treatment of primary noctural enuresis in children

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Treatment of primary nocturnal enuresis inchildren: a review cch_1146 153..160

M. L. Brown, A. W. Pope and E. J. BrownDepartment of Psychology, St. Johns University, Jamaica, NY, USA

Accepted for publication 22 June 2010

Keywordsevidence-basedtreatment,literaturereview,nocturnalenuresis

Correspondence:Alice W.Pope,PhD,Department of Psychology, St. JohnsUniversity, 8000 UtopiaParkway, Jamaica,NY11439,USAE-mail:[email protected]

AbstractPrimary nocturnal enuresis is a common childhood disorder.Treatment approaches bridge thepsychological and medical elds. A substantial body of literature addresses the various waysof treating enuresis, from pharmaceuticals to behavioural interventions.The medical andpsychological literatures have proceeded relatively independently from one another and there hasbeen little interconnection between the US and international literatures, resulting in a lack of discourse and integration among researchers investigating treatment outcomes for enuresis. Thisreview examined the evidence base for treatments of primary nocturnal enuresis in children.Psychological,pharmaceutical and multi-component interventions are discussed.This review soughtto provide an integrated interdisciplinary and international perspective on treatment efcacy fornocturnal enuresis by expressly gathering publications from psychological and medical elds, aswell as US and international sources. The literature supported the urine alarm as the most effectiveintervention for nocturnal enuresis and demonstrated the benet of combining the urine alarmwith other components, both behavioural and pharmaceutical. In particular, recent literature

showed that the urine alarm, when used in conjunction with antidiuretic medication (i.e.desmopressin), leads to more dry nights earlier in the conditioning process.Disparities betweenthe different literatures were discussed.

Introduction

The core element of nocturnal enuresis 1 is the repeated voidingof urine during the night into the bed while sleeping (AmericanPsychiatric Association 2000). The wetting must occur at leasttwice per week for at least 3 months or must have a negativeimpact on other important areas of functioning. The distur-bance must not be due to effects of a substance or a generalmedical condition. To meet criteria for diagnosis, the child mustbe at least 5 years old, or have a mental age of 5 in populationsthat are developmentally delayed. Prevalence of enuresis isapproximately 5%10% among 5-year-olds, 1.5%5% among

9- and 10-year-olds and about 1% among persons 15 years andolder (American Psychiatric Association 2000; Butler & Heron2008). Prevalence rates are higher for males than for females atall age-points (Butler & Heron 2008).Enuresis follows twotypesof courses: primary and secondary (American Psychiatric Asso-ciation 2000). In primary type enuresis, the child has neverachieved urinary continence, whereas in secondary type enure-sis, the disorder appears after the child has established a periodof at least 6 months of urinary control (American PsychiatricAssociation 2000; Butler & Holland 2000). Children with sec-ondary type wetting need more careful medical and psychologi-cal assessment before considering intervention, as there couldbe an external antecedent associated with the recurrence of urinary incontinence (i.e. illness, trauma or abuse) (Mellon&McGrath 2000). Another important distinction is between

1 Denitions employed throughout this text conform to the standards recom-mended by the International Childrens Continence Society except where spe-cically noted (see Neveus et al . 2006).

Child:care, health and developmentReview Article doi:10.1111/j.1365-2214.2010.01146.x

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that of monosymptomatic and polysymptomatic enuresis. Thisdistinction is based on the respective absence or presence of bladder overactivity, as indicated by frequent urinary voids (e.g.10 or more per day) and/or daytime wetting or urgency (Butler

et al . 2006; Butler & Heron 2008). Approximately 30%35% of children with nocturnal enuresis are reported to have the polysymptomatic form (Butler et al . 2006; Butler & Heron 2008).While an important distinction with regards to the course andtreatment of the disorder, this review will not distinguishbetween the two types, as research into the two classicationscontinues to grow and new ndings regarding treatment impli-cations continue to be put forth (e.g. Butler et al . 2006). In asimilar vein, daytime incontinence, which occurs in approxi-mately 20%35% of children with nocturnal enuresis (Butler &Heron 2008), is thought to be aetiologically distinct fromprimary nocturnal enuresis (Mellon & McGrath 2000; Houts2003) and is seen as a more complex clinical problem associatedwith polysymptomatic enuresis (Butler et al . 2006; Butler &Heron 2008). Therefore, daytime incontinence will also not bediscussed herein.

