heterogeneity is a statistical artefact caused by the high proportion of children who failed, because the heterogeneity disappears if the data are entered as cure rates instead of failure rates.

Only three trials involved delayed or unsupervised alarms, but the net effect was still generally in favour of the alarm group during treatment (Comparisons 01.03.02, 01.03.03, Other Data Tables 01.02.02, 01.02.03) (Bollard 1981a; Lynch 1984; Wagner 1985).

After treatment stops

About half the children failed or relapsed after stopping standard alarm treatment compared to nearly all after control interventions (45/81 (55%) versus 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68, Comparison 01.04.01) (Bollard 1981a; Bollard 1981b; Sloop 1973; Wagner 1982; Wagner 1985). There was no evidence of heterogeneity amongst these five trials for this outcome. There were no data for the number of wet nights after treatment stops.

Electric shock alarms

There was not enough evidence from two small trials to assess the electric shock (Uristop) alarms (Comparison 01.03.04, Hojsgaard 1979; 01.03.05, Elinder 1985). It was reported that some children were frightened of them, or their parents refused to let them be used.

2. COMPARISONS BETWEEN ALARMS (Comparison 02, Other Data Tables 02)

Eleven trials compared different alarms or their use in different circumstances. A large number of variations on standard alarm treatment were tested, including:

  • a body-worn alarm (Butler 1990a);

  • intermittent alarm (Taylor 1975);

  • time-delay before bell rings (Lynch 1984; Wagner 1985);

  • alarm used without supervision (Bollard 1981a);

  • loud versus quiet bells, with or without light (Finley 1973; Finley 1977);

  • an alarm which only wakes the parents (Finley 1973);

  • a double (twin) alarm using both a bell and a buzzer (Lovibond 1964a; Lovibond 1964c);

  • an electric stimulation (shock) alarm (Crosby Dri-nite, Lovibond 1964a); and

  • a body-worn audio alarm versus a body-worn vibrating alarm (Tobias 2001).

Immediate versus time delay alarm

In two small trials there were fewer wet nights when using an alarm which woke the child immediately rather than after a time-delay of 3 minutes (WMD -2.5, 95% CI -3.99 to -1.01, Comparison 02.01.01, Lynch 1984; Other Data Tables 02.02.02, Wagner 1985) and differences in failure or relapse rates were consistent with this but were not statistically significant (Comparisons 02.03.03, 02.04.03) (Lynch 1984; Wagner 1985).

Waking child versus waking parents

In one small trial, an alarm which woke the child directly was more successful than one which only woke the parents (Comparisons 02.03.06, 02.03.07, 02.04.06, 02.04.07; Other Data Tables 02.02.05, 02.02.06) (Finley 1973).

Body-worn versus bed alarm

In another small trial, body-worn alarms appeared to be as effective as standard bed pad alarms (albeit with wide confidence intervals) but children preferred the body-worn alarm (Comparisons 02.03.01, 02.04.01; Other Data Tables 02.02.01) (Butler 1990a).

Electric shock alarm

In one small trial, three children received corrosive skin burns and two others discontinued treatment due to fear when using an alarm which delivered an electric shock (Crosby Dri-nite, Lovibond 1964a). The alarm was therefore not used in subsequent trials.

Other alarms

There were no other clear differences between different types of alarms or different ways of using them. However, some children reported that the body-worn vibrating alarm was more uncomfortable than the audio alarm (Tobias 2001).

3. ALARMS COMPARED WITH BEHAVIOURAL INTERVENTIONS (Comparison 03, Other Data Tables 03)

Eight trials compared alarms with a variety of simple or complex behavioural interventions:

  • star charts or rewards (Ronen 1992);

  • star chart plus wakening (Baker 1969);

  • wakening or lifting (Fournier 1987; Lovibond 1964b);

  • retention control training and stop-start training (pelvic floor muscle training) (Bennett 1985); and

  • Dry Bed Training (complex intervention without an alarm) (Azrin 1978; Bollard 1981b; Caceres 1982).

Simple behavioural interventions

Alarms were better than stop-start training in terms of wet nights per week both during (WMD -2.25, 95% CI -4.2 to -0.3) and after (WMD -2.6, 95% CI -4.53 to -0.67) treatment in one small trial (Comparisons 03.01.02, 03.04.01) (Bennett 1985). However, the chance of cure was not significantly higher (Comparison 03.03.02) although in the same direction.

There were no significant differences between alarms and other simple behavioural methods such as lifting, wakening or rewards in four other trials (Baker 1969; Fournier 1987; Lovibond 1964b; Ronen 1992), although all trials tended to favour alarms in respect of mean wet nights (Comparison 03.01.01, Other Data Tables 03.02.01, 03.02.02, 03.02.03).

Complex behavioural interventions

During treatment, there was no clear difference in wet nights between alarm and dry bed training in three trials (without an alarm) (Comparison 03.03.03; Other Data Tables 03.02.03) (Azrin 1978; Bollard 1981b; Caceres 1982), but there was significant heterogeneity. In the Azrin trial, children only received treatment for two weeks before being switched to the other arm, which may not have been long enough for the alarm to work (Azrin 1978). Excluding this trial, the heterogeneity was no longer significant and the RR for failing to achieve 14 dry nights was 0.22, 95% CI 0.09 to 0.53 (Bollard 1981b; Caceres 1982). In the one small trial which provided data after the trial stopped, there was less chance of failure or relapse after alarm treatment alone than after dry bed training alone (RR 0.59, 95% CI 0.37 to 0.95, Comparison 03.05.03) (Bollard 1981b).

4. ALARMS COMPARED WITH ALARM PROGRAMMES AUGMENTED BY BEHAVIOURAL INTERVENTIONS (Comparison 04, Other Data Tables 04)

Sixteen trials compared alarms alone with alarm programmes augmented by behavioural interventions:

  • supplementation of the alarm by supervision (Bollard 1981a);

  • alarm plus retention control training (Bollard 1982a; Fielding 1980; Geffken 1986a; Geffken 1986b; Houts 1986);

  • alarm plus dry bed training (Azrin 1974; Bennett 1985; Bollard 1981b; Bollard 1982a; Butler 1988; Butler 1990b; Nawaz 2002);

  • alarm plus waking (Bollard 1982a);

  • alarm plus rewards with and without penalties (van Londen 1993);

  • alarm plus overlearning (Houts 1986; Taylor 1975; Young 1972); and

  • alarm plus positive practice with cleanliness training (Bollard 1982a).

Supplementing alarms with retention control training

Although alarms alone were better than alarms plus retention control training in five trials in terms of failure rates during treatment (RR 0.37, 95% CI 0.18 to 0.76, Comparison 04.03.02) (Bollard 1982a; Fielding 1980; Geffken 1986a; Geffken 1986b; Houts 1986), this was not reflected in terms of wet nights during treatment (Comparison 04.01.01) (Geffken 1986a; Geffken 1986b) or in failure or relapse rates after the end of treatment (RR 1.12, 95% CI 0.77 to 1.64, Comparison 04.04.02) (Fielding 1980; Geffken 1986a; Geffken 1986b; Houts 1986). However, the trials were all small.

Supplementing alarms with overlearning

Although the results during treatment were similar for alarms compared with alarms plus overlearning (Comparisons 04.03.04, 04.03.05) there may be less relapse after treatment stops if overlearning is used after successful alarm treatment (33/67 (49%) failed or relapsed after alarms alone versus 19/77 (25%) with overlearning, RR 1.92, 95% CI 1.27 to 2.92, Comparison 04.04.04) (Taylor 1975; Young 1972).

Supplementing alarms with dry bed training

In the five trials which compared an alarm alone with an alarm supplemented by dry bed training (Bennett 1985; Bollard 1981b; Butler 1988; Butler 1990b; Nawaz 2002) the trend in favour of supplementation did not reach statistical significance (Comparisons 04.01.02, 04.03.06, 04.04.04; and Other Data Tables 04.02.03) and there was significant heterogeneity in the three Comparisons. This heterogeneity could have been due to the inclusion of one trial (Butler 1990b) which used different types of alarms in the two arms (bed alarm plus DBT in one versus body-worn (pants) alarm in the other). All the children included in this trial had already failed using a standard bed alarm. Removal of this trial reduced or removed the heterogeneity: the failure or relapse rate was reduced in the group supplemented with dry bed training (20/32, 63% versus only 20/72, 27%: RR 2.0, 95% CI 1.25 to 3.20, Comparison 04.04.07) (Bollard 1981b; Nawaz 2002).

Supplementing alarms with rewards and penalties

In one trial, adding rewards for dry beds or correct behaviour to alarm treatment was associated with lower failure rates during treatment (Comparison 04.03.08) but using penalties for wet beds was less effective or counterproductive after treatment had finished (eg failure or relapse rate 10/36 (28%) after alarms alone versus 21/39 (54%) when supplemented by penalties, RR 0.52, 95% CI 0.28 to 0.94, Comparison 04.04.09 and RR 0.54, 95% CI 0.30 to 0.96, Comparison 04.04.10) (van Londen 1993).

Other methods of augmentation

In general, participants using alarms alone were as likely to attain 14 consecutive dry nights as those whose alarms were augmented with other strategies, but the confidence intervals were all wide. The pattern of results remained essentially the same when subsequent relapse rates were also taken into account.

5. ALARMS COMPARED WITH DRUGS (Comparison 05, Other Data Tables 05)

Nineteen trials included a comparison of alarms with drugs either alone or in combination. These included:

  • placebo (Fournier 1987; Kolvin 1972; Longstaffe 2000; Wright 1974);

  • desmopressin (Faraj 1999; Longstaffe 2000; Wille 1986);

  • alarm supplemented by desmopressin (Bradbury 1995; Gibb 2004; Leebeek 2001; Sukhai 1989; Rodriguez 2001);

  • imipramine and other tricyclics (Danquah 1975; Fournier 1987; Kolvin 1972; McKendry 1975; Motavalli 1994; Netley 1984; Wagner 1982);

  • alarm supplemented by a tricyclic (Fournier 1987; Scholander 1968); and

  • other drugs (Forrester 1964; Kennedy 1968; Wright 1974).

Alarm versus placebo alone

Alarms were better than placebo drug treatment in terms of fewer wet nights during and after treatment (Other Data Tables 05.02.01, 05.04.01) (Fournier 1987; Kolvin 1972; Wright 1974), and a lower failure rate during treatment (RR 0.68, 95% CI 0.48 to 0.97, Comparison 05.03.01) (Longstaffe 2000). Follow-up data after stopping treatment were not available..

Alarm versus desmopressin alone

In the first week of treatment, children had fewer wet nights during desmopressin treatment (WMD 2.1, 95% CI 0.99 to 3.21, Comparison 05.01.03) (Wille 1986). Towards the end of treatment, they had fewer wet nights on alarms in two trials but this did not reach statistical significance (Comparison 05.01.04, (Wille 1986); Other Data Tables 05.02.02, (Faraj 1999)). However, there was a lower failure rate during alarm treatment in three trials (RR 0.71, 95% CI 0.50 to 0.99, Comparison 05.03.02) (Faraj 1999; Longstaffe 2000; Wille 1986). Only one small trial provided follow-up data: fewer children failed or relapsed after alarm treatment stopped (4/22 (18%) versus 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69, Comparison 05.05.01) (Wille 1986), although the definition of cure was less strict than 14 consecutive dry nights in that trial.

Alarm versus alarm combined with desmopressin treatment

Data about wet nights during treatment were conflicting: children had fewer wet nights during combination treatment in three trials (WMD 0.78, 95% CI 0.49 to 1.07, Comparison 05.01.05) (Bradbury 1995; Gibb 2004; Sukhai 1989) but more wet nights in another which failed to report SDs (Other Data Tables 05.02.03) (Leebeek 2001). Failure rates during treatment were not significantly different (Comparison 05.03.03) (Bradbury 1995; Gibb 2004; Rodriguez 2001); nor were subsequent failure or relapse rates (RR 1.08, 95% CI 0.88 to 1.33, Comparison 05.05.02) (Bradbury 1995; Gibb 2004; Leebeek 2001) but the confidence intervals were wide. The number of wet nights at follow up was higher in the combined treatment group in the one trial without SDs (Other Data Tables 05.04.03) (Leebeek 2001).

Alarm versus tricyclics alone

Although there were fewer wet nights during alarm treatment compared with imipramine, amitriptyline or clomipramine in four trials arms out of five (Comparison 05.01.01, 05.01.02, Other Data Tables 05.02.04) (Fournier 1987; Kolvin 1972; Motavalli 1994; Wagner 1982); this did not reach statistical significance in any of them. However, fewer children failed during alarm treatment in three trials involving imipramine (61/105 (58%) versus 82/103 (80%), RR for failure 0.73, 95% CI 0.61 to 0.88, Comparison 05.03.04) (McKendry 1975; Netley 1984; Wagner 1982). After treatment stopped, fewer children failed or relapsed in one small trial (RR 0.58, 95% CI 0.36 to 0.94, Comparison 05.05.03) (Wagner 1982) and fewer had wet nights at follow up in another (Other Data Tables 05.04.02) (Kolvin 1972).

Alarm versus alarm combined with tricyclics

There was no clear evidence that supplementing alarm treatment with a tricyclic was better than the alarm treatment alone (Comparisons 05.03.06, 05.05.04 (Scholander 1968), Other Data Table 05.02.05 (Fournier 1987)) but each comparison was addressed in single small trials.

Alarm versus drugs other than desmopressin or tricyclics

There was too little information about a mixture of drugs (amphetamine, ephedrine and atropine) or methedrine compared with alarms (Other Data Table 05.02.06, (Wright 1974); Comparison 05.03.07) (Kennedy 1968)) although amphetamine alone was worse than alarms in one small trial (Comparison 05.03.08) (Forrester 1964).

Standard alarm versus electric shock alarms

In two trials (involving imipramine in other groups), children were frightened of receiving shocks from a body-worn alarm which delivered skin shocks (the Mozes detector), and in one of them, some reported burns or ulceration (McKendry 1975; Netley 1984). Some parents refused to let their children use these alarms.

6. ALARMS COMPARED WITH OTHER / MISCELLANEOUS TREATMENTS (Comparison 06, Other Data Tables 06)

Five trials compared alarms with interventions other than behavioural or drugs:

  • cognitive therapy or psychotherapy (Ronen 1992; Sacks 1974; Werry 1965);

  • ritual shaming (Danquah 1975); and

  • restricted diet (McKendry 1975).

During treatment

Although the number of wet nights during treatment was similar (Comparison 06.01) (Ronen 1992) more children achieved 14 dry nights during alarm treatment compared with cognitive or psychotherapy (RR for failure 0.68, 95% CI 0.52 to 0.90, Comparison 06.03.02) (Ronen 1992; Sacks 1974; Werry 1965) and restricted diet (Comparison 06.03.01) (McKendry 1975). There was statistically significant heterogeneity (P=0.0007). Amongst the three trials comparing alarms with cognitive or psychotherapy, one used a disproportionate method of allocation of children to groups, resulting in very small control and psychotherapy groups; there were also differences in baseline characteristics amongst the controls (Sacks 1974). Excluding this trial removed the statistical heterogeneity but also the significant difference in the chance of failure (RR 0.93, 95% CI 0.67 to 1.30): however, both remaining trials used quasi-randomised methods of allocation to groups (Ronen 1992; Werry 1965).

After treatment stops

Follow up data after the end of treatment were only available for two small trials: the RR for failure or relapse was higher in the alarm group than after cognitive therapy (9/15 (60%) versus 3/18 (17%), RR 3.60, 95% CI 1.18 to 10.95, Comparison 06.04.01) (Ronen 1992). Children had fewer wet nights after alarm treatment than after ritual shaming, but SDs were not provided (Danquah 1975).

ADVERSE EVENTS AND SIDE EFFECTS

Thirteen trials of conventional pad-and-buzzer alarms triggered by wetting included information about adverse effects (Baker 1969; Fournier 1987; Gibb 2004; Jehu 1977; Lovibond 1964a; McKendry 1975; Moffatt 1987; Netley 1984; Scholander 1968; Tobias 2001; Turner 1970; Wagner 1985; Wille 1986). Only one trial stated explicitly that there were no adverse events (Leebeek 2001). The remainder did not mention this outcome. The adverse events or side effects included: alarm failure; false alarms; fright; failing to wake the child; and waking others causing family disruption. A vibrating alarm was reported to be uncomfortable (Tobias 2001), and in a drug trial one headache and one nosebleed were reported (Gibb 2004). In two trials, non-compliance or dropout was attributed to the equipment being too difficult or complicated to use (Moffatt 1987; Turner 1970).

It was quite clear that the alarms which delivered electric shocks to the children's skin had unacceptable side effects (the Mozes detector, McKendry 1975; Netley 1984; the Uristop (Elinder 1985; Hojsgaard 1979) and the Crosby Dri-Nite (Lovibond 1964a). Not only were children (especially the younger ones) frightened of them (Netley 1984), there were incidents of skin burns and other damage (Lovibond 1964a; McKendry 1975).

DISCUSSION

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

This review updates two previous versions (Lister-Sharp 1997; Glazener 2001). In the previous update, 20 new trials were added, as were 12 trials which were previously included only in sensitivity analyses. The 12 previously excluded trials had failed to report on either baseline wetting or exclusion of organic causes, but it was decided to include them in this update as they were otherwise properly randomised controlled trials. In the current update, three new trials were added.

Data for several important outcomes were only reported in single small trials (such as failure and relapse rates following alarm treatment compared to desmopressin treatment, Wille 1986). The sample sizes were generally small. The lack of a sufficiently large sample can result in failure to detect a real treatment difference (because the confidence intervals are wide), or conversely, finding an exaggerated difference to be statistically significant by chance.

Quality of randomisation and follow-up data

Amongst the 53 included trials, the method of concealment of allocation to groups was only of good methodological quality in eight trials. Seven others used a suboptimal (quasi-randomised) method of randomisation. Only 26 of the 53 included trials provided longer term results after treatment was finished. This is a serious shortcoming of the research, as continued effectiveness is the main aim of treatment. However, in some cases, it reflected the clinical situation in which families whose children continue to wet the bed ask for alternative treatment.

Differential dropout

In three trials, dropout rates were different from different trial arms. In two trials, drop-out was related to unacceptability of treatment (Bollard 1981b; McKendry 1975). In these trials, dropouts have been counted as failures. In a third trial, trial data were not used in analyses because children were switched between groups, making the data unreliable (Turner 1970). In the remaining trials, dropout rates were evenly distributed amongst the trial arms and results excluded dropouts. The meta-analyses also excluded dropouts in these cases.

Organic causes and daytime wetting

It is likely that the underlying pathologies of night-only (monosymptomatic) bedwetting and mixed night and day (diurnal) wetting differ. Those with diurnal wetting are more likely to have an organic cause for their problem, and may be less likely to respond to treatment unless the underlying disease is treated (Jarvelin 1989; Jarvelin 1990). Although the focus of the review was on monosymptomatic nocturnal enuresis, only 16 trials specifically excluded children with daytime wetting and six included at least some such children (the remainder provided no information about this issue). However, of the six, four specifically excluded children with organic causes. In total, 48 trials specifically excluded children with known organic causes for their enuresis. Of the seven trials which did not specify whether they excluded children with organic causes or not, only two trials included some children with daytime wetting. Therefore the majority of included trials (51) were likely to be amongst children without a recognised physical cause for their problem. To have included only the 16 trials which explicitly excluded all children with daytime wetting would have limited the review. The results should be interpreted with this in mind.

Settings for treatment

Most of the included trials have recruited children from enuresis clinics or are hospital based. Participating families may be especially motivated to tackle the bed wetting. In addition, strict inclusion / exclusion criteria have been imposed in many of the trials. Consequently, the children involved are not necessarily representative of the wider population of those who wet the bed. Only three small trials included children who were learning disabled or from residential homes. The two larger of these trials favoured alarm treatment (Jehu 1977; Sloop 1973) but the data were too few to be generalisable.

EFFECTIVENESS OF ALARMS

Alarms versus no treatment

Alarm treatment was clearly better than no treatment or waiting list control interventions, both during treatment and in terms of continuing success rates after treatment was finished. About half the children fail or relapse after alarms compared with almost all who have a control treatment. Blinding of alarm treatment is difficult even if non-functioning equipment is used (as the patient will be aware that the alarm does not go off), and trials of conventional pad-and-buzzer alarms compared with sham alarms were not found. One trial of an electric shock device did use a sham alarm but the active treatment was not acceptable.

Different types of alarms

There was some evidence that an immediate alarm (compared to a delayed alarm or one which woke the parents rather than the child) was better. In another trial, children preferred a body-worn alarm to a bed pad, and an audio body-worn alarm to a vibrating body-worn alarm, but in general there was insufficient evidence to suggest that one type of alarm was better than another.

Alarms versus behavioural interventions

There was insufficient evidence to demonstrate a difference between alarms and simple behavioural interventions such as lifting, wakening or reward systems, because each intervention was addressed only by single small trials. Alarms resulted in fewer wet nights than stop-start training (teaching children to contract their pelvic floor muscles) but the single trial was too small to show reliably whether there was a difference in cure rates. Children were less likely to fail or relapse after alarm treatment alone than dry bed training alone in another small trial. There was some evidence that rewards increased the effectiveness of alarms whereas penalties after bed wetting appeared to reduce the likelihood of success.

Supplementing alarms with behavioural interventions

Although 16 trials addressed the issue of supplementing alarm treatment by reinforcing it with behavioural interventions, there was not much evidence to say whether or not this improved performance of the alarm: the trials were all small, many did not report SDs, and the confidence intervals, where available, were wide. However, two small trials suggested that overlearning after successful alarm treatment halved the relapse rate from 49% to 25% (Taylor 1975; Young 1965). Similarly, in two other trials, supplementing alarms with dry bed training reduced the relapse rate from 63% to 27% (Bollard 1981b; Nawaz 2002). Finally, one small trial suggested that giving children penalties for wet beds was unhelpful (van Londen 1993). These findings need to be confirmed in further research as the trials were small and some had methodological flaws. Retention control training (gradually trying to increase bladder capacity by teaching children to 'hold on') in addition to an alarm was detrimental during treatment, although it was not associated with significant differences in relapse rates after treatment stopped.

Alarms versus drugs

Limited evidence suggested that alarms were better than placebo drug treatment, and also better than desmopressin or tricyclics alone in terms of lower failure or relapse rates after treatment was finished. However, these findings were based on single or small trials, and need to be confirmed in future research.

Supplementing alarms with drugs

There is a move towards combining alarms with drug interventions (Howe 1992). The rationale is that the rapid onset of action of drugs is then combined with the more gradual treatment effect of alarms (Sukhai 1989). Low doses of desmopressin as an adjunct to alarm treatment may also be used to ensure that the child only wets the bed once each night to minimise changes of bedding (Djurhuus 1992). There was insufficient evidence to support this: while supplementing alarms with desmopressin did decrease the initial number of wet nights in three trials, success rates while on treatment or afterwards were not significantly different compared to an alarm alone. There was insufficient information about supplementing alarms with tricyclics.

Alarms versus other treatments

Limited evidence suggested that alarms were generally better than any of a variety of other classes of interventions while on treatment, but follow up data were only available from two small trials.

Acceptability of alarms

High dropout rates in some of the trials suggest that there were problems with compliance, often reflecting the unacceptability of the treatment. Potential difficulties, such as the time needed to attain success and the initial disruption to the family, need to be discussed with families before embarking on alarm treatment. Some child or family variables have been shown to predict dropout, such as parental intolerance, behavioural problems or the child's negative self image (Wagner 1982; Butler 1988; Wagner 1988; Butler 1994). These may be useful for identifying which treatment is most likely to succeed, or where the chances of success may be increased by giving the family extra attention.

ADVERSE EVENTS

Adverse events with standard pad-and-bell alarms which woke the children on wetting were limited to minor inconvenience due to alarm malfunction or disturbance to the family. In contrast, side effects with drugs may have more serious implications (Glazener 2002; Glazener 2003a). For example, tricyclics may have serious side-effects such as arrhythmias and heart block, convulsions, and hepatic and haematological reactions. These may present a particular risk of overdose to the children treated or other family members (Fitzwater 1992; Rushton 1993; Parkin 1972).

However, the alarms which delivered electric shocks to the children's skin on wetting were clearly unacceptable, in terms of frightening the children and causing burns and ulceration.

COSTS

In the UK, 16 weeks of drug treatment (the usual time allowed for fourteen consecutive dry nights to be attained using an alarm, Butler 1991) would cost (BNF 2002):

  • £78 for desmopressin nasal spray (20 µg per night) or £116 for desmopressin tablets (200 µg);

  • £4 for imipramine hydrochloride (25 mg tablet per night) or £14 for imipramine syrup (25 mg); and

  • enuresis alarms (including batteries & sensor) typically cost £33.60, although alarms but not sensors (£12) may be re-used several times.

This information relates only to some of the direct costs to the health service. Although treatment with tricyclic or related drugs is considerably less expensive than alarms or desmopressin, this does not take into account the administrative or the human costs involved in using alarms. Alarm systems may not be returned to clinics and have to be followed up. Alarm treatment is accompanied by broken nights for various family members until success is attained. Staff must be trained to teach the children and their parents how to use the alarms (particularly that the child must be fully wakened) and ensure that the equipment is working. Staff also need time to teach the parents and provide support during treatment.

The Guidelines on Minimum Standards of Practice (Morgan 1993) suggest that follow-up supervisory contacts should occur at least every three weeks, with management reviewed at least monthly. Against this must be set the likely reduced risk of relapse after stopping alarms compared with after stopping treatment with desmopressin, tricyclics or related drugs, and the potential for adverse events with tricyclics.

AUTHORS' CONCLUSIONS

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

Implications for practice

Using an audio alarm system on its own to condition children to wake before they wet the bed appears effective after treatment stops for about half of children with nocturnal enuresis. Supplementing alarm treatment with overlearning (giving children extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may reduce the relapse rate. Although the evidence suggests that desmopressin has a more immediate effect than alarms, alarms seem better than desmopressin or tricyclics in reducing the number of wet nights by the end of a course of treatment. There is no reliable evidence that the drugs are effective after treatment has stopped (Glazener 2002; Glazener 2003a) whereas half the children remain dry after alarm treatments.

Although the cost of alarm treatment is intermediate between desmopressin and tricyclics, greater motivation and time are needed by families until alarm treatment is successful. However, the finding that effects are better sustained after alarm treatment, and the risks of side effects associated with drugs, suggest that alarms may be preferable to the pharmacological options.

The limited evidence suggested that alarms on their own were as good as or better than most other behavioural or other classes of interventions.

Implications for research

Although treatment with alarms, desmopressin and tricyclics have each been shown to be effective in a number of trials, there are few direct comparisons between them, or between different types of alarms (eg loudness, type of stimulus). These need further investigation. Current evidence on which to judge behavioural or other interventions is limited, and further trials of these compared with alarms, desmopressin or tricyclics are needed. Such trials should allow comparison in different populations and for different purposes (such as in primary care, or as a short-term measure to cover nights away from home), in order to inform choice of treatment. They should include formal testing to identify pre-treatment factors which might modify or determine treatment effects. Important factors include age, presence of organic causes or daytime wetting and family circumstances.

Future trials should focus on children without organic causes of bedwetting, and should include adequate assessment of baseline levels of wetting. The difficulty in comparing interventions is exacerbated by the lack of uniformity in outcome measures, which should include: the number of wet nights during treatment and after the end of treatment; the number of children failing to achieve 14 consecutive dry nights; adverse events; acceptability of treatment; compliance; and especially relapse rates after treatment has stopped (expressed as a composite outcome of failure to achieve 14 dry nights and subsequent relapse). It is crucial to be able to assess the success rates of different treatments at least three months after they have finished.

Children with daytime enuresis are more likely to have specific pathology such as bladder dysfunction or urinary tract infections. Alternative managements for this condition are currently being assessed in a separate cochrane review (Sureshkumar 2000).

POTENTIAL CONFLICT OF INTEREST

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

JHCE has received reimbursement for attending a conference, fees for lecturing and a consultancy fee which was paid into a research fund from Ferring Pharmaceuticals, manufacturers of desmopressin.

Acknowledgements

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

This review was originally written for the National Health Service Centre for Reviews & Dissemination (CRD), University of York, UK, by Deborah Lister-Sharp, Susan O'Meara, Matthew Bradley and Trevor A Sheldon. It was 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). We were especially grateful to Deborah Lister-Sharp for transfer of data, trials and expertise, and were sad to learn of her death.

The CRD reviewers obtained information from a variety of sources, including organisations, manufacturers and individuals. These are listed in the original report, and we acknowledge their contribution to this review.

We are grateful to Penny Dobson (Enuresis Resource and Information Centre, ERIC, Bristol, UK) for help and encouragement, and also facilitating consumer reviewing. We would like to thank the external peer reviewers. We would also like to thank the Consumer Network at the Australasian Cochrane Centre for help with the synopsis.

TABLES

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES
Characteristics of included studies
StudyAzrin 1974
MethodsRCT - coin flip used to randomise each of pairs of children
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting: Not mentioned
Setting: respondents to a newspaper advertisement for enuretics
ParticipantsNo. of children (boys): 26 (19)
Excl: medical causes
Ages: 3+, mean 8 years
Baseline frequency 7 days/week.
InterventionsExperiment 1
A (7): DBT (parent-and-child alarm; PP; W; increasing fluid intake; rewards; CT; training in inhibiting urination
B (7): Child-only alarm for first 2 weeks only, then DBT
Experiment 2
C (6): DBT, parent-only alarm
D (6): Child-only alarm
OutcomesFewer wet nights in first 2 weeks with A+C (median 1 vs B+D 5 in second week, P<0.005).
More children achieving 6 dry nights in A
NotesPairs matched for age, sex and frequency of wetting
No useable data.
Allocation concealmentA
StudyAzrin 1978
MethodsRCT (details not given)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
ParticipantsNo. of children (boys): 55 (41)
Incl: Age at least 3 years; no daytime wetting; wetting at least 4x/week; able to understand instructions; medical examination and treatment
Age: mean 7 years (range 3-14) (20 less than 6 years)
Baseline wetting: 91% of nights
InterventionsA (28): Intensive DBT (PP, CT) plus rehearsing during the day with increased fluid intake, stream interruption exercises, Retention Control Training, repeated awakening, rewards for dry nights or compliance but NO ALARM
B (27): Alarm (pad-and-buzzer)
Duration of trial: 2 weeks, after which parents could swap to other arm
OutcomesPer cent wet nights during 2 wks: A, 15%; B, 76%
No. of children swapping to other group after 2 w: A, 0/27; B, 23/27
NotesComparability of groups at baseline not reported
No follow up possible after 2weeks
No SDs
Very young children (20 under age 6 years) included
Allocation concealmentB
StudyBaker 1969
MethodsRCT
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: recruited from newspaper advertisement
ParticipantsNo. of children (boys): 30 (20)
Incl: primary (26) and secondary (4) enuresis
Age median 8 years, range 6-12
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 no. 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
Allocation concealmentB
StudyBennett 1985
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Not mentioned
Daytime wetting excluded: Yes if only negligible
ParticipantsNo. of children (boys): 40 (25)
Dropouts: 32 (A,9; B,11; C,10; D,3)
Incl: primary nocturnal enuresis, referred to enuresis service by GP, negligible daytime wetting
Excl: encopresis, previous behavioural intervention, gross psychopathology
Age mean 8.5 years (SD 3.2) range 5-12
Baseline wetting: dry nights, boys 3/14; girls 2.4/14
InterventionsA: (9) Alarm (pad and buzzer)
B: (12) Stop-start training (sphinchter 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)
No. achieving 14 dry nights:
A, 4/9; B, 2/12; C, 5/10; D, 0/9
Mean dry nights at followup:
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 got star charts after their first dry night
High dropout rate
Allocation concealmentB
StudyBollard 1981a
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsExperiment 1
No. of children (boys): 45 (A:11, B:11, C:10)
No. of dropouts: A:0, B:3, C: 0
Incl: No underlying organic pathology
Previous treatment: no details
Mean age (years.months): A: 9.10 B: 9.9 C: 9.5
Baseline wetting: Mean number of wet nights per week: A: 5.3 B: 5.4 C: 4.2
InterventionsExperiment 1
A (15): enuresis alarm - supervised (weekly followup) B (15): enuresis alarm - unsupervised C (15): waiting list control
Duration of treatment: until achievement of 14 consecutive dry nights or 20 weeks
Follow up: 3, 6 and 12 months
OutcomesExperiment 1
Mean number of wet nights at end of 20 weeks: A:0.8, B:2.2, C:4.6
2 treatment groups did not differ significantly in number of wet beds at end of 20 weeks or number of days taken to reach dryness criterion
Number achieving 14 consecutive dry nights: A:12, B:9, C:0
Number relapsing at 12 m followup: A:4, B:5
NotesExperiment 1
No blinding
Comparability of groups not reported
Graphical data
No SDs
No baseline data for control group
Two analyses provided:
a) intention to treat basis;
b) excluding dropouts
Allocation concealmentB
StudyBollard 1981b
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsExperiment 2
No. of children: 100
No. of boys: A:14 B:13 C:16 D:14 E:14 F:11
No. of dropouts: 12 from D
Incl: thorough medical examination; regularly wetting at least one night per week; no other treatment during trial
Previous treatment: no details
Mean age (years.months): A:9.3 B:8.11 C:9.7 D:8.6 E:8.8 F:8.10
Baseline wetting: mean number of wet nights: A:5.8 B:5.2 C:6.0 D:5.7 E:6.0 F:4.7
InterventionsExperiment 2
A (20): DBT (A + W + CT + PP) with therapist at home
B (20): DBT (A + W + CT + PP) with therapist at hospital
C (20): DBT (A + W + CT + PP) with parents as therapists at home
D (20): DBT (W + CT + PP) with parents as therapists at home WITHOUT enuresis alarm
E (20): alarm
F (20): waiting list control
Duration of treatment: until 14 consecutive dry nights or 20 weeks
Follow up at 3, 6 and 12 months
OutcomesExperiment 2
Comparing DBT with alarm only - DBT significantly more effective in terms of number of wet nights and days to dryness
Mean number of wet nights per week at end of week 20
(incl dropouts) A:0, B:0, C:0, D: (n=20) 3.8, E: 0.6, F: 4.4
(excl dropouts) A:0, B:0, C:0, D:(n=8) 1.3, E:0.6, F:4.4
No. achieving 14 consecutive dry nights: A:20, B:20, C:20, D:5, E:16, F:2
(p < 0.05)
No. relapsing: A:5, B:6, C:4, D:2, E:6, F:2 NS
ie no. failing or relapsing: A: 5/20, B: 6/20, C: 4/20, D: 17/20, E: 10/20, F: 20/20
NotesExperiment 2
No details of blinding
DBT no alarm group (D) younger than others and
more girls in waiting list control group (F)
No SDs
Analysed on intention to treat basis and with dropouts included
Allocation concealmentB
StudyBollard 1982a
MethodsMainly RCT but also comparison with previous study [A] and [H] from another study
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children (2 groups combined) (boys): 127 (88)
Incl: no underlying organic pathology
Previous treatment: many had previously sought help but none undergoing any form of enuresis related drug or psychotherapy at the time of the study.
Mean age: 9 yrs 10 m
Baseline wetting: Overall mean number of wet nights per week = 5.5
Interventions[A (35): alarm only (A)]
B (12): alarm (A) + waking schedule (W)
C (12): A+retention control training
D (12): A+ positive practice (PP)+ cleanliness training (CT)
E (12): A+W+retention control training
F (12): A+W+PP +CT
G (12): A+retention control training+PP +CT
[H (20): Full DBT]
Duration of treatment: 20 weeks
Follow up: none
OutcomesMean no. of wet nights during 20 week treatment period:
A: 27 B: 13 C: 24 D: 23 E: 14 F: 10 G: 21 H: 11
Number of cases becoming dry: A: 31 B: 12 C: 11 D: 10 E: 12 F: 12 G: 11 H: 20
Significant difference in response rate of group with waking schedule vs those without (Chi squared = 13.04, df = 3, p < 0.01)
NotesGroups A and H from another trial, data not used
No analysis of comparability of groups
No blinding
No SDs
No follow up
Allocation concealmentB
StudyBradbury 1995
MethodsRCT (quota allocation system based on age, baseline wetting, family or housing problems, gender, previous alarm use, daytime wetting and previous dry periods)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: No
ParticipantsNo. of children: 71 (boys 48)
Dropouts A: 3, B: 8
Incl: nocturnal enuresis at least 1 night per wk (40/71 = severe, >4x/week);
Excl: neuropathic bladder, urinary tract abnormailites, cystic fibrosis, allergic rhinitis, deafness/learning difficulties, UTI
Previous treatment: 29 had used alarms
InterventionsA (36): desmopressin 40 mcg intranasally + alarm (bell-and-pad or Mini Drinite)
B (35): alarm alone
Duration of treatment: 6 weeks or until dry
Follow up: 6 months
OutcomesMean DRY nights/week: A: n=33, mean = 6.1 95% CI 5.6-6.7; B: 27, 4.8, 4.0-5.6
No. not achieving 4 dry nights: A: 6/33; B: 11/27
No. failing + no. relapsing: A: 10/33; B: 14/27
Side effects: none reported
Subgroup analysis in more severe group: A still better than B
NotesMini Drinite = body-worn alarm
Relapsing = >2 wet nights in 2 weeks after 4 weeks dry
Authors recommend using combined desmopressin + alarm only for children with severe wetting problems
Allocation concealmentA
StudyButler 1988
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children (boys): 74(A: 18, B: 29)
Dropouts: 11 excluded after baseline assessments
Incl: age at least 6 years;wetting at least five nights a week for a month; normal clinical exam; normal urine on microscopy; normal intelligence (assessed by reference to educational background and parental-child interview); not having any form of enuresis related drug or psychotherapeutic treatment
Previous treatment: 36 (48.6%) enuresis alarm
Mean age: A: 8.99 B: 9.86
Baseline wetting: mean number of dry nights during 4 weeks
A: 1.07 B: 1.02
InterventionsA (28): Standard enuresis alarm treatment (A)
B (35): Modified DBT + alarm (A + W + PP + retention control training) WITHOUT reprimands during CT
Duration of treatment: 16 weeks
Follow up: none
OutcomesMean number of dry nights in last 4 weeks
A:20.76 B:23.79 F(1,46) = 1.77
Number of children achieving 14 dry night criterion
A:20/28 (71%) B: 25/35 (71%) no significant difference
Mothers in dropout group significantly more angry with bedwetting than other groups
NotesNo significant difference between groups for demographic factors but modified-DBT group more likely to have previously used alarm. Analysis of covariance adjusted for the effects of previous experience with enuresis alarm
No blinding
Not intention to treat
No SDs
Allocation concealmentB
StudyButler 1990a
MethodsCCT (alternate allocation)
Experiment 1
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsExperiment 1
No. of children: 40 (boys A: 14 B: 11)
Dropouts A: 3 B: 2
Incl: wetting at least 4 nights a week for a month; nomal physical examination; normal urine microscopy; normal intelligence (assessed by reference to educational background and parent\child interview)
Previous treatment: None
Mean age: A: 8.2 B: 9.1
Baseline wetting: mean number of DRY nights per week: A: 1.2 B: 0.7
No significant difference between groups on any variable
InterventionsExperiment 1
A (20): pad and bell alarm
B (20): body worn alarm
Duration of treatment: 16 weeks
FU after 6 months
OutcomesExperiment 1
Mean number of wet nights in 16 weeks: A: 18.9 B: 15.3
Number (%) children achieving 14 consecutive dry nights: A: 14 (70) B: 14 (70)
Mean number of wet nights until achievement of 14 consecutive dry nights A: 54.8 B: 35.3 (t = 2.8, df = 26, p < 0.01)
Number (%) children relapsing A: 4/14 (29) B: 3/14 (21)
The majority of children preferred body-worn alarm to pad and bell
NotesSmall groups
Experiment 1
No blinding
Unclear if intention to treat analysis
Poor randomisation
No SDs
Allocation concealmentC
StudyButler 1990b
MethodsCCT (alternate allocation)
Experiment 2
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
ParticipantsExperiment 2
No. of children: 48 (boys A: 20 B:20)
Number of dropouts: A: 2 B 1
Incl: wetting at least 4 nights a week for a month; nomal physical examination; normal urine microscopy; normal intelligence (assessed by reference to educational background and parent\child interview); no associated diurnal enuresis
Previous treatment: unsuccessful treatment with pad and bell alarm
Mean age (years): A: 10.2 B: 11.2
Severity at baseline: mean number of DRY nights per week: A: 1.2 B: 1.3
Groups did not differ significantly on any variable
InterventionsExperiment 2
A (24): Modified DBT + pad-and-bell alarm (A + W + retention control training)
B (24): body-worn alarm (A)
Duration of treatment: 16 weeks
FU after 6 months
OutcomesExperiment 2
Mean number of wet nights in 16 weeks A: 28.7 B: 25.0
Number (%) attaining 14 consecutive dry nights A: 14 (58) B: 20 (83)
Mean number of wet nights to achievement of 14 consecutive dry nights A: 53.7 B: 40.7
Number (%) children relapsing: A: 7 (50) B: 9 (45)
NotesExperiment 2
Unclear if intention to treat analysis
Poor randomisation
No SDs
Dry bed training included a pad-and-bell alarm, a waking schedule and retention control training
Allocation concealmentC
StudyCaceres 1982
MethodsRCT 'double blind'
Systematic baseline measure of wetting: Yes
Organic causes excluded: No
Daytime wetting excluded: No
ParticipantsNo. of children (boys): 14 (9)
Incl: enuresis, or behaviour problem + enuresis. Some were not daytime toilet trained
Previous treatment: all had failed with psychotherapy, drugs or fluid restriction
Age: mean 9 years (range 6-14)
Baseline wetting: every night
InterventionsA (7): Enuresis alarm (Mowrer's pad-and-bell)
B (7): DBT (but WITHOUT alarm) + rewards
Duration: 1 m, then crossed over to other arm if not 50% improved
OutcomesNot cured on original treatment: A: 0/7, B: 5/7
NotesChildren crossed over to alternative treatment if not successful (5 of B group changed to A). Cure rates given while on first treatment
Allocation concealmentB
StudyDanquah 1975
MethodsRCT - but mention of matching
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: Ghanian fishing community
ParticipantsNo. of children (boys): 30 (all boys)
Excl: more than a week of traditional treatment
Mean age: 10.4 years
Mean frequency of wetting at baseline: A: 5.6 B: 4.00 C: 3.20
InterventionsA (10): traditional shaming
B (10): amitriptyline hydrochloride
C (10): alarm
Duration of treatment: 7 weeks
Follow up after 3 months
OutcomesMean frequency of wetting after treatment: A: 5.6; B: 4.00; C: 3.2
Subjects of traditional shaming seemed depressed and evidence of loss of self esteem and patients isolating themselves from friends.
Drug treatment was said to cause drowsiness at first. Parents not disturbed by alarm because they slept outside
NotesNo details of dropouts
No SDs
No details of previous treatment
Groups comparable in age and intelligence
Traditional shaming consisted of being carried from home by a singing mob and being thrown into the lagoon
Allocation concealmentB
StudyElinder 1985
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
ParticipantsNo. of children (boys): 53 (45)
No. of dropouts: A:9; B:6 due to technical problems or discomfort
Incl: Age at least 7 years; primary nocturnal enuresis; at least 3 wet nights/week; no daytime wetting
Excl: physical or psychological /psychiatric disease
Previous treatment: tricyclics (A:20, B:7); alarm (1, 2)
Ages: 39 7-11 years; 14 over 11 years
InterventionsA (36): Functioning Uristop device
B: (17) Non-functioning Uristop device
Duration of treatment: 6 weeks
Follow up 12 months
OutcomesNo. not cured: A: 0/36, B: 0/17
NotesDevice delivers electric impulse to pudendal nerve in groin when urine is passed
Power calculation given
Groups comparable at baseline except more upsetting life events and psychiatric contact in B
Failure ascribed to incorrect theory or incorrect construction (wrong placement of electrodes or impulse too low)
Allocation concealmentB
StudyFaraj 1999
MethodsRCT (random number tables, details not given)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
ParticipantsNo. of children: 135
Dropouts: 23 excluded for non-compliance, and 39 lost to follow up including 12 failed with alarms
Incl: monosymptomatic nocturnal enuresis, age >5 years
Excl: previous treatment with desmo or alarm, urological pathology, diurnal enuresis, UTI
Age mean 11.2 years
Baseline wetting A 21% dry nights, B 14% dry nights
InterventionsA (62): Desmo 20 µg intranasally increasing to 40 µg if response partial
B (73): alarm (pad-and-bell)
Duration of treatment 3 m. If failed at that time, changed to alternative arm Follow up: none
OutcomesDRY nights at 3 months: A 85%; B: 90%
No. not achieving 14 dry nights: A 12/39; B: 6/37
Side effects: not mentioned
Notes
Allocation concealmentB
StudyFielding 1980
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
ParticipantsNo. of children (boys): 45 (6 lost at baseline) (30)
Dropouts: 11
Incl: 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) retention control training and enuresis alarm
B: (17) enuresis 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
NotesAnalysed on intention to treat basis
Parallel study specifically includes diurnal wetters (results not given here)
No blinding
Not reported if comparable groups
No SDs
Allocation concealmentB
StudyFinley 1973
MethodsRCT
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: Children's Medical Centre, Tulsa, Oklahoma USA
ParticipantsNo. of children (boys): 30 (30)
Incl: primary nocturnal enuresis, at least 3 wet nights/week, own room and bed
Excl: daytime wetting, organic cause for enuresis, emotional disturbance
Ages: 6 to 8 years
Baseline wetting: 3x/week, 7 to 8 wet episodes per week
InterventionsA (10): enuresis alarm (105 dB bell) + light
B (10): enuresis alarm (80 dB bell), intermittent action (70% active)
C (10): alarm (78 dB) in parents' room 20 mins after wetting
Duration of treatment 6 weeks
Follow up 3 months
OutcomesMean wet episodes during 6th w: A: 0.2, B: 0.6, C: 8
No. not achieving 7 dry nights: A: 1/10, B: 2/10, C: 10/10
No. failing or relapsing after 'cure': A: 5/10, B: 3/10 (C all failed: 10/10)
NotesNo SDs
Data estimated from graph
Allocation concealmentB
StudyFinley 1977
MethodsRCT
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: Children's Medical Centre, Tulsa, Oklahoma USA
ParticipantsNo. of children (boys): 20 (20)
Incl: primary nocturnal enuresis
Excl: emotional disturbance, organic causes, daytime wetting
Age: 6-9 years
Baseline wetting: 6-7 wet nights/week
InterventionsA (10): alarm with 105 dB bell
B (10): alarm with 80 dB bell
Duration of treatment: 7 weeks
Follow up 16-24 months
OutcomesNo. not achieving 14 dry nights: A: 3/10, B: 6/10
Relapse rate: A: 3/7, B: 1/4
Failed or relapsed: A: 6/10, B: 7/10
NotesGroup comparability at baseline not stated
Allocation concealmentB
StudyForrester 1964
MethodsRCT
Systematic baseline measure of wetting: No
Organic causes excluded: No
Daytime wetting excluded: Not mentioned
Setting: children recruited from community survey
ParticipantsNo. of children 118 (33 properly included in trial)
Dropouts: 25 cured before trial, 32 improved, 9 not suitable, 15 defaulted, 4 received wrong intervention
Incl: aged 8-14, wet at least 1x/week, suitable family circumstances
Ages: 8-14 years
InterventionsA (16): Alarm (+ amphetamine for some children if not wakened by bell)
B (17): Amphetamine 2.5 to 5mg, increasing weekly if no response, decreasing if response, stopped if sleepless or restless
Duration of treatment: up to 6 months
OutcomesNo. not achieving 21 dry nights: A: 6/16, B: 14/17
Failure to comply with treatment properly: A: 4/17, B: 6/16
NotesSuccessful treatment requires the families to understand the commitment involved
Results including failure to comply in group as allocated
Allocation concealmentB
StudyFournier 1987
MethodsRCT (double-blind)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting: Not mentioned
ParticipantsNo. of children (boys): 64 (47) completed the study
5 extra children dropped out
Incl: no treatment in past 3 months
Mean age: 8 y 5m
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): enuresis alarm
C (8): placebo
D (8): random awakening
E (8): alarm + imipramine
[F (8): Alarm + placebo
G (8): random awakening + placebo
H (8): imipramine + random awakening]
Duration of treatment: 6 weeks
Follow up 3 months but some children continued on treatments
OutcomesMean 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
4 boys dropped out because of side-effects or non-compliance, 1 girl with UTI
NotesParallel groups
No SDs
Differences in baseline severity of wetting - MANOVA used
Allocation concealmentB
StudyGeffken 1986a
MethodsRCT
Children were stratified by maximal functional bladder capacity
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children (boys): initially 50
(Boys: A: 8 C: 6)
10 dropouts
Incl: nocturnal enuresis of at least 3 months duration; at least 2 wetting episodes a week
Mean age A: 9.0 C: 9.4
Baseline wetting: Mean (SD) number of wet nights per week
A: 4.9 (1.7) C: 5.4 (1.1)
InterventionsLarge maximal functional bladder capacity:
A (10): alarm
C (10): alarm + retention control training
Duration of treatment: 14 weeks
Follow up after 8 or more weeks
OutcomesMean (SD) number of wet nights per week A: 1.7 (1.2) C: 2.5 (0.9)
Significant interaction between maximal functional bladder capacity and treatment F(1, 33) = 4.90, p 0.03
Number of children achieving initial arrest during 14 weeks treatment A: 9 C: 9
Number of children relapsing during follow up A: 3 C: 4
NotesNot intention to treat analysis
Short follow up
No details of previous treatment
Payment required
For those who completed treatment there were no significant difference between the groups in terms of sex, age, child adjustment measures or the Tolerance and Nuisance Scales
Retention control training consisted of increasing fluid intake and delaying urination for increasing periods of time to expand bladder capacity
Allocation concealmentB
StudyGeffken 1986b
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children (boys): initially 50
(Boys: B: 5 D: 6)
10 dropouts
Incl: nocturnal enuresis of at least 3 months duration; at least 2 wetting episodes a week
Mean age B: 7.7 D: 8.0
Baseline wetting: Mean (SD) number of wet nights per week
B: 5.7 (1.3) D: 4.9 (1.2)
InterventionsSmall maximal functional bladder capacity:
B (10): alarm
D (10): alarm + retention control training
Duration of treatment: 14 weeks
Follow up after 8 or more weeks
OutcomesMean (SD) number of wet nights per week
B: 2.3 (1.0) D: 1.6 (1.1)
Significant interaction between maximal functional bladder capacity and treatment F(1, 33) = 4.90, P=0.03
Number of children achieving initial arrest during 14 weeks treatment B: 10 D: 9
Number of children relapsing during followup B: 6 D: 3
NotesNot intention to treat analysis
Short follow up
No details of previous treatment
Payment required
For those who completed treatment there were no significant differences between the groups in terms of sex, age, child adjustment measures or the Tolerance and Nuisance Scales
Retention control training consisted of increasing fluid intake and delaying urination for increasing periods of time to expand bladder capacity
Allocation concealmentB
StudyGibb 2004
MethodsRCT (drug dispensed randomly by pharmacist)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: No
Setting: Paediatric outpatients, Children's Hospital, Melbourne, Australia
ParticipantsNumber of children (boys): 207/210 (A:64, B:78)
Dropouts: 10 eligible children declined, incomplete data on A:9/101, B:17/106 but dropouts counted as failures for analysis
Inclusion criteria: Non-responders to desmopressin treatment (<50% reduction in wet nights), age 6-16 years, wetting at least twice per week, some daytime wetting (A:11, B:8)
Exclusion criteria: Neuropathic bladder, urinary tract abnormality, cystic fibrosis, allergic rhinitis, UTI in previous 2 weeks, imipramine or diuretics
Previous treatment: some had alarm (A:37, B:32) or desmopressin (A:31, B:28)
Age: mean 9.4 years (SD 2.08)
Baseline wet nights in 28 days: A: 23.9 (SD 5.05), B: 23.7 (5.83)
InterventionsA (84/101): desmopressin (40 µg nasal spray) + alarm (pad and bell)
B (85/106): placebo (nasal spray) + alarm (pad and bell)
Duration of treatment: 8 weeks
Follow up: 2 months
OutcomesCure = 28 dry nights, relapse = 2 wet nights in 2 weeks
Wet nights during treatment (number, mean (SD)): A: 101, 1.8 (1.13), B: 106, 2.4 (1.53)
Cure during treatment: A: 52/101, B: 51/106 P=0.63 (failed: A: 49/101, B: 55/106)
Relapse after treatment stopped: A: 7, B: 3
Failed or relapsed: A: 56/101, B: 58/106
Adverse effects: A: 1 (headache), B: 1 (nose bleed)
Other: compliance same in both groups
Cure in daytime wetting: A: 6/11, B: 3/8
NotesIntention to treat analysis
Groups comparable at baseline on age, wetting, gender, family history, secondary enuresis, daytime wetting and previous treatment
Allocation concealmentB
StudyHojsgaard 1979
MethodsRCT
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children (boys): 62
InterventionsA (32): Uristop device
B (30): no treatment
OutcomesCured: A: 20/32, B: 17/30
Improved: A: 5/32, B: 6/30
NotesNorwegian language
Uristop device gives 'electrical stimulation' to the children
Allocation concealmentB
StudyHouts 1986
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: No
Daytime wetting excluded: Not mentioned
Setting: media recruitment and paediatric referrals
ParticipantsNo. of children (boys): 45 (35)
Dropouts: A: 2, B: 2, C: 3
Incl: Primary enuresis
Age 5-13 years
Baseline wetting: mean 5.41 (SD 1.63) wet nights/week
InterventionsA (15): Enuresis alarm + over-learning + retention control training (Full Spectrum Home Training Package)
B (15): Enuresis alarm + retention control training
C (15): Enuresis alarm alone
D (11): Waiting list control
Duration of treatment: 16 weeks
Follow up: 1 year
OutcomesA: cured 9, failed 4, dropout 2; B: cured 13, dropped out 2; C: cured 9, failed 3, dropped out 3; D none cured (11/11 failed)
Relapse at end of study after retreatment if necessary: A: 1, B: 6, C: 3
ie. failed or relapsed: A 5/13, B: 6/13, C: 6/12
NotesGroups comparable at baseline
A, B + C received 1 hour group training and CT
Relapses were retreated with initial treatment allocated
Children who failed were older, and dropouts were younger
Allocation concealmentB
StudyJehu 1977
MethodsRCT
Analysis curtailed after 12 weeks to accomodate the loss of some control children
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: Children resident in Children's Homes but attending normal rather than special school so that treatment not impractical -eg children only spent weekends or school holidays at the home
ParticipantsNo. of children (boys): 39 (boys A: 8 B: 17)
1 dropout
Incl: age 4 years or over; wetting frequency of at least 4 nights per week during baseline; not previously treated by alarm within last year; no gross physical handicap
Previous treatment: drug therapy (7), alarm treatment (2)
Mean age 9 years 4 months (range 4 years 9 montha to 14 years 7 months)
Baseline wetting: For treatment group only mean no. wet nights per week = 4
InterventionsA (19): enuresis alarm
B (20): no treatment control
Duration of treatment: 3 or 4 months - until success achieved (achieved 14 dry nights)
Follow up: after 6 months then 20 months
OutcomesMean number of wet nights in week 12: A: 0.3 B: 5.3
Achieved 14 dry nights: A: 18/19 B: 0/20
One had absconded (counted as failure)
3 children had relapsed at 6 months and another at 8 months (needed repeat treatment)
NotesComparability of groups not reported
No baseline for control - probably should compare from week 4 for control to compensate for this
Not intention to treat
More girls in alarm group
No SDs
Allocation concealmentB
StudyKennedy 1968
MethodsRCT (alternate allocation)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: A+B clinic attenders and paediatric referrals; C+D residents in Sunland Training Centre, Florida
ParticipantsNo. of children (boys): A+B 10 (8); C+D 8
Incl: C+D had learning difficulties
Excl: organic cause for enuresis
Age: A+B 6-12 years; C+D 9-12 years
InterventionsA (5): Alarm + methedrine 5mg
B (5): Alarm only
C (3): Alarm + methedrine 5mg
D (5): Alarm only
Duration of treatment: 8 weeks
Follow up: 13 months
OutcomesNo. not achieving 14 dry nights: A: 0/5, B: 0/5, C: 0/3, D: 4/5
NotesGroups A+C and B+D combined for analysis
Baseline comparability not mentioned
Drug did not affect outcome but numbers too small to be reliable
Allocation concealmentC
StudyKolvin 1972
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children (boys): 94 (56)
2 dropouts
Incl: wetting at least 3 nights a week; age range (not stated); not receiving treatment elsewhere
Previous treatment: no details
Mean age: 9 years 4 months (range 8 to 10)
Baseline wetting: mean number of wet nights per month A: 22.7 B: 22.0 C: 20.9
InterventionsA (35): imipramine
B (32): pad and buzzer alarm
C (27): placebo
Duration of treatment: 2 months
Follow up: after 4 months
OutcomesMean number of wet night in final month (% improvement)
A: 9.3 (64) B: 9.1 (62) C: 11.0 (53)
At follow up mean number of wet nights per month (% improvement)
A: 13.4 (43) B: 9.3 (64) C: 11.3 (54)
NotesNo details of blinding
Not reported if comparable groups
Not intention to treat
No SDs
Allocation concealmentB
StudyLeebeek 2001
MethodsRCT (double blind parallel group study)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
ParticipantsNo. of children (boys): 93 (62)
Incl: at least 6 wet nights/week
Excl: treatment in previous 2 weeks; daytime wetting/pollakisuria; urological or psycholigical disease; poor motivation to use alarm
Previous treatment: none in previous 2 weeks
Age: 6-14 years
Baseline wetting: mean number of wet nights: A: 6.14, B: 6.12 (not significant)
InterventionsA (47) alarm + desmo 40 µg intranasal for 3 weeks, then alarm + desmopressin 20 µg for 3 weeks, then alarm alone for 3 weeks
B (46): alarm + placebo for 6 weeks, then alarm alone for 3 weeks
Follow up: at 2 weeks and 6 months after end of trial
Outcomes(Number), mean wet nights:
1st 3 weeks: A: (47), 2.93, B: (45), 3.86 (P=0.014)
Last 3 weeks, alarm only: A: 43, 2.77, B: 39, 2.21
Cured 2 weeks after end of trial: A: 15/47, B: 17/46
Cured 6 months after end of trial: A: 17/47, B: 17/46
ie failed at 6 months: A: 20/47, B: 21/46
Mean wet nights at 6 months: A: 41, 2.72, B: 37, 1.90
Adverse events: none in either group
NotesPower calculation provided
SDs not given (authors contacted for more information)
Groups comparable for sex and age
Study supported by drug company (Ferring)
Allocation concealmentA
StudyLongstaffe 2000
MethodsRCT (computer generated randomisation)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: recruited from hospital clinic and advertising
ParticipantsNo. of children: 182
At 6 months 17 withdrew due to failure (A 8; B 5; C 4)
Incl: primary monosymptomatic nocturnal enuresis, age >7 years, wet >3 x/week, normal bladder capapcity
Excl: daytime wetting, CNS disorder, developmental delay, current alarm or desmo treatment, encopresis, other medical problems
InterventionsA (61): alarm
B (60): desmopressin intranasally
C (61): placebo
Duration of treatment: 6 months, then failures crossed over to alternative arm for 6 months (not randomised)
OutcomesNo. not achieving 14 dry nights after 6 months: A: 26/61; B: 31/60; C: 38/61
All children improved psychologically, eg behaviour and self concept, regardless of outcome or treatment assignment
Side effects: not mentioned
NotesDose of desmopressin not given
No follow up as failures assigned alternative treatment
Blinding to method not possible for alarm group
Allocation concealmentA
StudyLovibond 1964a
MethodsRCT (stratified by age and sex)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: school children and GP referrals
ParticipantsNo. of children (boys): 36 (20)
Dropouts: B: 2
Incl: wet at least 3x/week; co-operative families
Excl: organic causes
Ages: 6 to 7 years 5 months: 7 years 6 months to 10 years 5 months: 10 years 6 months to 14
InterventionsExperiment 1
A (12): Twin signal alarm (hooter then buzzer) + 'escape training'
B (12): Crosby Dri-nite (pad electrode but no genital electrode)
C (12): Mowrer pad-and-bell
Duration of treatment: until 14 dry nights achieved, fluid intake increased if dry for 7 nights (=overlearning) or 50 days
Follow up: 31 months
OutcomesExperiment 1
No. not achieving 14 dry nights: A 0/12, B: 6/12, C: 1/12
No. failing or relapsing after trial: A: 5/12, B: 6/12, C: 5/12
Adverse events: B: corrosive skin burns (3); discontinued due to fear of shocks (2)
Notes
Allocation concealmentB
StudyLovibond 1964b
MethodsRCT (stratified by age, sex and wetting frequency)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children (boys) 20 (12)
Incl: wet at least 3x/week; co-operative families
Excl: organic causes
Ages: 8-12 years
InterventionsExperiment 2
A1 (5): Twin signal alarm triggered by wetting
A2 (5): Twin signal alarm but parents (not wetting) triggered the alarm after 2 dry nights (false alarm)
B1 (5): Mowrer pad-and-bell alarm triggered by wetting
B2 (5): Mowrer pad-and-bell alarm but parents (not wetting) triggered the alarm after 2 dry nights (false alarm)
Duration: until 14 dry nights achieved including increased fluid intake after 7 dry nights (=overlearning) or 50 days
Follow up: 24 m
OutcomesExperiment 2
No. not achieving 14 dry nights: A1: 0/5, A2: 0/5, B1: 0/5, B2: 0/5
No. failing or relapsing after 24 months: A1: 3/5, A2: 3/5, B1: 3/5, B2: 2/5 or:
Standard (A1 + B1) 6/10 vs False (A2 + B2) 5/10
Notes'False' alarm equivalent to 'waking' by parents
Data from 'standard' vs 'false' only used
Allocation concealmentB
StudyLovibond 1964c
MethodsRCT (stratified by age and sex)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children (boys) 24 (12)
Incl: wet at least 3x/week; co-operative families
Excl: organic causes
InterventionsExperiment 3
A (12): Modified Twin Signal (bell instead of buzzer, then second weaker alarm)
B (12): Mowrer pad-and-bell alarm
Duration: until 14 dry nights achieved including increased fluid intake after 7 dry nights (=overlearning) or 50 days
Follow up: 24 months
OutcomesExperiment 3
No. not achieving 14 dry nights: A: 0/12, B: 2/12
No. failing or relapsing: A: 5/12, B: 6/12
Notes
Allocation concealmentB
StudyLynch 1984
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: No
Daytime wetting excluded: Yes
Setting: School or paediatric referrals
ParticipantsNo. of children (boys): 60
No. of dropouts: A:2, B:2, C:2
Incl: at least 2 wet nights/w
Excl: daytime wetting
Ages: 5-12
Baseline wetting in 14 nights, mean (SD): A: 11.11 (2.9), B: 11.33 (2.99), C: 11.55
InterventionsA (20): star chart for 2 weeks then enuresis alarm - immediate
B (20): star chart for 2 weeks then enuresis alarm - 3 minute delay + CT
C (20): control, no treatment
Duration of treatment: 10 weeks
Follow up: None
OutcomesWet nights in last 2 weeks, n, mean (SD): A: 18, 3.38 (4.55), B: 18, 8.38 (4.55), C: 18, 8.11 (3.25)
No. not achieving 14 dry nights: A: 11/18, B: 17/18, C: 18/18
NotesGroups comparable at baseline
One dropout from alarm group due to stress from alarm
Allocation concealmentB
StudyMcKendry 1975
MethodsRCT
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: No
Setting: Paediatric outpatients, Toronto, Canada
ParticipantsNo. of children (boys): 222 (151)
No. of dropouts: 53 (A: 9, B:12, C:32)
Incl: primary nocturnal enuresis, 'a few' had diurnal wetting
Excl: organic causes
Ages: Mean 9 years (range 5-17)
Baseline wetting (self reported): A: 83.4%, B: 82.3%, C: 87.4%
InterventionsA (73): restricted diet
B (74): imipramine 10 mg at bedtime, increased to max 40 mg for age 5-9, up to 60 mg for 10+
C (75): Mozes Detector (body-worn detector, sounds alarm + delivers electric shock when a few drops of urine pass)
Duration of treatment: 2 months
Follow up: A: 3 months, B: 19 months, C: 14 months
OutcomesNo. not achieving 14 dry nights: A: 63/64, B: 49/62, C: 20/43
Adverse events: A: 2/12 children became aggressive; B: 3/16 had headaches, abdominal pain or fatigue, C: 10/16 showed fear or anxiety about the machine. For C, electric shocks resulted in skin erythema, discolouration, painless cold burns and ulceration
NotesDiet = no dairy, eggs, citrus, tomato, chocolate
A: most parents requested transfer to another treatment within 1-2 months due to finding diet unsuccessful and restricting
C: high dropout rate was due to parents refusing to allow their child to use the Mozes detector,
or finding it too expensive, or children fearing it especially if under age 8y
Data entered counting dropouts as failures (for above reasons)
Allocation concealmentB
StudyMoffatt 1987
MethodsRCT (opaque envelopes)
Systematic baseline measure of wetting: Yes
Organic causes excluded: No
Daytime wetting excluded: No
Setting: Enuresis clinic, Montreal Children's Hospital
ParticipantsNo. of children: 121
No. of dropouts: A: 5
Incl: primary nocturnal enuresis, spoke English or French, 7 had daytime urgency (treated with retention control training or anticholinergic drugs)
Ages: 8-14 years
Baseline wetting: 64% wet nights in each group
InterventionsA (66): enuresis alarm + overlearning if successful
B (55): waiting list control
Duration of treatment mean (SD): A: 18.4 weeks (5.8), B: 13.2 weeks (1.9)
OutcomesNo. not achieving 14 dry nights: A: 19/61, B: 54/55
Adverse events: 4 of A could not cope with alarm method
NotesGroups comparable at baseline but A assessed later if likely to be successful
Children's self-concept improved when they were successful
Allocation concealmentA
StudyMotavalli 1994
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children (boys): 29 (A: 6 B: 4 C: 4)
Incl: age 5 - 14; no organic causes; normal intelligence; wetting 2+ times a week; no treatment in previous 2 months
Mean age A: 9.1 years B: 9.2 C: 8.3
Baseline wetting: mean (SD) number of wet nights in 15 days: A: 9.1 (4.1) B: 11.2 (3.8) C: 10.9 (3.3)
InterventionsA (10): imipramine - dose depended on age
B (9): clomipramine
C (10): alarm
Duration of treatment: 8 weeks
Follow up: none
OutcomesMean (SD) frequency of wetting during final two weeks of treatment
A: 4.1 (2.6) B: 6.6 (5.5) C: 2.8 (4.3)
NotesTurkish language
No significant difference between groups in terms of age or IQ
Not blinded
Unclear if intention to treat
Allocation concealmentA
StudyNawaz 2002
MethodsRCT (random allocation to groups following matching on age and sex)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: community health centres in Glasgow, Scotland
ParticipantsNo. of children (boys): 36 (18)
Dropouts: 0
Incl: Age 7-12 years, baseline wetting at least twice per months, attending mainstream school and willing to be randomised
Excl: medical, physiological or psychiatric pathology, diurnal enuresis, encopresis
Previous treatment: some, but stopped during trial
Age: Mean 9.9 years (SD 1.83)
Baseline wetting: mean 5.67 per week (SD 1.26) for 4 weeks
InterventionsA (12): DBT + alarm
B (12): alarm only
C (12): untreated controls continued recording wet nights for 16 weeks, then offered treatment they preferred
A + B also received standardised instructions (manual and videotape) and had 2 weekly telephone calls
Duration of treatment: 16 weeks or until 14 dry nights if earlier
Follow up: 6 months
OutcomesWet nights per week during trial (final week): A: mean 0.83 (SD 1.40), B: 3.25 (2.67), C: 5 (2.26)
No. not achieving 14 dry nights: A: 4/12, B: 9/12, C: 11/12
No. relapsing after end of trial: A: 1, B: 1
Fail or relapse rate: A: 5/12, B: 10/12
NotesGroups comparable on age, sex, baseline wetting and DepCat (deprivation) scores
DBT described as: intensive first night, arousing child and taking him to toilet, accident contingencies and normal routine
Allocation concealmentB
StudyNetley 1984
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: Hospital for Sick Children Enuresis Clinic, Toronto
ParticipantsNo. of children (boys): 62
No. of dropouts: 27
Incl: primary nocturnal enuresis, age 6-12 years
Ages: mean A: 9 years, B: 10.7
InterventionsA (31): imipramine
B (31): Mozes detector (buzzer + electric shock to abdominal wall on wetting)
Duration of treatment unclear, ? till dry for 2 months
OutcomesFinal outcome, after 2 dry months: A: 13/17 failed, B: 7/18 failed
NotesHigh dropout rate (44%)
Groups not comparable on age at baseline
Younger children (<8 years) apprehensive about detector
Authors conclude Mozes detector is suitable for children >8 years
Allocation concealmentB
StudyRodriguez 2001
MethodsRCT (method not specified)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: Hospital clinic, Spain
ParticipantsNo. of children: 84 (80% boys)
3 dropouts after 3 months
Incl: wetting at least 1x/week, age >7 years
Excl: diurnal enuresis, encopresis, neurological abnormalities
Previous treatment: 38% of children
Age range 7-14 years
InterventionsA (30): bed alarm
B (29): alarm + desmopressin 20 µg or 40 µg for more frequent wetters (>2x/week)
Duration of treatment: 4-6 months
OutcomesResponse: A: 73.3%; B: 58.6%
[=no. not achieving 14 dry nights: A: 8/30; B: 12/29]
All children treated with desmopressin if not cured at 6 months, therefore follow up not possible
Side effects: not reported
NotesSpanish language
No follow up
Allocation concealmentB
StudyRonen 1992
MethodsRCT (assigned chronologically in order of application)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting: Not mentioned
Setting: children attending a community mental health clinic
ParticipantsNo. of children (boys): 77 (39)
Dropouts: 23 (A, 2; B, 4; C, 6; D, 11)
Incl: primary enuresis
Excl: medical or developmental problems; age <5 years
Age: mean 10.05 years (SD 2.28)
Baseline wetting: mean wet nights in 3 week (SD): A, 19.8 (1.73); B, 19.8 (2.14); C, 18.9 (2.21); D, 18 (8.72)
InterventionsA (20): Cognitive + behavioural self-control education therapy counselling
B (19): enuresis alarm (bell and pad)
C (20): token economy (star chart + rewards)
D (18): control (waiting list for 3 months)
Duration of treatment: 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
No. of wet nights in 3 weeks at end of treatment: A, (18 children) mean 1.03, (SD2.15); B, (15) 1.23 (5.28); C, (14) 3.33 (5.8); D, (16) 17.22 (9)
Actual failure or relapse after 6 months (excluding dropouts): A, 3/18; B, 9/15; C, 8/14
Adverse events: not mentioned
NotesA (cognitive treatment) had lowest dropout, highest success and lowest relapse compared with B, C or D
Allocation concealmentC
StudySacks 1974
MethodsRCT (random but disproportionate allocation)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children: 83 (from previous study)
Excl: severe psychosis or organic causes
Ages: 5.5 to 14 years
InterventionsA (64): conditioning (? alarm)
B (10): psychotherapy, counselling (12 weekly 40 min sessions + 20 min with mother)
C (9): Control
Duration of treatment: B 12 weeks
OutcomesNo. not achieving 14 dry nights: A: 13/64, B: 8/10, C: 7/9
NotesControl group was older and had fewer boys
Allocation concealmentB
StudyScholander 1968
MethodsRCT (double-blind)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children (boys): 30 (23)
No dropouts
Previous treatment: all had received imipramine, amitriptyline or nortriptyline
Age range 7 to 17 years
Severity of wetting at baseline: wet bed between 2 and twelve times a week
InterventionsThird week:
A (15): enuresis alarm + placebo
B (15): enuresis alarm + nortrityline 25-50 mg
Duration of treatment: 5 weeks
FU after 6 to 12 months
OutcomesNumber with no wet nights in third week (during drug/placebo treatment):
A: 3/15
B: 0/15
Number with no wet nights in fifth week (after drug/placebo treatment):
A: 6/15
B: 9/15
Side effects: 1 child frightened of the mattress, 'a few' children on nortrityline had dry mouth or troubled sleep
NotesSwedish language
No details of inclusion\exclusion criteria
Groups comparable in age and frequency of wet nights
Allocation concealmentB
StudySloop 1973
MethodsInitially RCT
Subjects paired on IQ, sex, age and number of wet nights during baseline then one from each pair randomly allocated to conditions
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: residential training centres for learning disabled children
ParticipantsNo. of children: 42 (boys: A: 11 B: 11)
Excl: epileptics; severe behaviour problems; encopretics;
residents in beds with side rails which prevent them arising; residents on nightly tranquilising medications;
measured IQ below 20; not wetting bed at least once during baseline
Previous treatment: none
Mean age: A: 13 years, B: 12 (range 7 to 18)
Baseline wetting: mean number of wet nights: Boys: A: 4.18 B: 4 Girls: A: 3.64 B: 3.54
InterventionsA (21): enuresis alarm
B (21): control - usual “potting” procedure - taken to the toilet twice a night
Duration of treatment: 11 weeks
OutcomesNumber of wet nights in 7 weeks (boys, n=11) A: 46 B: 108
No significant difference for girls (no data)
Number (%) dry: A: 11/21 (52) B: 1/21 (5)
Number relapsed: A: 4/11 B: 0/1
NotesMales and females analysed separately
Not clear if intention to treat
One pair of boys switched after 3 nights of treatment
Allocation concealmentB
StudySukhai 1989
MethodsRCT (double blind randomised cross-over with 2 weeks washout)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
ParticipantsNo. of children: 28 (21 boys)
Dropouts: none
Incl: Normal urine concentration capacity of 800 mosmol/kg or higher; 3 or more wet nights per week during observation period; informed parental consent; no urological or renal disorder; no history of daytime wetting; no chronic urinary tract infection; no neurological or cardiovascular disease
Mean age: 11 years (range 7 to 16)
Previous treatment: 19 had previous attempts at treatment, including alarm (n=9) and tricyclic antidepressants (n=10)
Severity at baseline: mean (SEM) number of dry nights per week = 1.4 (0.3)
InterventionsA: (28) enuresis alarm and bedtime dose of 20 µg DDAVP (desmopressin)
B: (28) enuresis alarm and bedtime dose of placebo
2 week washout period
Duration of treatment: 2 weeks in each arm
Follow up: 4 weeks to 6 months
OutcomesMean (SEM) DRY nights during treatment: A: 5.1 (0.4) B: 4.1 (0.4)
6wk follow up: 14 dry, 5 relapsed
4.5 month follow up: 9 remained dry
Side effects: none reported
Mean urine osmolality significantly increased from baseline
Significantly higher urine osmolality with DDAVP than placebo
Steady significant increase in body weight
NotesVery good study
Allocation concealmentA
StudyTaylor 1975
MethodsCCT - sequential allocation
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: No
ParticipantsNo. of children (boys): 82 (68)
No. of dropouts unclear because some replaced by next admission to enuresis clinic
Incl: aged between 4-16; parents saw enuresis as a problem; no relevant organic pathology
Previous treatment: no details
Age range 4 to 15 years: mean boys = 8.8; mean girls = 9.3
Daytime wetting: 16 children
Baseline wetting: no details
Severity of wetting at baseline: no details
number of dropouts unclear because some subjects replaced by next admission to enuresis clinic
InterventionsA (21): continuous alarm - bed alarm triggered as soon as bed wet
B (18): alarm + intermittent reinforcement schedule - continuous alarm for 14 days then parents told to switch alarm off whenever indicated by reinforcement schedule (50% of the time). Child unaware of reinforcement schedule
C (22): alarm + overlearning - when patient achieved 7 consecutive dry nights, fluid intake increased by 1-2 pints prior to going to bed. This regime continued until success criterion achieved
Duration of treatment: Until success criterion met ie no more than 1 wetting incidence in 28 days
Follow up: after 3 m
OutcomesNumber (%) achieving no more than one wetting incidence in 28 days: A: 13/21 (62) B: 9/18 (50) C: 13/22 (59)
Chi sq = 0.6 df = 2 not significant.
Number (%) of successes who relapsed A: 9/13 (69) B: 4/9 (44) C: 3/13 (23)
Chi sq = 5.6 df = 2 P=0.001
NotesResults from 61 participants analysed
Number of subjects at any given stage unclear
Probably atypical population due to referral process.
Comparability of groups at baseline not reported
Not intention to treat
No details of previous treatment
Includes children with diurnal wetting (n=6), encopresis (n=10) and both (n=6)
Over-learning is initiated after successful alarm treatment (eg achievement of 14 consecutive dry nights). Extra drinks are given at bed-time to cause additional stress to the detrusor muscles in the bladder. Alarm treatment is then continued until 14 consecutive dry nights are again achieved
Allocation concealmentC
StudyTobias 2001
MethodsRCT (random numbers table)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: urban paediatric medical centre
ParticipantsNo. of children (boys): 54 (33)
No. of dropouts: 7 lost to follow up or did not comply with treatment
Inclusion: primary or secondary enuresis, 3 wet nights of 7, age 6 to 12 years
Exclusion: Daytime wetting, chronic illness, UTI, urinary tract pathology
Previous treatment: yes but children asked to stop these while in trial
Age: mean 8.6 years (SD 1.9)
InterventionsA (23): body worn audio alarm
B(24): body worn vibrating alarm
Duration of treatment: 90 nights or until 14 dry nights achieved
Follow up: none
OutcomesNo. not achieving 14 dry nights: A: 10/23, B: 14/24
Adverse events: some children did not wake, some were upset when woken, false alarm
Vibrating alarm was reported to be more uncomfortable than the audio alarm
NotesAll children used star charts to record wet and dry nights but rewards for dry nights were not mentioned
Allocation concealmentB
StudyTurner 1970
MethodsRCT (stratified by age (4-7 and 7-15) and sex (12:8 M:F))
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting: Not mentioned
ParticipantsNo. 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
Incl: primary (103) and secondary (12) enuresis
Excl: organic pathology; adverse home conditions; bedwetting <3x/week; previous alarm treatment
Age: mean 7.5 years (SD 2.6)
InterventionsA: (15) alarm, continuous signal
B: (15) alarm, twin signal
C: (12) Alarm, intermittent twin signal (after first 2 wks, 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 wk; B, 6.2 wk; C, 10.2 wks
OutcomesFailed at 4 weeks: A, 12/15; B, 13/15; D, 14/15; E, 13/17
Mean wet nights per week at 4 wks: 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 yrs: A+B combined, 13/20; C, 3/11
Adverse events: non-compliance, failure or family disruption caused high dropout rate
NotesDropouts replaced by next child referred to the clinic. Some failures treated with methedrine. Trial unable to reach required sample size of 20 children per group during 5 year recruitment period
Therefore unreliable trial and data not useable
Adverse events caused high dropout rate in alarm groups due to inability to use the equipment or family disruption or strife
Allocation concealmentA
StudyWagner 1982
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: referrals from paediatric cinics, doctors, schools and newspaper advertisements
ParticipantsNo. of children (boys): 49 (40)
Dropouts: 13
Incl: age 6-16 years, IQ >70, primary nocturnal enuresis
Excl: daytime wetting, physical or neurological disorders, treatment with drugs or alarms in previous year
Ages: 6-16
Baseline wetting: min 3x/week, A: 75%, B: 77%, C: 64%
InterventionsA (12): alarm (pad-and-bell /buzzer)
B (12): imipramine (if <32 kg, 25 mg/day, if >32 kg, 50 mg/day)
C (12): waiting list
Duration of treatment: 14 w or until dry for 14 nights
FU: max 44 days
OutcomesPer cent wet nights in 14th week: A: 8.25%, B: 39.25%, C: 60.83% (A significantly better than B or C)
No. not achieving 14 dry nights: A:2/12, B:8/12, C:11/12
No. not achieving 14 dry nights or relapsing: A: 7/12, B: 12/12, C:12/12
Time from cure to relapse: A: 37.8 days (range 25-44), B: 17 (3-27)
NotesGroups comparable on baseline wetting
No SDs or means
Allocation concealmentB
StudyWagner 1985
MethodsCCT (alternate allocation to groups)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children (boys): 39 (20)
No dropouts
Incl: between 5 and 16 years old; IQs not less than 70; no physical or neurologic disorders as assessed by the child's physician; wet the bed at least 3 nights a week before treatment; not had conditioning treatment for at least a year; agreed to random assignment
Previous treatment: No details
Mean age: 7.9 years (range: 5 to 14)
Severity at baseline: % wet nights per week: A: 80 B: 83 C: 90
InterventionsA (13): contiguous enuresis alarm
B (13): delayed response enuresis alarm - 3 second delay
C (13): waiting list control
Duration of treatment: 12 weeks
Follow up: after 6 months
OutcomesPercentage of wet nights per week in week 12
A: 5.38 B: 20.67 C: 72.90
Number achieving 14 consecutive dry nights:
A: 8 B: 7 C: 1
Number relapsing
A: 2/8 B: 5/7 C: 1/1
Malfunction significantly greater problem for delayed alarm as compared with contiguous model
NotesClinicians blind to specfic purpose of the study
CCT rather than RCT
No significant differences in groups in terms of age, sex, recruitment source, psychological measures, baseline wetting frequencies
No SDs or means
Contiguous alarm sounds as soon as wetting occurs
Delayed alarm sounds after a 3 second delay
Allocation concealmentC
StudyWerry 1965
MethodsRCT (initial allocation by random numbers, in second half of trial stratified by age and sex)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: not mentioned
Setting: enuresis clinic, Paediatric Hospital, Montreal, Canada
ParticipantsNo. of children (boys): 70 (46)
No. of dropouts: 10 (A:1, B:4, C:5)
Incl: primary enuresis
Excl: dry more than 3 months, organic causes
Ages: mean 9.99 years (SD 2.5)
Baseline wetting: min 1 x/week (mean 5-6 x/week)
InterventionsA (27): Control (no treatment for 4 m)
B (21): brief psychotherapy (6-8 sessions over 3 months)
C (22): alarms (bedbuzzer) once per night
Duration of treatment: 3-4 months
Follow up: none
OutcomesFailure to achieve 14 dry nights (defined as no wet beds in preceeding month): A: 26/27, B:19/21, C:15/21
(C significantly better than A or B)
C (alarm) most economic as required least professional input
NotesGroups comparable on age, class, wetting severity and psychopathology
Majority of enuretic children were not emotionally disturbed (compared with, and found similar to, non-enuretiic siblings)
Allocation concealmentC
StudyWille 1986
MethodsRCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Distribution of social class of parents in 2 groups was similar
Dropouts not included in analysis
ParticipantsNo. of children: 50
Incl: age over 6 years; not dry for more than 6 months (= 'primary enuresis'); at least 3 wet nights per week at baseline; written informed parental consent
Excl: treatment for enuresis during previous year; daytime wetting; cardiovascular disease; renal disorder; neurological disease; urinary tract infection
Age: over 6 years
Baseline wetting: mean number of dry nights per week: A:2.1, B:1.9
Number completing treatment: A:24, B:22
InterventionsA (25): intranasal desmopressin (20 µg)
B (25): enuresis alarm
Duration of treatment: 3 months
Failures crossed over to alternative, relapses continued on same treatment
OutcomesMean (SEM) number of dry nights per week
In first week of treatment: A: 4.5 (0.4), B: 2.4 (0.4)
In 14th week: A: 4.9 (0.4), B: 5.9 (0.4)
No. failing during treatment (>5 wet nights in 28 or no change in enuresis score): A: 7/24, B: 3/22
A: 10 relapses given 3 months more desmopressin treatment. Successful for 7/10 but 4/7 relapsed immediately and 1/7 after 2 months
B: 1 relapsed and further alarm treatment unsuccessful
No. not cured after treatment (failed or relapsed): A: 16/24, B: 4/22
Mean (SEM) dry nights after trial: A: 3.5 (0.4), B: 5.7 (0.4)
Side effects: A: nasal discomfort (5); nose bleeds (1); bad taste in throat (2); B: false alarms (21); alarm did not go off (5); alarm did not wake child (15); other family members woken (15); child frightened by alarm (1).
Lab tests: urine osmolality and density higher during treatment with desmopressin and urine osmolality in alarm group lower during treatment than before
NotesDirect comparison of desmopressin and alarm
Results estimated from graph
Cure/relapse rates based on less strict definition of cure than usual
Allocation concealmentB
StudyWright 1974
MethodsRCT
Medications on double blind basis
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
ParticipantsNo. of children: 23
Dropouts: A: 0 B: 0 C: 2 D: 0
Age range 4 to 10 years
Baseline wetting: mean number of wettings per week: A + B: 4.9 C: 3.0 D: 6.6
InterventionsA (3): amphetamine sulphate (2.5mg)
B (5): ephedrine sulphate (75mg) + atropine sulphate (Enuretrol, 1.15mg)
C (5): placebo twice daily
D (10): enuresis alarm
Duration of treatment: 5 weeks
Follow up: after 4 weeks
OutcomesMean number of wet nights in final week of treatment
A+ B: 4.1 C: 3.5 D: 1.7
NotesGroups seem very different at baseline
More likely to detect more wettings per night in pad and bell group
All active drugs groups combined
No details of inclusion\exclusion criteria
Data estimated from graph
No SDs
Allocation concealmentB
StudyYoung 1972
MethodsRCT (children chosen at random from children cured on alarm treatment)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: not mentioned
Setting: Local authority enuresis clinic, UK
ParticipantsNo. of children (boys): 144 (99)
Dropouts: A:6 B:37
Incl: primary and secondary nocturnal enuresis, age >4 years, already cured using alarm treatment
Ages: 4-15 years
Baseline wetting: min 2 wet nights per week before cure
InterventionsA (61): alarm + overlearning
B (83): alarm alone (already cured)
Duration of treatment: 3 months or until relapse or cured again
Follow up: at 3 + 6 months, then 6-monthly till 2 years
OutcomesNo. relapsing (failing to remain dry or regain dryness): A:7/55, B: 16/46
NotesA further 6 were withdrawn from A due to severe recurrence of enuresis with overlearning, but they then regained dryness
Allocation concealmentB
Studyvan Londen 1993
  1. RCT = randomised controlled trial; CCT = controlled clinical trial with quasi-randomised method of allocation; Incl = Inclusion criteria; Excl = Exclusion criteria; cc = cubic centilitres; SD = Standard Deviation; SEM = standard error of the mean; No. = number; dB = decibels (measure of volume);

