Medline ® Abstracts for References 14,29,34
Clinical practice. Evaluation and management of enuresis.
N Engl J Med. 2009;360(14):1429.
Childrens' Clinic, Calgary, AB, Canada. email@example.com
The influence of small functional bladder capacity and other predictors on the response to desmopressin in the management of monosymptomatic nocturnal enuresis.
Rushton HG, Belman AB, Zaontz MR, Skoog SJ, Sihelnik S
J Urol. 1996;156(2 Pt 2):651.
PURPOSE: The relationship of functional bladder capacity as well as other variables to the responsiveness to desmopressin in children with monosymptomatic nocturnal enuresis was investigated.
MATERIALS AND METHODS: A total of 95 children 8 to 14 years old with monosymptomatic nocturnal enuresis (6 or more of 14 nights wet) were evaluated in a double-blind study followed by open label crossover extension using 20 to 40 mcg. desmopressin. Evaluated predictors of response included patient age, gender, race, family history, number of baseline wet nights, urine osmolality parameters and maximum functional bladder capacity (as a percent of predicted bladder capacity based on the formula, patient age + 2 x 30 = cc). Responders to desmopressin were classified as excellent (2 or less of 14 nights wet) or good (50% or greater decrease but more than 2 of 14 nights wet) and nonresponders were defined by a less than 50% decrease in wet nights.
RESULTS: Of the 95 patients 25 (29.5%) achieved an excellent response to desmopressin and 18 (18.9%) had a good response for a cumulative response rate of 45.3%. Theremaining 52 patients (54.7%) were nonresponders. There were no significant differences between responders and nonresponders in regard to gender, race, positive family history or baseline urine osmolality parameters. Response to desmopressin was associated with older age, fewer baseline wet nights and larger bladder capacity. Patients with a functional bladder capacity greater than 70% predicted bladder capacity were 2 times more likely to respond to desmopressin.
CONCLUSIONS: The responsiveness of children with nocturnal enuresis to desmopressin is adversely affected by reduced functional bladder capacity. The results of this study have implications regarding the potential use of combination pharmacotherapy with desmopressin and an anticholinergic for enuretic patients who are nonresponsive to single drug therapy.
Children's National Medical Center, Washington, D.C. 20010, USA.
Bladder dysfunction in children with refractory monosymptomatic primary nocturnal enuresis.
Yeung CK, Chiu HN, Sit FK
J Urol. 1999;162(3 Pt 2):1049.
PURPOSE: We studied bladder dysfunction in children with significant primary nocturnal enuresis refractory to treatment.
MATERIALS AND METHODS: We evaluated 33 Chinese boys and 8 girls with a mean age of 10.4 years, who had significant monosymptomatic primary nocturnal enuresis (3 or more wet nights weekly) after desmopressin treatment with or without an enuretic alarm failed. Daytime cystometry, continuous nighttime cystometry and electroencephalography monitoring during sleep, and detailed recording of daytime and nighttime urinary output were performed.
RESULTS: We recognized 5 patterns of bladder dysfunction and its association with sleep-arousal status. Pattern 1 was normal daytime urodynamics with significant bladder instability at night with normal volume voiding precipitated by unstable detrusor contractions in 14 boys (34%). Pattern 2 was normal daytime urodynamics with frequent small volume voiding at night, probably representing latent bladder instability, in 4 boys (10%). Pattern 3 involved abnormal daytime urodynamics with small bladder capacity, a discoordinated daytime voiding pattern and marked nighttime bladder instability associated with poor sleep in 6boys (15%). Pattern 4 was abnormal daytime urodynamics with an obstructive pattern, and marked daytime and nighttime detrusor hypercontractility (mean maximum detrusor pressure 178 cm. water) in 8 boys (20%). Pattern 5 was abnormal daytime urodynamics with a dysfunctional daytime voiding pattern and frequent small volume nighttime voiding in 8 girls and 1 boy (22%). In all patients functional bladder capacity was smaller than expected for age and the majority had no nocturnal polyuria. Despite underlying bladder dysfunction a 4-week course of 400 microg. desmopressin orally at bedtime still produced a significant response with a greater than 50% decrease in the number of wet nights during treatment in 47% of the patients, although enuretic symptoms immediately relapsed on cessation of therapy in all. Notably cystourethroscopy in 7 of the 8 boys with pattern 4 dysfunction revealed bladder trabeculations and abnormal urethral lesions, including congenital obstructive posterior urethral membranes in 4, Moormann's ring in 2 and irregular scarring at the bulbous urethra in 1.
CONCLUSIONS: Abnormal bladder function, including small functional capacity, instability during sleep and marked detrusor hypercontractility, was common in our enuretic children in whom treatment failed. More importantly, nocturnal enuresis may be the only presenting symptom and there may be a response to desmopressin with a decreased number of wet nights even in cases of significant underlying bladder dysfunction. These findings may have important implications for our management strategy for monosymptomatic primary nocturnal enuresis.
Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital.