Enuresis is a common pediatric condition with a high incidence. Data show that the prevalence of enuresis in children in Europe and the United States is 3.8% to 18.9%: the prevalence of enuresis in preschool children in Asia is as high as 21.0% to 27.8%, and 6.9% to 11.2% in school-age children. The disease can affect the quality of life of the child, and some children may also have underlying diseases and associated urological and neurological disorders.
Children with enuresis tend to have low self-esteem, anxiety, poor social adjustment, and even more serious psychiatric problems that can last into adulthood. Since most enuresis is self-healing, doctors and parents do not pay enough attention to the dangers of enuresis, and children with the disease lose the best time for treatment. Studies have concluded that enuresis can be caused by a variety of abnormalities in the neurological, endocrine, psychological, and anatomical and functional aspects of the urinary system, and that the occurrence and severity of enuresis are often closely related to the child’s growing habits, family education, and timing of treatment.
In recent years, early diagnosis and standard treatment of enuresis have attracted great attention from scholars at home and abroad.
I. Diagnosis of enuresis
Nocturnal enuresis in children is defined as involuntary nocturnal urination in children aged ≥5 years old at least twice a week on average and lasting for more than 3 months.
The main points of diagnosis include.
①The child’s age is ≥5 years old (5 years old as the age criterion for judging nocturnal enuresis in children is somewhat subjective, but it reflects the degree of development of the child’s ability to control urination);
(2) Children with involuntary urination during sleep, ≥2 times per week for more than 3 months (children with occasional urination due to fatigue or excessive drinking before bedtime are not considered pathological);
③The number of nocturnal enuresis can be relaxed appropriately for older children with diagnostic criteria.
II. Classification of enuresis
Enuresis can be divided into primary enuresis (PNE) and secondary enuresis (SNE); or single symptom nocturnal enuresis (MNE) and non-single symptom nocturnal enuresis (NMNE).
Primary enuresis is defined as bedwetting that continues from infancy and has never had a bedwetting-free period of more than 6 months, and secondary factors such as congenital diseases, urinary tract infections, and neuromuscular diseases are excluded; secondary enuresis is defined as bedwetting that occurs after having had a bedwetting-free period of more than 6 months. Primary enuresis is common in clinical practice.
Single-symptom nocturnal enuresis refers to bedwetting at night only, with normal daytime urination, not accompanied by anatomical or functional abnormalities of the urinary system and the nervous system; non-single-symptom nocturnal enuresis, also called complex enuresis, refers to daytime symptoms of the lower urinary system (such as bladder irritation symptoms, urinary incontinence, etc.) in addition to bedwetting at night, often secondary to urinary or neurological diseases.
III. Treatment of enuresis
The pathogenesis of primary enuresis in children has 3 main aspects: delayed or impaired development of the sleep-wake response to bladder filling, insufficient nocturnal antidiuretic hormone secretion and reduced functional bladder capacity at night. Before starting treatment for enuresis, an assessment of the enuresis condition should be performed to determine the condition and develop appropriate treatment measures. The evaluation should include the determination of enuresis, the presence of underlying disease, clinical presentation and staging, possible pathophysiological pathogenesis or triggers, lifestyle habits, previous treatment experience, and the motivation, compliance, and tolerance of the child and parents to treatment.
2010. In the latest guidelines for the treatment of enuresis in children published by the National Institute of Clinical Practice in the UK, special emphasis is placed on the assessment of the condition prior to treatment, particularly the need to communicate fully with the child’s parents before treatment to understand their needs and expected goals for treatment, with the results of the assessment guiding the treatment measures and the level of care. Secondly, we should exclude possible triggers that may cause enuresis, such as bedtime drinking habits, sleep ventilation disorders caused by concomitant rhinitis and adenoid hypertrophy, perineal and urinary tract infections, and psychosomatic stimulation.
The current domestic treatment methods for enuresis in children include: behavioral therapy, awakening training, medication, acupuncture and biofeedback therapy, etc.
1. Behavioral therapy: including control of fluid intake, adjustment of diet time and structure, training of normal urination and defecation habits, and establishment of appropriate reward feedback mechanisms.
Controlling fluid intake is not simply restricting water, but ensuring adequate daily fluid intake for each child, which varies depending on the child’s exercise level, environment and diet. Inadequate fluid intake may mask underlying bladder disease and prevent the development of normal bladder volume.
The correct approach is to ensure daytime fluid intake and control fluid intake before bedtime, i.e., the recommended amount of water to drink during the day should be: for children 4 to 8 years of age, 1000 to 1400 ml for both sexes; for children 9 to 13 years of age, 1400 to 2300 ml for males and 1200 to 2100 ml for females; for children 14 to 18 years of age, 2100 to 3200 m1. for males and 1400 to 2500 ml for females. Minimize the intake of caffeinated beverages; have an early dinner with less salt and oil; and limit the intake of food and water from 2 hours before sleep. All of these points are helpful to improve the symptoms of nocturnal enuresis.
Parents should encourage the child to urinate every 2 to 3 hours during the day and to empty the bladder before bedtime. In addition, since constipation is closely related to enuresis, parents should provide timely and symptomatic treatment if they find constipation in their children. This will help to cure enuresis.
2.Wake up treatment: including alarm, alarm clock wake up training and dry bed training. Alarms are more commonly used abroad and are recommended as first-line treatment in both NICE and ICCS guidelines for the treatment of enuresis, with a high level of evidence. However, alarms require special equipment and are rarely used in China, and currently l clinical application is mainly alarm clock wake-up training. In some randomized trials or similar randomized trials comparing alarm clock treatment with no treatment, about 2/3 of children in the treatment group were cured during alarm clock treatment, and 1/2 of children did not relapse after stopping treatment.
However, alarm clock wake-up training requires prolonged educational instruction, encouraging feedback and support of long-term follow-up, short-term symptom improvement is not obvious, and alarm clock treatment has poor compliance and high early withdrawal rate when applied. The timing of alarm clock settings, sound selection, and feedback methods need to be individualized, and conditions should be evaluated before treatment to see if they are conducive to alarm clock therapy, and it is especially important to obtain the active cooperation of the child and parents. In Beijing Children’s Hospital, the wake-up call training is used to treat children with different conditions of enuresis in the outpatient clinic, and long-term follow-up is provided.
Most children with single-symptom nocturnal enuresis can be cured with only behavioral training and wake-up training. Dry bed training requires a lot of parental effort and time, and parents need to be fully informed and given the necessary education and assistance. It is not suitable for all children with enuresis because it can easily lead to sleep fragmentation, and it is not suitable for children with anxiety, depression, sleep disorders and uncooperative children.
3.Medication: mainly desmopressin, anticholinergic drugs and tricyclic antidepressants.
(1) Desmopressin: It is an antidiuretic hormone (ADH), also known as vasopressin (AVP), etc. It is a peptide hormone, and its main role in human body is to control the amount of water excreted in urine. Desmopressin acetate (DDAVP) is an analogue of AVP, and the structural changes have increased desmopressin’s role in antidiuresis and decreased vasopressin’s role, and desmopressin has become an important drug in the treatment of enuresis and enuresis.
Desmopressin has a rapid onset and short-term effect in improving the symptoms of enuresis, and is the recommended drug for the treatment of nocturnal enuresis at the 4th International Consultation on Incontinence (ICI) Class I level A. Desmopressin can be used as a first-line drug for the treatment of enuresis when the alarm clock does not work or when the alarm clock is not acceptable. It is especially suitable for children with nocturnal polyuria and high bladder capacity, and is the drug of choice when the condition is more urgent or when parents and children need immediate relief of enuresis symptoms.
It is clinically recommended for children over 7 years of age, and may be considered for children 5 to 7 years of age who have severe symptoms and require rapid symptom control.
Desmopressin should be taken at bedtime and water should be restricted 1 h before and 8 h after taking it to allow the drug to work and reduce adverse effects. After 4 weeks of application of desmopressin, we should observe whether there is a decrease in the size of urinary blisters and the number of bedwetting to assess the response to the booster, and if there is a response, we should continue the treatment for 3 months. However, some children are prone to relapse after discontinuation of the drug. It is recommended to combine the treatment with awakening training and gradually reduce the dosage until discontinuation of the drug.
A randomized clinical trial found no difference in adverse effects and complications and immediate remission rates between gradual and immediate discontinuation in patients with severe enuresis, but the long-term remission rate was higher with gradual discontinuation.
Both desmopressin and arousal training can be used as first-line treatment for enuresis, and most randomized clinical trials comparing the efficacy of the two have concluded that the difference between them is not statistically significant. Moreover, the addition of desmopressin has an adjuvant effect on alarm clock treatment in the short term, and in the long term follow-up, there is no difference with alarm clock treatment alone. However, desmopressin has better compliance and less withdrawal rate than alarm clock treatment.
(2) Anticholinergic drugs: Anticholinergic drugs have the effect of relaxing bladder smooth muscle and are used to treat daytime urinary incontinence caused by overactive detrusor muscles and small bladder capacity. The main anticholinergic drugs used in clinical practice are oxybutynin and belladonna. They are more effective in forced urinary muscle-dependent enuresis and are indicated for functional small bladder capacity with daytime incontinence. Studies have shown an increased rate of remission of enuresis with anticholinergic drugs in those who do not respond to desmopressin.
The toxicity of anticholinergic drugs is low and adverse effects, such as dry mouth and constipation, may limit their use in clinical practice. Simple application is not recommended in children with impaired bladder emptying and increased residual urine volume.
(3) Tricyclic antidepressants: The mechanism of tricyclic antidepressants, mainly promethazine, for the treatment of enuresis is unclear and may be to reduce the excitability of the detrusor muscle and increase the bladder capacity. The application of tricyclic drugs for the treatment of enuresis is three to four times lower than the dose and blood concentration required for the treatment of depression. Promethazine also has a higher relapse rate in the treatment of enuresis, and is not recommended as a first-line clinical drug because of certain adverse effects.
4.Acupuncture treatment: Acupuncture has good effect on enuresis and can be one of the options for short-term treatment of enuresis. However, acupuncture treatment is traumatic and stressful to the child, requires the cooperation of parents and the child, and is prone to relapse.
5, biofeedback therapy: biofeedback therapy is a behavioral treatment method, the principle is to amplify the extremely weak, usually imperceptible physiological activities and bioelectric activity information within the human body, and become visible waveforms and audible sound display, the individual with the help of visual and auditory organs, through the feedback information to understand their own changes, and according to the changes gradually learn to control and correct to a certain extent The process of these activities.
When used in the training of pelvic floor muscles, it can improve the stretching and contraction of pelvic floor muscles and strengthen the pelvic floor muscle group, thus treating some abnormal excretion diseases such as enuresis.
Biofeedback therapy is suitable for children with enuresis who have vesicourethral dysfunction. Biofeedback therapy is useful for improving the maximum urinary flow rate and urine volume in children with primary enuresis, helping to establish a normal urinary flow curve and adjusting the coordination of contraction of the detrusor and sphincter muscles. The treatment requires special equipment and software, as well as the child’s compliance with the treatment and a certain level of understanding, and is suitable for older children.
IV. Treatment modalities for enuresis
In recent years, the treatment of enuresis in children has become more focused on improving the psychological, behavioral, and social activities of children with enuresis, rather than on relieving the symptoms of enuresis. The treatment plan for enuresis should be based on the child’s enuresis condition, lifestyle, psychological factors, self-awareness, family relationships, economic and cultural background, the child’s parents’ goals and expected outcomes of enuresis treatment, and the child’s compliance and tolerability of treatment.
The 2010 NICE guideline on enuresis also recommends that physicians, parents, and children should be involved in the development and implementation of treatment plans, and that physician encouragement, child participation, and parental adherence are essential to successful treatment.