  2. A = Alarm; Overlearning = giving extra fluids at bedtime to child already cured using alarm treatment; Stream interrruption exercises = practising interruption of urination; PP = Positive Practice (practising getting up and voiding repeatedly); CT = Cleanliness Training (changing the bed); W = Waking (waking child to void, earlier on subsequent nights if dry); Retention Control Training = increasing fluid intake and delaying urination for increasing periods of time to expand bladder capacity; FSHT = Full Spectrum Home Training (A + CT + Overlearning + Retention Control Training); DBT = Bry Bed Training (training night, CT, PP and W);

  3. Random Wakening = wakening the child to urinate at random times; Alarm = enuresis alarm triggered by wetting; Clock Alarm = clock set to ring at specified time after going to bed; Volume Alarm = alarm triggered by ultrasound measurement of bladder volume, triggered at prespecified volume before wetting occurs;

  4. UTI = urinary tract infection; IQ = intelligence quotient

MethodsRCT (sequential random allocation in order of contact)
Systematic baseline measure of wetting: No
Organic causes excluded: No
Daytime wetting excluded: Not mentioned
Setting: parents who contacted an alarm rental agency, Utrecht, Holland
ParticipantsNo. of children (boys): 127 (89)
No. of dropouts: 14 (A:3, B:2, C:9)
Incl: Primary (110) or secondary (17) enuresis
Ages: mean 8.6 y (range 6-12)
InterventionsA (38): alarm + reward stickers for correct behaviour at the time ('arousal therapy' = turning off alarm in 3 mins, going to bathroom to empty bladder, resetting alarm)
B (39): alarm + reward stickers in morning for dry bed and penalty (1 sticker) for wet bed
C (36): alarm only
Duration of treatment: 20 weeks
FU at two and a half years
OutcomesNo. not achieving 14 dry nights during trial: A:1/38, B:6/39, C:10/36
Failure + relapse rate during FU period: A: 11/38, B:21/39, C:10/36
Final failure + relapse rate at FU *: A:1/38, B:2/39, C:4/36
* but children who failed or relapsed received further treatment (repeat of trial arm, other alarm method, desmopressin, imipramine, homeopathy, hospital referral, reduced drinking, regular 'wake-up' alarm clock, chiropractic, iriscopist, acupuncture, supervised child care) more often in B+C than A
NotesGroups comparable at baseline on age, gender, diagnosis and frequency of wetting
'Arousal therapy' described as 'bibliotherapy' beacuse parents received their instructions in written form
Allocation concealmentC
Characteristics of excluded studies
  1. DBT = Dry Bed Training (complex behavioural intervention)

Azrin 1973Excluded because participants were adults, and no useable data provided.
RCT: Yes
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: Yes
Systematic outcome measure: Yes
Intervention: Alarms, dry bed training in adults with severe learning difficulties in a state hospital
Bollard 1977RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measure: Yes
Intervention: Dry bed training
Bollard 1982bRCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: Yes
Systematic outcome measure: Yes
Intervention: Dry bed training with and without alarm + control group
Butler 2001RCT: No
Comparison group: No
Intervention: Withdrawal from desmopressin or imipramine treatment, use of alarms optional
Collins 1973RCT: No
Comparison group: Yes
Organic causes excluded: No
Systematic baseline measurement of wetting: No
Systematic outcome measure: Yes
Intervention: Pad-and-bell alarm, delayed alarm and no-treatment control group
Crisp 1984RCT: Yes
Comparison group: Yes
Systematic Baseline: No
Systematic outcome measure: No
Organic causes excluded: No
Intervention: Alarms vs wire mesh in adults
Finley 1982RCT: No
Comparison group: Yes
Organic causes excluded: No
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Varying alarm schedules
Fly-Hansen 1995RCT: No
Comparison group: No
Organic causes excluded: No
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms (pad and bell)
Fordham 1989RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: Yes
Systematic outcome measures: Yes
Interventions: Alarms (bed based bell and pad, pants based sensor and mini-alarm)
Forsyth 1970RCT: No
Comparison group: No
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms
Freyman 1963RCT: No
Comparison group: No
Organic causes excluded: No
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms
Gillison 1958RCT: No
Comparison group: No
Organic causes excluded: No
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms
Goel 1984RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: No
Interventions: Alarms
Halliday 1987RCT: Yes
Comparison group: Yes
Interventions: Pants alarm for daytime enuresis
Hanson 1988RCT: Yes but population young adults (age 13-29) with learning difficulties in residential centre
Comparison group: Yes
Organic causes excluded: No
Systematic baseline measurement of wetting: Yes
Systematic outcome measures: Yes
Interventions: Alarms, DBT, yoked awakening, rewards
Kahane 1955RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline: No
Systematic outcome measure: Yes
Intervention: Alarms
Kaplan 1988RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms, dry bed training, motivation
Kooijman 1986RCT: No
Comparison group: Yes (from another study)
Organic causes excluded: No
Systematic baseline: No
Systematic outcome measure: Yes
Intervention: Alarms with and without parental supervision
Kyneb 1975RCT: No
Comparison group: No
Organic causes excluded: Yes
Systematic baseline: No
Systematic outcome measure: Yes
Intervention: Alarms
Lovibond 1964dRCT: No
Comparison group: No
Organic causes excluded: Yes
Systematic baseline: No
Systematic outcome measure: Yes
Intervention: Twin Signal alarm
McConaghy 1969RCT: Yes
Comparison group: Yes
Organic causes excluded: No
Systematic baseline: No
Systematic outcome measure: Yes
Interventions: Imipramine, amphetamine, alarms, behavioural method
Excluded because children moved between trial arms, data therefore unreliable
Monda 1995RCT: No
Comparson group: Yes
Organic causes excluded: Yes
Systematic baseline: No
Systematic outcome measures: Yes
Intervention: desmopressin, imipramine, alarms
Peterson 1969RCT: No (unclear method, close group matching)
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline: Yes
Systematic outcome measure: Yes
Interventions: Alarms (no delay, delay)
Philpott 1970RCT: No
Comparison group: No
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Imipramine, alarms
Said 1991RCT: No
Comparison group: No
Systematic baseline: Yes
Organic causes excluded: Yes
Intervention: Alarms, overlearning
Shulz 1978RCT: No
Comparison group: yes
Systematic baseline: no
Organic causes excluded: yes
Systematic outcome measure: yes
Intervention: DBT, alarms
Taylor 1963RCT: No
Comparison group: No
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms
Wickes 1958RCT: No
Comparison group: No
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms
Young 1965RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Central nervous system stimulants and conditioning (alarms)
de Leon 1966RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: Yes
Systematic outcome measures: Yes
Interventions: Alarm (pad and buzzer), psychotherapy (counselling), no treatment control
Characteristics of ongoing studies
StudyBryant 2002
Trial name or titleRandomised trial of bladder training versus enuresis alarm versus combined bladder training/enuresis alarm in children with nocturnal enuresis
Participants106 children with nocturnal enuresis
InterventionsBladder training, alarms
Outcomes 
Starting date1st July 2001
Contact informationCharmaine Bryant, Prince of Wales Hospital Sydney
NotesRecruitment finishes 30th June 2002

ANALYSES

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES
Table Comparison 01. ALARM vs CONTROL
Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size
01 Mean number of wet nights per week  Weighted Mean Difference (Fixed) 95% CISubtotals only
02 Mean number of wet nights per week (no SDs)  Other dataNo numeric data
03 Number not achieving 14 consecutive dry nights  Relative Risk (Fixed) 95% CISubtotals only
04 Numbers not achieving 14 dry nights or relapsing  Relative Risk (Fixed) 95% CISubtotals only
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Figure Analysis 01.01. Comparison 01 ALARM vs CONTROL, Outcome 01 Mean number of wet nights per week

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Table Analysis 01.02. Comparison 01 ALARM vs CONTROL, Outcome 02 Mean number of wet nights per week (no SDs)
Alarm vs control
StudyAlarmControl
Baker 19691.8 wet nights, n=105.9 wet nights, n=10
Bollard 1981a0.8 wet nights, n=154.6 wet nights, n=15
Bollard 1981b0.6 wet nights (n=20)4.4 wet nights (n=20)
Jehu 19770.3 wet nights, n=195.3 wet nights, n=20
Wagner 19820.58 wet nights, n=124.26 wet nights, n=12
Wagner 19850.38 wet nights, n=135.1 wet nights, n=13
delayed alarm vs control
StudyAlarmControl
Wagner 19851.45 wet nights, n=135.10 wet nights, n=13
unsupervised alarm vs control
StudyAlarmControl
Bollard 1981a2.2 wet nights, n=154.6 wet nights, n=15
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Figure Analysis 01.03. Comparison 01 ALARM vs CONTROL, Outcome 03 Number not achieving 14 consecutive dry nights

