High initial efficacy of full-spectrum therapy for nocturnal enuresis in children and adolescents

Authors


Abstract

Objective  To investigate the initial efficacy and predictive factors of full-spectrum therapy in the treatment of children and young adolescents with nocturnal enuresis (NE).

Patients and methods  Combined therapy for NE comprises an enuresis alarm, bladder training, motivational therapy and pelvic floor muscle training, and is more effective than each of the components alone or than medical intervention. A total of 60 children and adolescents (aged 4–20 years) with NE were treated once a week with full-spectrum therapy for a maximum of 6 months.

Results  Overall the therapy was successful (14 consecutive dry nights) in 52 of 60 patients. At 30 days the cure rate was 33%, after 60 days 72% and after 98 days, 87%. The remaining 13% did not achieve 14 consecutive dry nights; seven patients improved, having fewer dry nights/week. One patient discontinued the treatment because of lack of motivation. In children with an initial maximum bladder capacity less than normal for age, the capacity increased from 53% of the normal maximum bladder capacity in week 1 to 88% at the end of treatment. Neither age, gender, sleep arousal, bladder capacity, family history and pathophysiological profile had any association with the success rate.

Conclusion  The short-term success rate of full-spectrum therapy for NE is high. Age, gender, sleep arousal, bladder capacity, family history and pathophysiological profile of enuresis are unrelated to the success of the intervention.

Introduction

Nocturnal enuresis (NE) is a frustrating disorder of childhood; affected children who consult primary-care physicians probably represent only a proportion of the actual number of cases. Families are often disinclined to mention the problem and in medical practice NE is often regarded as a minor health problem that will recover spontaneously. However, children with NE have low self-esteem that may become normal with appropriate treatment [1,2].

NE has been attributed to maturational delay [3] and the prevalence decreases with increasing age [2–6]. NE is less common amongst girls than boys and can be the result of a small bladder capacity, unstable detrusor contractions or high urine production during the night, or delayed arousal from sleep; it is also influenced by genetic and psychosocial factors [3].

There is a wide range of treatment regimens for NE [7] but full-spectrum therapy (FST), consisting of an enuresis alarm, bladder training, motivational therapy and pelvic floor muscle training, is better than medical treatment, e.g. desmopressin, oxybutynin or tricyclic antidepressants [7–10]. The enuresis alarm remains the most effective single treatment for NE; the success rate is high, at ≈ 70% [2,3,11]. The individual components of FST, e.g. fluid intake and voiding charts, reward systems and exercises, have been shown to have a minimal effect when used alone. In combination with all the other available therapies it is possible to achieve better results [7–19].

The efficacy of FST related to age, gender, sleep arousal, bladder capacity, family history and different pathophysiological profiles (e.g. primary or secondary enuresis, or NE with urge symptoms) is unknown. Therefore, the aims of the present study were to investigate the efficacy and predictive factors of FST in the treatment of children and young adults with NE.

Patients and methods

Sixty consecutive children and adolescents with NE (mean age 10.4 years, range 4–20; 40 males and 20 females) were referred from the Department of Urology and treated with FST. Exclusion criteria were renal malformations or a history or presence of UTI. FST was specifically chosen by the child and parents; if the patient and parents were not motivated, desmopressin was proposed. Monosymptomatic primary NE was diagnosed in 37 patients, secondary enuresis in 11 and NE with urge symptoms in 12.

During the 2 weeks before the start of FST, 36 patients wet the bed daily, three did so six times a week, seven four to five times a week, eight two to three times a week, and two once a week; one was wet one to three times in the previous month. In three patients the number of wet nights was very variable; in one week they were wet almost every night while in another only once or twice.

Fifty patients were referred after several other treatments were attempted; 19 had tried alarm treatment alone, 20 used a voiding chart, six followed bladder training and 39 parents woke their child during the night. These treatments had been unsuccessful. Thirty-three patients tried medical treatment (desmopressin, oxybutynin or imipramine).

FST consists of different treatments including an enuresis alarm, bladder training, motivational therapy and pelvic floor muscle training. The objective of the enuresis alarm is to associate the sensation of a full bladder with awakening and eventually with inhibition of voiding. The patient and the parents were instructed that when the alarm sounded, he or she must get up, go to the bathroom, urinate and control the bladder volume, return to bed and reset the alarm. The parents were asked to ensure that the patient was completely awake.

For bladder training the patient had to urinate and drink at fixed times; advice was given on prompted voiding. The patient had to drink two glasses during a meal and one glass at 10.00 hours and 15.00 hours. They were not allowed to drink during the evening until they were dry for 14 consecutive nights. Then they were asked to drink one glass before going to sleep. When they were dry for 7 consecutive nights they were asked to drink two glasses. If dry after 7 consecutive nights, the treatment was ended. They were motivated to urinate seven times a day.

After a dry night the patient was immediately rewarded to reinforce the motivation. A reward system was also devised during the night to praise the patient every time he/she went to the bathroom. In this way the behaviour was gradually modified until the NE was under control.

Every week the patient attended the physiotherapy department; during the first session the patient and parents were instructed about the anatomy and physiology of the bladder, and given an explanation of NE and its treatment. This took at least 20 min. The patient was taught to contract and relax the pelvic floor muscles. At every session the results of the therapy were discussed and the pelvic floor muscles exercises repeated. These exercises were combined with biofeedback training using surface electrodes on the central tendon of the diaphragm. The therapist created a pleasant atmosphere so that the patient enjoyed the treatment. The last few minutes of every treatment were devoted to sporting activities. When the patient was improving, small rewards were given by the physiotherapist. At the last treatment session they could choose any activity.

The voided volumes were recorded on a voiding chart; each week the largest volume was used as the maximal functional bladder capacity (FBC), which allowed changes in bladder capacity to be assessed in enuretic patients during FST. The normal bladder capacity was calculated using Koff's formula ((age + 2)×30).

