Abstracts
Adolescents (Bedwetting)
Adolescents
Referred adolescents were 7 times more likely to wet the bed than their community counterparts. There was a small but significant association between nocturnal enuresis and hyperactivity.
Depressed adolescents were half as likely to wet the bed as those without depression. Bedwetters had more problems relating to peers but were not disliked more often. There was no association between bedwetting, oppositionality, conduct problems and gender.
Clinicians need to inquire about symptoms of attention deficit hyperactivity disorder in adolescents who present with enuresis and vice versa.
Rey JM et al., Bedwetting and psychopathology in adolescents. J Paediatr Child Health, 1995 Dec, 31:6, 508-12.
Chromosome 13q
Chromosome 13q
Nocturnal enuresis, or nightly bedwetting in children more than seven years of age affects about 10% of seven-year-old children, with a wide range of frequencies between populations.
The affliction is often linked to major social maladjustments and occupies considerable time in general practice. From the age of seven there is a spontaneous cure rate of 15% per year, such that few remain affected after the age of 16 years.
There are two types of nocturnal enuresis: type I (PEN1, primary) with at least three nightly episodes in children above seven years, where the child has always had the disorder and type II (secondary) where the child has been dry for at least six months, but enuresis has recurred.
Among some 400 Danish, mostly three-generation families, we have found 17 families with nocturnal enuresis. Markers flank the disease locus at chromosome 13q13-q14.3.
Eiberg H et al., Assignment of dominant inherited nocturnal enuresis (ENUR1) to chromosome 13q. Nat Genet, 1995 Jul, 10:3, 354-6.
Conditioning
Conditioning
50 children with a mean age of 7.8 yr. were treated using the conditioning technique originally developed by Mowrer and Mowrer in 1938. The parents were trained to handle the equipment and to keep records of progress.
The treatment was successful after one treatment for 72% (n = 36) of the children, after one relapse and two treatments for an additional 10% (n = 5), and after two relapses and three treatments for an additional 8% (n = 4).
Ten per cent (n = 5) of the children experienced a third relapse after the third treatment.
Gustafson R: Conditioning treatment of children's bedwetting: a follow-up and predictive study. Psychol Rep, 1993 Jun, 72:3 Pt 1, 923-30.
Economics
Economics
Bedwetting is a common complaint, affecting approximately 10% of 7-year old children in the developed world and causing an economic drain on society. Not only is the cost of nocturnal enuresis borne by the families (necessitating washing and drying, and the costs of the treatment itself) but also by national health services and state health insurance.
The critical factors influencing overall costs were the number of wet nights per week,. Overall, the study found that total costs of not treating enuresis in heavy bedwetters can be higher than with any of the treatment alternatives, which must be seen as an additional burden to families with a child "suffering" from lower self-esteem.
Pugner K & Holmes J: Nocturnal enuresis: economic impacts and self-esteem preliminary research results. Scand J Urol Nephrol Suppl, 1997, 183:, 65-9.
Nocturnal (Bedwetting)
Nocturnal
Nocturnal enuresis is a very common pediatric problem which often has strong genetic roots. In the vast majority of children it resolves spontaneously, with time, therefore research and treatment of bedwetting cannot carry any risk to the child.
Research has focused on sleep disturbances, nocturnal urine production and functional bladder capacity. So far it has not provided conclusive evidence of the pathophysiology of the phenomenon. It is possible that different factors may be predominant in different age groups. Although bedwetters are basically mentally healthy, several studies have shown that the problem may cause secondary emotional and social problems which can be alleviated with successful intervention.
Of the treatment modalities currently available to the pediatrician, the most effective is the moisture alarm. Combined with its safety and low cost it should become the treatment of choice in most cases.
Alon US: Nocturnal enuresis [corrected and republished with original paging Pediatr Nephrol, 1995 Jun, 9:3, 94-103.
Pathophysiology
Pathophysiology
Bedwetting is the most common urologic complaint among children. Wetting frequency at age 7 years varies from 5% to 15%. Treatment has been multimodal: drugs to depress bladder activity, increase urethral resistance, or modulate sleep; electrophysiologic treatment; and, recently, urine production modulation. All of these approaches reflect a lack of sufficient knowledge of the underlying pathophysiology of nocturnal enuresis.
Over the last 13 years, enuresis studies at the Institute of Experimental Clinical Research, the University of Aarhus, Denmark, have focused on sleep disturbances, bladder reservoir function, urine output, and a combination of the three.
Sleep studies indicate that: enuretic patients are normal sleepers; the voiding characteristics of an enuretic episode are similar to those of voluntary voiding during the day; and enuresis can take place during any stage of sleep, but generally occurs when the bladder is filled to the equivalent of maximal daytime functional capacity.
Bladder reservoir capacity appears to be normal and bladder instability an unimportant factor in the pathology of nocturnal enuresis.
However, enuretic patients have been shown to lack the normal nocturnal increase in antidiuretic hormone levels and had nocturnal urine production up to four times the volume of functional bladder capacity, which explains the need for bladder emptying. These findings open new avenues to the approach to treatment based on antidiuretic therapy.
Nirgaard JP & Djurhuus JC: The pathophysiology of enuresis in children and young adults. Clin Pediatr (Phila), 1993 Jul, Spec No:, 5-9.
Preschoolers & Bedwetting
Preschoolers
To determine whether children concentrate their urine overnight and to assess the correlation between specific gravity of a first morning urine specimen and the results of a questionnaire concerning bedwetting, voiding habits, and continence in 47 healthy children aged 3 to 6 years.
Forty of 47 children had a urine specific gravity greater than 1.020. None of these children wet the bed during this study, although four (11%) of 36 had a history of bedwetting.
Furthermore, seven children with a urine specific gravity of 1.015 or lower had a history of bedwetting and wet the bed during this study. A voiding frequency of six or more times per day, by history, was associated with a 3:1 relative risk of bedwetting but did not segregate children with primary enuresis from those with secondary enuresis.
Our results indicate that healthy children aged 3 to 6 years are able to concentrate their urine. In addition, urine specific gravity was an accurate predictor of the presence of nocturnal enuresis in this group of children. Our results suggest that a specific gravity of the first morning urine specimen should be correlated with appropriate history before extensive diagnostic evaluation or empiric therapy is performed in children with nocturnal enuresis.
Mevorach RA et al., Urine concentration and enuresis in healthy preschool children [see comments]. Arch Pediatr Adolesc Med, 1995 Mar, 149:3, 259-62.
Renal Functions
Renal Functions
Investigated the pathophysiologic cause(s) of primary nocturnal enuresis. Therefore, electrolyte concentrations of urine specimens were evaluated in the morning, and alterations compared between enuretics and nonenuretics.
The urinary Ca/Cr ratio, tubular reabsorption of phosphorus (TRP) and fractional sodium (FE Na%) and potassium excretions (FE K%) were determined for patients and controls. RESULTS: There was no significant difference in the Ca/Cr ratio and TRP between patients and controls, but enuretic patients had significantly higher FE Na% and FE K% values than controls.
There were significant positive correlations between FE Na% and FE K% and the frequency of bedwetting, respectively, among enuretic patients.
Since Na and K excretion of enuretic patients was higher than in nonenuretics, it can be concluded that there may be a benign hereditary and/or postural renal tubular handling disorder of Na and K in enuretic children.
Vurgun N et al., Renal functions of enuretic and nonenuretic children: hypernatriuria and kaliuresis as causes of nocturnal enuresis. Eur Urol, 1997, 32:1, 85-90.
Urinary Incontinence in Adults
Urinary Incontinence in Adults
Although it is widely underdiagnosed and underreported, urinary incontinence (UI), is known to be widely prevalent. Practitioners remain uneducated about this condition and patients are embarrassed to seek professional help. Further, there are significant variations in UI diagnostic and treatment practices as well as associated medical costs.
A new guideline for urinary incontinence in adults needed to be developed.
The treatment of UI can improve or cure most patients. Surgery should be considered only in very specific cases.
USDHHS: Urinary incontinence in adults: clinical practice guideline. United-States-Department-of-Health-and-Human-Services-Publications-Public-Health-Service (US-DEPT-HHS-PUBL-Public-Health-Serv) 1992 Mar #AHCPR 92-0038: (125 p).
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