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Figure Analysis 01.04. Comparison 01 ALARM vs CONTROL, Outcome 04 Numbers not achieving 14 dry nights or relapsing

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Table Comparison 02. COMPARING ALARMS
Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size
01 Mean number of wet nights per week  Weighted Mean Difference (Fixed) 95% CISubtotals only
02 Mean number of wet nights per week (no SDs)  Other dataNo numeric data
03 Numbers not achieving 14 dry nights  Relative Risk (Fixed) 95% CISubtotals only
04 Numbers not achieving 14 dry nights or relapsing  Relative Risk (Fixed) 95% CISubtotals only
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Figure Analysis 02.01. Comparison 02 COMPARING ALARMS, Outcome 01 Mean number of wet nights per week

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Table Analysis 02.02. Comparison 02 COMPARING ALARMS, Outcome 02 Mean number of wet nights per week (no SDs)
bed alarm vs body alarm
StudyAlarm 1Alarm 2
Butler 1990a1.2 wet nights, n=171 wet night, n=18
immediate alarm vs delayed alarm
StudyAlarm 1Alarm 2
Wagner 19850.38 wet nights, n=131.45 wet nights, n=13
supervised alarm vs unsupervised alarm
StudyAlarm 1Alarm 2
Bollard 1981a0.8 with supervised alarm, n=152.2 with unsupervised alarm, n=15
loud alarm vs quiet alarm
StudyAlarm 1Alarm 2
Finley 19730.2 wet nights, n=100.6 wet nights, n=10
alarm with 105 dB bell + light vs alarm with 78 dB bell in parents' room
StudyAlarm 1Alarm 2
Finley 19730.2 wet episodes, n=108 wet episodes, n=10
alarm with intermittent 80 dB bell vs alarm with 78 dB bell in parents' room
StudyAlarm 1Alarm 2
Finley 19730.6 wet episodes, n=108 wet episodes, n=10
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Figure Analysis 02.03. Comparison 02 COMPARING ALARMS, Outcome 03 Numbers not achieving 14 dry nights

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Figure Analysis 02.04. Comparison 02 COMPARING ALARMS, Outcome 04 Numbers not achieving 14 dry nights or relapsing

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Table Comparison 03. ALARM vs BEHAVIOURAL INTERVENTIONS
Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size
01 Mean number of wet nights per week  Weighted Mean Difference (Fixed) 95% CISubtotals only
02 Mean number of wet nights per week (no SDs)  Other dataNo numeric data
03 Numbers not achieving 14 dry nights  Relative Risk (Fixed) 95% CISubtotals only
04 Mean number of wet nights at follow-up  Weighted Mean Difference (Fixed) 95% CISubtotals only
05 Numbers not achieving 14 dry nights or relapsing  Relative Risk (Fixed) 95% CISubtotals only
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Figure Analysis 03.01. Comparison 03 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 01 Mean number of wet nights per week

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Table Analysis 03.02. Comparison 03 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 02 Mean number of wet nights per week (no SDs)
alarm vs random wakening
StudyAlarmBehavioural
Fournier 19872.5 wet nights, n=83.3 wet nights, n=8
alarm vs star chart + wake-up alarm clock
StudyAlarmBehavioural
Baker 19691.8 wet nights, n=103.1 wet nights, n=10
alarm vs dry bed training (no alarm)
StudyAlarmBehavioural
Azrin 19785.32 wet nights, n=271.05 wet nights, n=28
Bollard 1981b0.6 wet nights, n=203.8 wet nights, n=20
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Figure Analysis 03.03. Comparison 03 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 03 Numbers not achieving 14 dry nights

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Figure Analysis 03.04. Comparison 03 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 04 Mean number of wet nights at follow-up

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Figure Analysis 03.05. Comparison 03 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 05 Numbers not achieving 14 dry nights or relapsing

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Table Comparison 04. ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS
Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size
01 Mean number of wet nights per week  Weighted Mean Difference (Fixed) 95% CISubtotals only
02 Mean number of wet nights per week (no SDs)  Other dataNo numeric data
03 Number not achieving 14 consective dry nights  Relative Risk (Fixed) 95% CISubtotals only
04 Numbers not achieving 14 dry nights or relapsing  Relative Risk (Fixed) 95% CISubtotals only
05 Mean number of wet nights at follow-up  Weighted Mean Difference (Fixed) 95% CISubtotals only
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Figure Analysis 04.01. Comparison 04 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 01 Mean number of wet nights per week

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Table Analysis 04.02. Comparison 04 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 02 Mean number of wet nights per week (no SDs)
unsupervised alarm vs supervised
StudyAlarmAugmented alarm
Bollard 1981a2.2 wet nights with unsupervised alarm, n=150.8 with supervised alarm, n=15
alarm vs alarm + retention control training
StudyAlarmAugmented alarm
Bollard 1982a0.65 wet nights, n=12 (group B)0.7 wet nights, n=12 (group E)
Fielding 19800.6 wet nights, n=171.5 wet nights, n=16
alarm vs alarm + dry bed training
StudyAlarmAugmented alarm
Bollard 1981b0.6 wet nights, n=200 wet nights, n=60
Bollard 1982a0.65 wet nights, n=12 (group B)0.5 wet nights, n=12 (group F)
Butler 19881.81 wet nights, n=201.05 wet nights, n=29
Butler 1990b1.6 wet nights, n=241.8 wet nights, n=24
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Figure Analysis 04.03. Comparison 04 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 03 Number not achieving 14 consective dry nights

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Figure Analysis 04.04. Comparison 04 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 04 Numbers not achieving 14 dry nights or relapsing

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Figure Analysis 04.05. Comparison 04 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 05 Mean number of wet nights at follow-up

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Table Comparison 05. ALARM vs DRUGS
Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size
01 Mean number of wet nights per week  Weighted Mean Difference (Fixed) 95% CISubtotals only
02 Mean number of wet nights per week (no SDs)  Other dataNo numeric data
03 Numbers not achieving 14 dry nights during treatment  Relative Risk (Fixed) 95% CISubtotals only
04 Number of wet nights at follow-up (no SDs)  Other dataNo numeric data
05 Number not achieving 14 dry nights or relapsing  Relative Risk (Fixed) 95% CISubtotals only
06 Mean number of wet nights at follow-up  Weighted Mean Difference (Fixed) 95% CISubtotals only
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Figure Analysis 05.01. Comparison 05 ALARM vs DRUGS, Outcome 01 Mean number of wet nights per week

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Table Analysis 05.02. Comparison 05 ALARM vs DRUGS, Outcome 02 Mean number of wet nights per week (no SDs)
alarm vs placebo
StudyAlarmControl / drug
Fournier 19872.5 wet nights, n=85 wet nights, n=8
Kolvin 19722.3 wet nights, n=322.7 wet nights, n=27
Wright 19741.7 wet nights, n=103.5 wet nights, n=5
alarm vs desmopressin
StudyAlarmControl / drug
Faraj 19990.7 wet nights, n=731.05 wet nights, n=62
alarm vs alarm + desmopressin
StudyAlarmControl / drug
Leebeek 20013.9 wet nights, n=452.9 wet nights, n=47
alarm vs imipramine
StudyAlarmControl / drug
Fournier 19872.5 wet nights, n=81.9 wet nights, n=8
Kolvin 19722.3 wet nights, n=322.3 wet nights, n=35
Wagner 19820.58 wet nights, n=122.75 wet nights, n=12
alarm vs alarm + imipramine
StudyAlarmControl / drug
Fournier 19872.5 wet nights, n=81 wet night, n=8
alarm vs amphetamine sulphate\Enetrol (ephedrine + atropine)
StudyAlarmControl / drug
Wright 19741.7 wet nights, n=104.1 wet nights, n=8
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Figure Analysis 05.03. Comparison 05 ALARM vs DRUGS, Outcome 03 Numbers not achieving 14 dry nights during treatment

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Table Analysis 05.04. Comparison 05 ALARM vs DRUGS, Outcome 04 Number of wet nights at follow-up (no SDs)
alarm vs placebo
StudyAlarmControl / drug
Kolvin 19722.33 wet nights, n=322.83 wet nights, n=27
alarm vs alarm + desmopressin
StudyAlarmControl / drug
Leebeek 20011.9 wet nights, n=372.7 wet nights, n=41
alarm vs imipramine
StudyAlarmControl / drug
Kolvin 19722.3 wet nights, n=323.4 wet nights, n=35
alarm vs amitripyline
StudyAlarmControl / drug
Danquah 19753.2 wet nights, n=104 wet nights, n=10
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Figure Analysis 05.05. Comparison 05 ALARM vs DRUGS, Outcome 05 Number not achieving 14 dry nights or relapsing

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Figure Analysis 05.06. Comparison 05 ALARM vs DRUGS, Outcome 06 Mean number of wet nights at follow-up

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Table Comparison 06. ALARM vs OTHER / MISCELLANEOUS TREATMENTS
Outcome titleNo. of studiesNo. of participantsStatistical methodEffect size
01 Mean number of wet nights per week  Weighted Mean Difference (Fixed) 95% CISubtotals only
03 Numbers not achieving 14 dry nights  Relative Risk (Fixed) 95% CISubtotals only
04 Number not achieving 14 dry nights or relapsing  Relative Risk (Fixed) 95% CISubtotals only
05 Mean number of wet nights per week at follow up (no SDs)  Other dataNo numeric data
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Figure Analysis 06.01. Comparison 06 ALARM vs OTHER / MISCELLANEOUS TREATMENTS, Outcome 01 Mean number of wet nights per week

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Figure Analysis 06.03. Comparison 06 ALARM vs OTHER / MISCELLANEOUS TREATMENTS, Outcome 03 Numbers not achieving 14 dry nights

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Figure Analysis 06.04. Comparison 06 ALARM vs OTHER / MISCELLANEOUS TREATMENTS, Outcome 04 Number not achieving 14 dry nights or relapsing

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Table Analysis 06.05. Comparison 06 ALARM vs OTHER / MISCELLANEOUS TREATMENTS, Outcome 05 Mean number of wet nights per week at follow up (no SDs)
alarm vs shaming
StudyAlarmOther
Danquah 19753.2 wet nights, n=105.6 wet nights, n=10

COVER SHEET

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES

Title

Alarm interventions for nocturnal enuresis in children

Authors

Glazener CMA, Evans JHC, Peto RE

Contribution of author(s)

CMAG (the contact reviewer) originally based this review on work done at the NHS Centre for Reviews and Dissemination, University of York, UK (see acknowledgements). CMAG used the data extracted by the York reviewers, converted them into Cochrane Review format, and separated them into seven component intervention reviews (of which this is one). This update includes 32 new trials. REP and CMAG performed double data abstraction for the new trials. All three reviewers edited the text and JHCE also provided a clinical perspective and interpretation.

Issue protocol first published

2001/1

Review first published

2001/1

Date of most recent amendment

22 February 2005

Date of most recent SUBSTANTIVE amendment

22 February 2005

What's New

This review was first published in Issue 1, 2001. It was first updated in Issue 2 2003. 12 trials which were previously included only in a sensitivity analysis and 20 new trials were added. Two previously included trials were excluded. Compared to the previous version, there was more evidence that alarms were better than no treatment, desmopressin or tricyclics. Overlearning may reduce the relapse rate.

The second update was published in Issue 2 2005. Three new trials (Gibb 2004, Nawaz 2002 and Tobias 2001) were added. There was some evidence that dry bed training may reduce the relapse rate.

Date new studies found and included/excluded

22 November 2004

Date authors' conclusions section amended

26 February 2003

Contact address

Dr Cathryn Glazener Senior Clinical Research Fellow, Health Services Research Unit, University of Aberdeen Polwarth Building, Foresterhill, Aberdeen, Scotland, AB25 2ZD, UK, E-mail: c.glazener@abdn.ac.uk, Tel: +44 1224 553732, Fax: +44 1224 554580