For the outcome to be deemed successful the patient had to attain 14 consecutive dry nights. The first night of the 14 was taken as the date after treatment began for calculating the period required for success. The treatment was considered to have failed if the patient did not attain success within 6 months of starting treatment, and as discontinuation if the patient interrupted the treatment before the end of 6 months. The duration required to achieve success was analysed using the Kaplan–Meier method. The influence of several factors on treatment outcome, e.g. age, gender, bladder capacity before treatment, sleep arousal (by asking whether the patient was a deep sleeper or not), family history and pathophysiological profile were assessed. The effect of age and bladder capacity were assessed using anova and categorical data (gender, arousal, family history and pathophysiological profile) using the chi-square test.

Results

Fifty-two (87%) patients were successful; the duration to success is shown in Fig. 1. At 30 days the cure rate was 33%, after 60 days 72% and after 98 days, 87% of the patients were dry. The mean duration was 41 nights for the 52 successful patients. Seven patients (12%) had fewer dry nights but they were not deemed successful; one (1%) discontinued treatment. In 35 (58%) of the patients the maximum FBC before treatment was smaller than expected for age. Figure 2 shows the development of FBC during treatment; it increased from 53% of normal in week 1 to 88% at the end of treatment.

Figure 1.

The percentage of enuretic children and adolescents who followed FST and did not achieve the criterion of 14 consecutive dry nights, as a function of time.

Figure 2.

The change in the mean maximum FBC of 35 enuretic children with an initial FBC smaller than normal for their age.

To examine the influence of various factors on success, the patients were divided in four groups categorised by the time needed to become dry, i.e. 1 month, 2 months, 98 days and >180 days (Table 1). The mean age in the four groups was very similar, with no significant difference among the groups (Table 1). Although the mean initial FBC was higher in the first group and lower in the last there was no significant difference among the four groups (Table 1). Thirty-five males and 17 females were successful, requiring a mean (sd, range) of 39 (23, 7–91) and 45 (26, 21–98) days, respectively, the difference not being significant (Table 1). Forty-eight (80%) patients were considered to be ‘deep sleepers’ with a high arousal threshold but there were no significant differences in this factor (Table 1). In 22 (37%) patients, NE was frequent in the family; 12 of the patients' fathers and 11 mothers had had the same problem when they were children, but family history had no significant influence on the success of combined therapy (Table 1). The patients had different pathophysiological profiles (Table 1) but there was no difference in success among the profile groups.

Table 1.  Predictive factors of the duration of FST to achieve the criterion of 14 consecutive dry nights
FactorDays before successP
306098>180
No. (%)20 (33)23 (38)  9 (15)  7 (12)
Mean age, years10.89.79.99.40.824
Initial bladder
 capacity
 (% of normal)
786869620.358
Gender
 female79220.772
 male131476
Sleep arousal, n
 high1618860.893
 low4512
Family history
 positive106330.443
 negative101765
Profile of enuresis
Monosymptomatic1314630.852
Primary
Secondary4412
Daytime urge3522

Discussion

The initial efficacy of FST for NE, using the traditional definition of 14 consecutive dry nights, was high in the present study. Contrary to our expectation, neither age, gender, initial FBC, sleep arousal, family history and pathophysiological profile of enuresis had any predictive value for the efficacy of FST.

Although bedwetting is a benign condition it may cause considerable distress for the child and parents, and thus require intervention; 50 of the present 60 patients were referred after receiving a variety of other treatments, so patients attending our hospital are not necessarily representative of all those with NE. Bedwetting is less common among females than males; two-thirds of the present patients with NE were male. A small FBC can be a risk factor for NE; previous studies suggest that once the child is cured they usually do not get up at night to void but remain asleep all night [16]. This is also our experience; in the present patients 35 (59%) had an initial maximum FBC smaller than expected for their age. FST was associated with an increase in FBC and success was not attributable to a decrease in nocturnal urine volume. Fergusson et al.[5] reported that a family history of enuresis was the strongest predictor for a child to develop enuresis; in the present study 22 (37%) of enuretic patients had a positive family history. Parents frequently report that their enuretic child sleeps more deeply than other children, but research in this field has shown conflicting results. Graham [20] concluded that it is uncertain whether enuretic children are more or less easy to wake than those who are not enuretic; apparently NE can occur in both deep and less deep sleepers [21]. In the present study, 80% of parents reported that their child was a deep sleeper.

FST (maximum 6 months) was successful in 87% of the present patients, the maximum being reached after 98 days; a mean of 41 nights was needed for success. Thus FST seems to be fast and effective, producing a success rate in the present study that was higher than expected from spontaneous recovery alone. To be deemed successful, any treatment must produce an improvement rate of >15%/year, i.e. the spontaneous recovery rate [2–6]. The present success rate was also higher than in studies using bladder training only (30%) or pharmacological treatment (≈ 60%) [7,13]. The most important factor is that the physiotherapist persists and is always prepared to motivate the patient and the parents. The therapy is easy to undertake by children and adolescents, and is safe and with no side-effects. Only one of the present patients discontinued therapy. There were no differences in treatment duration needed for success among the different age groups, with gender, in patients with high or low sleep arousal, with bladder capacity, with family history of NE or pathophysiological profile.

The present results cannot be compared with other studies because predictive factors of FST were not published. FST depends largely on the cooperation and motivation of the patient and parents. FST requires a considerable investment in time but is rewarding because patients and parents are grateful for success.

M. Van Kampen, University Hospital KU Leuven, Department of Physiotherapy, Herestraat 49, 3000 Leuven, Belgium.
e-mail: marijke.vankampen@uz.kuleuven.ac.be

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