To date, numerous empirical studies of treatment outcomesand reviews of evidence-based treatments for nocturnal enure-sis have been conducted. Evidence-based treatments in bothpsychology and medicine refer to those that combine the bestavailable research evidence with clinical expertise while takinginto account patient-specic factors (Institute of Medicine2001; American Psychological Association 2005). This work has

made important contributions to the ongoing conversationamong practitioners regarding the best treatments for childrenwho suffer from this disorder. Of issue is the fact that enuresis isa disorder that bridges both the psychological and medicalelds; traditionally, each eld has produced its own literature.Similarly, it is a disorder that is researched and studied interna-tionally, but with a lack of global discourse. This present review seeks to provide a more integrated interdisciplinary and inter-national view of the treatment outcomes and evidence-basedtreatments for nocturnal enuresis.

The goals of this paper are: (1) to provide a comprehensivereview and critique of current treatment outcome andevidence-based treatment literature and (2) to discuss clinicalapplications and future directions for the study of enuresis. Thefocus of this paper will be primary nocturnal enuresis, as themajority of the extant literature focuses on this subtype.

Method

A literature review of articles on the methods of interventionand treatments for primary nocturnal enuresis in children was

performed using the PsycINFO and MEDLINE research data-bases, which together contain publications from 1911 to thepresent. Free text searches were conducted, involving the termsenuresis, primary nocturnal enuresis and elimination disor-

ders, combined with the terms treatment, behaviour and chil-dren. The resulting article titles and abstracts were scanned forrelevance and those that discussed methods of intervention andtreatments for childhood primary nocturnal enuresis wereobtained and included in the review. The reference sections of these articles were then screened to identify other relevantpapers, with special attention given to accumulating both inter-national and domestic publications in both the medical andpsychological elds.

Review of treatment outcome literature

Evidence-based behavioural interventions

Urine alarm

The urine alarm works by using a moisture-sensitive switchingsystem that, when closed by contact with urine, completes asmall-voltage electrical circuit and activates a stimulus, such asa bell or buzzer, which is strong enough to cause the child towake (Friman 2008). The alarm is thus an aversive stimulus,which leads to a conditioned avoidance response of contractingthe pelvic oor along with the external sphincter of the bladder

neck. In other words, the alarm stimulus may startle the child,leading to muscle contractions and an interruption in the ow of urine, as well as waking the child. In the classical behaviouralsense, this physiological reaction (the unconditioned responseto the alarm) becomes the conditioned response to feelings of afull bladder and the child will wake before urinating in order toavoid being startled by the alarm. Another conceptualization isthat the urine alarm is an operant, whereby the waking is anavoidance response and is maintained by the negative reinforce-ment of not having to be awakened and not lying in a wet bed(Mellon & McGrath 2000).

The original alarm began as a pad that was placed on thechilds bed, under the sheet (i.e. bell and pad); more recently smaller units have been developed, which clip onto underwearor pajamas (Moffatt 1997). Some alarms can be set up to wakethe childs parents rst, who then wake the child. There is noconvincing evidence that any one type of alarm leads to signi-cantly better results, yet there appears to be some evidencesupporting alarms that wake the child directly versus alarmsthat wake the parents (Glazener et al . 2004). The urine alarmhas never been fully standardized or packaged as a clinical

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procedure with scripted instructions to parents and children(Nawaz et al . 2002). Instead it is available for purchase atmedical supply stores or from online vendors, with each varia-tion of the alarm (i.e. the particular brand or make) providing

its own instructions for use.Several review studies and well-controlled experiments have

established the basic urine alarm as an effective treatment fornocturnal enuresis, alone or in combination with other treat-ment components, such as dry-bed training (DBT) (Houts et al .1994; Moffatt 1997; Mellon & McGrath 2000; Van Hoeck et al .2007; Glazener et al . 2009). In a meta-analytical review of over75 randomized trials conducted until 1989, Houts and col-leagues (1994) concluded that urine alarm treatment is superiorto every other type of intervention for enuresis. In a more recentreview by Glazener and colleagues (2004) that used data fromrandomized and quasi-experimental designs dating back to the1960s, the authors determined that the urine alarm was themost effective treatment for children suffering from enuresiswith a reduction in night-time incontinence seen in approxi-mately 50% of children during treatment and at follow-up.

