10 July 2007
NOCTURNAL ENURESIS: APPLICATION OF EVIDENCE-BASED MEDICINE IN COMMUNITY PRACTICE
As Urologists working in a major metropolitan paediatric hospital we commend Dr Cutting and his team on the success they have experienced with the use of an enuresis alarm and support programme.1 However, we feel that their success due to use of the enuresis alarm was overstated and draw attention to the flow chart labelled Figure 1 in the original article.1 This figure shows treatment outcomes initially, at 6-month and 24-month follow-up.
Of all patients treated (n = 505), the initial success of 79% (399/505) after 16 weeks of alarm use is higher than current literature. This represents a relative risk for failure of 0.24 after 16 weeks of alarm use, in comparison to 0.38 from the latest Cochrane review of alarm use for nocturnal enuresis.2 However, at the 6-month follow-up, 270 children remain dry. This represents 53% of the original cohort treated (270/505). Alternatively, it represents 67% of the cohort who achieved initially achieved dryness (270/399), rather than the 73% as stated by Cutter et al. This is similar to the current Cochrane review where 55% of children relapsed after stopping alarm treatment.2
Similarly, at 24-month follow-up 171 children remain dry, that is 34% of the original cohort (171/505) or 43% of the cohort who achieved initially achieved dryness (171/399).
We suggest a revised flow chart (Fig. 1) that gives a more accurate picture of the outcome achieved with their technique. At 24-month follow-up, the success rate is 34% (171/505). Over 2 years, this is similar to the 15% per year spontaneous remittance rate.3
We agree the use of an enuresis alarm is an effective tool in the management of nocturnal enureisis with two-thirds of children becoming dry during alarm use, however, the relapse rate after finishing alarm intervention is up to 55%3 which is similar to the corrected relapse rate (53% at 6 months) for this group. We strongly agree with all management of nocturnal enuresis including alarm use, that frequent supportive follow-up is required for good long-term outcome. The rate of relapse for alarm use can be improved with the additional use of motivational therapy or behavioural therapy with timed voiding, with relapse rates as low as 16% after 1 year.4