DOI

10.1002/14651858.CD002911.pub2

Cochrane Library number

CD002911

Editorial group

Cochrane Incontinence Group

Editorial group code

HM-INCONT

REFERENCES

  1. Top of page
  2. Abstract
  3. BACKGROUND
  4. OBJECTIVES
  5. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW
  6. SEARCH METHODS FOR IDENTIFICATION OF STUDIES
  7. METHODS OF THE REVIEW
  8. DESCRIPTION OF STUDIES
  9. METHODOLOGICAL QUALITY
  10. RESULTS
  11. DISCUSSION
  12. AUTHORS' CONCLUSIONS
  13. POTENTIAL CONFLICT OF INTEREST
  14. Acknowledgements
  15. SOURCES OF SUPPORT
  16. TABLES
  17. ANALYSES
  18. COVER SHEET
  19. REFERENCES
  • References to studies included in this review
  • Azrin 1974 {published data only}
  • Azrin NH, Sneed TJ, Foxx RM. Dry-bed training: rapid elimination of childhood enuresis. Behaviour Research & Therapy 1974;12(3):147-56. [MedLine: 75054129].
  • Azrin 1978 {published data only}
  • Azrin NH, Thienes PM. Rapid elimination of enuresis by intensive learning without a conditioning apparatus. Behaviour Therapy 1978;9:342-54.
  • Baker 1969 {published data only}
  • Baker BL. Symptom treatment and symptom substitution in enuresis. Journal of Abnormal Psychology 1969;74(1):42-9. [MedLine: 69166759].
  • Bennett 1985 {published data only}
  • Bennett GA, Walkden VJ, Curtis RH, Burns LE, Rees J, Gosling JA, et al. Pad-and-buzzer training, dry-bed training, and stop-start training in the treatment of primary nocturnal enuresis. Behavioural Psychotherapist 1985;13:309-19.
  • Bollard 1981a {published data only}
  • Bollard J. A 2-year follow-up of bedwetters treated by dry-bed training and standard conditioning. Behaviour Research & Therapy 1982;20(6):571-80. [MedLine: 83126391].
  • Bollard J, Nettelbeck T. A comparison of dry-bed training and standard urine-alarm conditioning treatment of childhood bedwetting. Behaviour Research & Therapy 1981;19(3):215-26. [MedLine: 82045721].
  • Bollard 1981b {published data only}
  • Bollard J. A 2-year follow-up of bedwetters treated by dry-bed training and standard conditioning. Behaviour Research & Therapy 1982;20(6):571-80. [MedLine: 83126391].
  • Bollard J, Nettelbeck T. A comparison of dry-bed training and standard urine-alarm conditioning treatment of childhood bedwetting. Behaviour Research & Therapy 1981;19(3):215-26. [MedLine: 82045721].
  • Bollard 1982a {published data only}
  • Bollard J, Nettelbeck T. A component analysis of dry-bed training for treatment for bedwetting. Behaviour Research & Therapy 1982;20(4):383-90. [MedLine: 83022183].
  • Bradbury 1995 {published data only}
  • Bradbury M. Combination therapy for nocturnal enuresis with desmopressin and an alarm device. Scandinavian Journal of Urology & Nephrology 1997;Supplementum. 183:61-3. [MedLine: 97308385].
  • * Bradbury MG, Meadow SR. Combined treatment with enuresis alarm and desmopressin for nocturnal enuresis. Acta Paediatrica 1995;84(9):1014-8. [MedLine: 96112940].
  • Butler 1988 {published data only}
  • Butler RJ, Brewin CR, Forsythe WI. A comparison of two approaches to the treatment of nocturnal enuresis and the prediction of effectiveness using pre-treatment variables. Journal of Child Psychology & Psychiatry & Allied Disciplines 1988;29(4):501-9. [MedLine: 89109292].
  • Butler 1990a {published data only}
  • Butler RJ, Forsythe WI, Robertson J. The body-worn alarm in the treatment of childhood enuresis. British Journal of Clinical Practice 1990;44(6):237-41. [MedLine: 91001782].
  • Butler 1990b {published data only}
  • Butler RJ, Forsythe WI, Robertson J. The body-worn alarm in the treatment of childhood enuresis. British Journal of Clinical Practice 1990;44(6):237-41. [MedLine: 91001782].
  • Caceres 1982 {published data only}
  • Caceres J. Comparative efficacy between two methods for the treatment of enuresis. Revista de Psicologia General y Aplicada 1980;35(4):597-616.
  • Caceres J. Enuresis: Cortical control or social reinforcement?. Behaviour Therapist 1982;5(2):65-7.
  • Caceres J. Enuresis: Cortical control or social reinforcement?. Revista de Psicologia General y Aplicada 1979;34(161):1067.
  • Danquah 1975 {published data only}
  • Danquah SA. Comparative treatment of nocturnal enuresis among Ghanaian school children. Psychopathologie Africaine 1975;11(3):363-73.
  • Elinder 1985 {published data only}
  • Elinder G, Soback S. Effect of Uristop on primary nocturnal enuresis. A prospective randomized double-blind study. Acta Paediatrica Scandinavica 1985;74(4):574-8. [MedLine: 85275411].
  • Faraj 1999 {published data only}
  • Faraj G, Cochat P, Cavailles ML, Chevallier C. [Treatment of isolated nocturnal enuresis: alarm or desmopressin?]. [French]. Archives de Pediatrie 1999;6(3):271-74. [MedLine: 99207616].
  • Fielding 1980 {published data only}
  • Fielding D. The response of day and night wetting children and children who wet only at night to retention control training and the enuresis alarm. Behaviour Research & Therapy 1980;18(4):305-17. [MedLine: 81062334].
  • Finley 1973 {published data only}
  • Finley WW, Besserman RL, Bennett LF, Clapp RK, Finley PM. The effect of continuous, intermittent, and “placebo” reinforcement on the effectiveness of the conditioning treatment for enuresis nocturna. Behaviour Research & Therapy 1973;11(3):289-97. [MedLine: 73243969].
  • Finley 1977 {published data only}
  • Finley WW, Wansley RA. Auditory intensity as a variable in the conditioning treatment of enuresis nocturna. Behaviour Research & Therapy 1977;15(2):181-5. [MedLine: 77201389].
  • Forrester 1964 {published data only}
  • Forrester RM, Stein Z, Susser MW. A trial of conditioning therapy in nocturnal enuresis. Developmental Medicine & Child Neurology 1964;6:158-66.
  • Fournier 1987 {published data only}
  • Fournier JP, Garfinkel BD, Bond A, Beauchesne H, Shapiro SK. Pharmacological and behavioral management of enuresis. Journal of the American Academy of Child & Adolescent Psychiatry 1987;26(6):849-53. [MedLine: 88115081].
  • Geffken 1986a {published data only}
  • Geffken G, Johnson SB, Walker D. Behavioral interventions for childhood nocturnal enuresis: the differential effect of bladder capacity on treatment progress and outcome. Health Psychology 1986;5(3):261-72. [MedLine: 86300621].
  • Geffken 1986b {published data only}
  • Geffken G, Johnson SB, Walker D. Behavioral interventions for childhood nocturnal enuresis: the differential effect of bladder capacity on treatment progress and outcome. Health Psychology 1986;5(3):261-72. [MedLine: 86300621].
  • Gibb 2004 {published data only}
  • Gibb S, Nolan T, South M, Noad L, Bates G, Vidmar S. Evidence against a synergistic effect of desmopressin with conditioning in the treatment of nocturnal enuresis. Journal of Pediatrics 2004;144(3):351-7.
  • Hojsgaard 1979 {published data only}
  • Hojsgaard A, Genster H. Effect of Uristop in children with enuresis. A prospective randomized clinical trial. [Danish]. Ugeskrift for Laeger 1979;141(10):647-8. [MedLine: 79139924].
  • Houts 1986 {published data only}
  • Houts AC, Peterson JK, Whelan JP. Prevention of relapse in full-spectrum home training for primary enuresis: A components analysis. Behaviour Therapy 1986;17:462-9.
  • Jehu 1977 {published data only}
  • Jehu D, Morgan RT, Turner RK, Jones A. A controlled trial of the treatment of nocturnal enuresis in residential homes for children. Behaviour Research & Therapy 1977;15(1):1-16. [MedLine: 77111772].
  • Kennedy 1968 {published data only}
  • Kennedy WA, Sloop EW. Methedrine as an adjunct to conditioning treatment of nocturnal enuresis in normal and institutionalized retarded subjects. Psychological Reports 1968;22:997-1000. [MedLine: 68274635].
  • Kolvin 1972 {published data only}
  • Kolvin I, Taunch J, Currah J, Garside RF, Nolan J, Shaw WB. Enuresis: a descriptive analysis and a controlled trial. Developmental Medicine & Child Neurology 1972;14(6):715-26. [MedLine: 73066897].
  • Leebeek 2001 {published data only}
  • Leebeek-Groenewegen ANJA, Blom J, Sukhai R, van der Heijden B. Efficacy of desmopressin combined with alarm therapy for monosymptomatic nocturnal enuresis. Journal of Urology 2001;166(6):2456-8. [MedLine: 21553449].
  • Longstaffe 2000 {published data only}
  • Longstaffe S, Moffatt ME, Whalen JC. Behavioral and self-concept changes after six months of enuresis treatment: a randomized, controlled trial. Pediatrics 2000;105(4:Pt 2):935-40. [MedLine: 20209556].
  • Lovibond 1964a {published data only}
  • Lovibond SH. Field experiment I: Experimental comparison of twin signal, Crosby and Mowrer instruments. Conditioning and Enuresis. New York: MacMillan (Pergamon Press), 1964:94-101.
  • Lovibond 1964b {published data only}
  • Lovibond SH. Field experiments on the reduction of the relapse rate. Conditioning and Enuresis. New York: MacMillan (Pergamon Press), 1964:121-31.
  • Lovibond 1964c {published data only}
  • Lovibond SH. Field experiments on the reduction of the relapse rate. Conditioning and Enuresis. New York: MacMillan (Pergamon Press), 1964:121-31.
  • Lynch 1984 {published data only}
  • Lynch NT, Grunert BK, Vasudevan SV, Severson RA. Enuresis: comparison of two treatments. Archives of Physical Medicine & Rehabilitation 1984;65(2):98-100. [MedLine: 84127291].
  • McKendry 1975 {published data only}
  • McKendry JB, Stewart DA, Khanna F, Netley C. Primary enuresis: relative success of three methods of treatment. Canadian Medical Association Journal 1975;113(10):953-5. [MedLine: 76063959].
  • Moffatt 1987 {published data only}
  • Moffatt ME, Kato C, Pless IB. Improvements in self-concept after treatment of nocturnal enuresis: randomized controlled trial. Journal of Pediatrics 1987;110(4):647-52. [MedLine: 87168949].
  • Motavalli 1994 {published data only}
  • Motavalli N, Tuzun U, Tuna S, Yargic I, Aydogmus K. Comparison of the effectiveness of three different treatment modalities in enuresis nocturna. Noropsikiyatri Arsivi (Archives of Neuropsychiatry - Turkish) 1994;31(3):146-50.
  • Nawaz 2002 {published data only}
  • Nawaz S, Griffiths P, Tappin D. Parent-administered modified dry-bed training for childhood nocturnal enuresis: Evidence for superiority over urine-alarm conditioning when delivery factors are controlled. Behavioral Interventions 2002;17(4):247-60.
  • Netley 1984 {published data only}
  • Netley C, Khanna F, McKendry JB, Lovering JS. Effects of different methods of treatment of primary enuresis on psychologic functioning in children. Canadian Medical Association Journal 1984;131(6):577-9. [MedLine: 85001664].
  • Rodriguez 2001 {published data only}
  • Rodriguez Do FA, Ariceta IG. Results of a therapeutic strategy against monosymptomatic nocturnal enuresis background. Anales Espanoles de Pediatria 2001;54(1):38-43.
  • Ronen 1992 {published data only}
  • Ronen T, Rahav G, Wozner Y. Self-control and enuresis. Journal of Cognitive Psychotherapy : An International Quarterly 1995;9:249-58.
  • * Ronen T, Wozner Y, Rahav G. Cognitive intervention in enuresis. Child & Family Behaviour Therapy 1992;14(2):1-14.
  • Sacks 1974 {published data only}
  • Sacks S, De Leon G, Blackman S. Psychological changes associated with conditioning functional enuresis. Journal of Clinical Psychology 1974;30(3):271-76. [MedLine: 74306370].
  • Scholander 1968 {published data only}
  • Scholander T. [Treating enuresis nocturna by a combination of medicines and conditioning]. [Swedish]. Lakartidningen 1968;65(46):4552-6. [MedLine: 70200421].
  • Sloop 1973 {published data only}
  • Sloop EW, Kennedy WA. Institutionalized retarded nocturnal enuretics treated by a conditioning technique. American Journal of Mental Deficiency 1973;77(6):717-21. [MedLine: 73241944].
  • Sukhai 1989 {published data only}
  • Sukhai RN, Mol J, Harris AS. Combined therapy of enuresis alarm and desmopressin in the treatment of nocturnal enuresis. European Journal of Pediatrics 1989;148(5):465-7. [MedLine: 89153190].
  • Taylor 1975 {published data only}
  • Taylor PD, Turner RK. A clinical trial of continuous, intermittent and overlearning 'bell and pad' treatments for nocturnal enuresis. Behaviour Research & Therapy 1975;13(4):281-93. [MedLine: 76061221].
  • Tobias 2001 {published data only}
  • * Tobias NE, McCain GC. A comparison of two enuresis alarms. Urologic Nursing 2001;21(5):349-53.
  • Turner 1970 {published data only}
  • Turner RK, Young GC, Rachman S. Treatment of nocturnal enuresis by conditioning techniques. Behaviour Research & Therapy 1970;8(4):367-91. [MedLine: 71062269].
  • van Londen 1993 {published data only}
  • * van Londen A, van Londen-Barentsen MW, van Son MJ, Mulder GA. Arousal training for children suffering from nocturnal enuresis: a 2 1/2 year follow-up. Behaviour Research & Therapy 1993;31(6):613-5. [MedLine: 93349306].
  • van Londen A, van Londen-Barentsen MW, van Son MJ, Mulder GA. Relapse rate and subsequent parental reaction after successful treatment of children suffering from nocturnal enuresis: a 2 1/2 year follow-up of bibliotherapy. Behaviour Research & Therapy 1995;33(3):309-11. [MedLine: 95243898].
  • Wagner 1982 {published data only}
  • Wagner W, Johnson SB, Walker D, Carter R, Wittner J. A controlled comparison of two treatments for nocturnal enuresis. Journal of Pediatrics 1982;101(2):302-7. [MedLine: 82241436].
  • Wagner 1985 {published data only}
  • Wagner WG, Matthews R. The treatment of nocturnal enuresis: a controlled comparison of two models of urine alarm. Journal of Developmental & Behavioral Pediatrics 1985;6(1):22-6. [MedLine: 85131790].
  • Werry 1965 {published data only}
  • Werry JS, Cohrssen J. Enuresis - an etiologic and therapeutic study. Journal of Pediatrics 1965;67(3):423-31.
  • Wille 1986 {published data only}
  • * Wille S. Comparison of desmopressin and enuresis alarm for nocturnal enuresis. Archives of Disease in Childhood 1986;61(1):30-3. [MedLine: 86157697].
  • Wille S. Primary nocturnal enuresis in children. Background and treatment. Scandinavian Journal of Urology & Nephrology Supplementum 1994;156:1-48. [MedLine: 95025668].
  • Wright 1974 {published data only}
  • Wright L, Craig SC. A comparative study of amphetamine, ephedrine-atropine mixture, placebo and behavioral conditioning in the treatment of nocturnal enuresis. Journal - Oklahoma State Medical Association 1974;67(10):430-3. [MedLine: 75078843].
  • Young 1972 {published data only}
  • * Young GC, Morgan RT. Overlearning in the conditioning treatment of enuresis. Behaviour Research & Therapy 1972;10(2):147-51. [MedLine: 72194405].
  • Young GC, Morgan RT. Overlearning in the conditioning treatment of enuresis: a long-term follow-up study. Behaviour Research & Therapy 1972;10(4):419-20. [MedLine: 73051336].
  • References to studies excluded from this review
  • Azrin 1973
  • Azrin NH, Sneed TJ, Foxx RM. Dry bed: a rapid method of eliminating bedwetting (enuresis) of the retarded. Behaviour Research & Therapy 1973;11(4):427-34. [MedLine: 74097620].
  • Bollard 1977
  • Bollard RJ, Woodroffe P. The effect of parent-administered Dry-Bed training on nocturnal enuresis in children. Behaviour Research & Therapy 1977;15:159-65. [MedLine: 77201386].
  • Bollard 1982b
  • Bollard J, Nettelbeck T, Roxbee L. Dry-bed training for childhood bedwetting: a comparison of group with individually administered parent instruction. Behaviour Research & Therapy 1982;20(3):209-17. [MedLine: 82231116].
  • Butler 2001
  • Butler RJ, Holland P, Robinson J. Examination of the structured withdrawal program to prevent relapse of nocturnal enuresis. Journal of Urology 2001;166(6):2463-6. [MedLine: 21553451].
  • Collins 1973
  • Collins RW. Importance of the bladder-cue buzzer contingency in the conditioning treatment for enuresis. Journal of Abnormal Psychology 1973;82(2):299-308. [MedLine: 74033838].
  • Crisp 1984
  • * Crisp AH, Sireling LI, Faizey J. Nocturnal activity and the enuresis alarm device. Postgraduate Medical Journal 1984;60(702):280-1. [MedLine: 84221695].
  • Macaulay AJ, Gupta M, Crisp AH, Bhat AV. The relationship between nocturnal motility and the enuresis alarm device. Journal of Psychosomatic Research 1986;30(1):63-5. [MedLine: 86199808].
  • de Leon 1966
  • De Leon G, Mandell W. A comparison of conditioning and psychotherapy in the treatment of functional enuresis. Journal of Clinical Psychology 1966;22(3):326-30. [MedLine: 67014937].
  • Finley 1982
  • Finley WW, Rainwater AJ, Johnson G 3d. Effect of varying alarm schedules on acquisition and relapse parameters in the conditioning treatment of enuresis. Behaviour Research & Therapy 1982;20(1):69-80. [MedLine: 82159985].
  • Fly-Hansen 1995
  • Hansen AF, Jorgensen TM. Treatment of nocturnal enuresis with the bell-and-pad system. Scandinavian Journal of Urology & Nephrology 1995;Suppl 173:101-2. [MedLine: 96363554].
  • Fordham 1989
  • Fordham KE, Meadow SR. Controlled trial of standard pad and bell alarm against mini alarm for nocturnal enuresis. Archives of Disease in Childhood 1989;64(5):651-6. [MedLine: 89272170].
  • Forsyth 1970
  • Forsythe WI, Redmond A. Enuresis and the electric alarm: study of 200 cases. British Medical Journal 1970;1(690):211-3. [MedLine: 70105005].
  • Freyman 1963
  • Freyman R. Follow-up study of enuresis treated with a bell apparatus. Journal of Child Psychology and Psychiatry 1963;4:199-206.
  • Gillison 1958
  • Gillison TH, Skinner JL. Treatment of nocturnal enuresis by the electric alarm. British Medical Journal 1958;ii:1268-72.
  • Goel 1984
  • Goel KM, Thomson RB, Gibb EM, McAinsh TF. Evaluation of nine different types of enuresis alarms. Archives of Disease in Childhood 1984;59(8):748-55. [MedLine: 84305992].
  • Halliday 1987
  • Halliday S, Meadow SR, Berg I. Successful management of daytime enuresis using alarm procedures: a randomly controlled trial. Archives of Disease in Childhood 1987;62(2):132-7. [MedLine: 87155424].
  • Hanson 1988
  • Hanson RH, Thompson T, Wieseler NA. Methodological considerations in enuresis-treatment research. A three-treatment comparison. Behavior Modification 1988;12(3):335-52. [MedLine: 89149651].
  • Kahane 1955
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  • References to other published versions of this review
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