Controlled comparative trials have demonstrated that thealarm has greater efcacy than other forms of therapy, such asindividual talk psychotherapy and medication (Mellon &McGrath 2000; Houts 2003). It is considered the most effectivecurrent treatment and costs considerably less than availablemedications (Friman2008).In a review by Mellon and McGrath(2000), the authors determined that the average success rate

(dened as 14 consecutive dry nights) for the urine alarm is77.9%.Other controlled evaluations of the alarm indicate that itis 65%75% effective, with a duration of treatment of 512weeks and a 6-month relapse rate of 15%30% (Wagner 1987;Houts 2003; Friman 2008). Treatment is usually terminatedwhen the child reaches a specied goal, usually 14 consecutivedry nights.

Despite its effectiveness, not all children respond successfully to the urine alarm. Pre-treatment factors associated with pooroutcome or dropout with urine alarm treatment are daytimewetting, multiple occurrences of wetting at night, family history of enuresis, prior failed treatment experience, childrenspsychological problems (e.g. psychopathology, developmentaldelay), childrens behavioural problems (e.g. oppositionalbehaviour, lack of motivation to change), parental intoleranceof bedwetting, aversive home environment and stressed familialrelationships (Mellon & McGrath 2000; Butler & Gasson 2005).Within-treatment factors found to be associated with urinealarm failure are wetting early in thenight and the childs inabil-ity to wake in response to a triggered alarm (Butler & Gasson2005).

Over-learning

Over-learning is initiated after successful treatment and refers tothe process of training children to a higher criterion than is

normally thought to be necessary, with the goal of furtherreducing the relapse rate (Christophersen & Mortweet 2001).Over-learning is not well understood in terms of its mechanismof action (Moffatt 1997; Friman 2008; Glazener et al . 2009). Asan intervention for enuresis, the process is achieved by havingthe child drink between 16 and 32 ounces of uid beforebedtime and generally results in a relapse of wetting. The over-learning process is thencontinued until a success criterion (any-where from 14 to 28 nights without wetting) is again met. Houts(2003) utilized a graduated over-learning procedure duringwhich the child begins by drinking a specied amount of water.That amount is then increased by two ounces after two consecu-tive dry nights. The process continues until the child reaches amaximum amount of water, dened as one ounce for each yearof age plus two ounces. Moffatt (1997) found that when condi-tioning is not followed by over-learning, relapse ranges from20% to 40%. With over-learning, the relapse rate drops toapproximately 10%. Graduated over-learning has not yet beentested in randomized clinical trials.

Evidence-based medical interventions

Reviews of the literature indicate that the common healthcarepractice among physiciansand paediatricians is to treat enureticchildren with medication rather than behavioural interventions(Houts et al . 1994; Friman 2008). Although pharmacotherapy has been demonstrated to be an effective treatment for theshort-term management of enuresis, it is thought by researchersto be more appropriate as a second line of management whenthe urine alarm has failed or is impractical (Moffatt 1997;Brown et al . 2008). The two types of medications that are mostcommonly used for the treatment of enuresis are antidepres-sants and antidiuretics.

Antidepressants

The pharmacological treatment of nocturnal enuresis hasincluded antidepressants in particular, tricyclic antidepres-sants ever since a report in the 1960s that a depressed adultsuffering from incontinence became continent as a side effect of taking the antidepressant imipramine (Wagner 1987; Houtset al . 1994). Although it is unknown exactly how these drugswork, the most common theories are that they work as a

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stimulant, lightening sleep levels and thus allowing children toarouse more easily to the need to urinate, and through theiranticholinergic effect, whereby they inhibit the transmission of parasympathetic nerve impulses and reduce spasms of smooth

muscle (such as that in the bladder) (Moffatt 1997). Littlesupport has been found for the anticholinergic theory, as otheranticholinergics do not have similar effectiveness; thus thestimulant theory is typically the one more accepted by experts(Moffatt 1997). Reviews of the literature indicated success ratesranging from approximately 20% to 43% for imipramine and33% for other tricyclics (Houts et al . 1994; Glazener et al . 2004).However, relapse rates for these drugs tend to be quite high andmost outcomes at follow-up are no better than placebo or base-line (Glazener et al . 2004). Because the onset of drug effects israpid, imipramine can be utilized as needed, for specic occa-sions, such as sleepovers or camping trips. Imipramine is alsorelatively inexpensive. Of concern for children is the fact thatantidepressants have potentially severe side effects such as car-diovascular problems, rashes, mood alterations and sleep dis-turbances, as well as risk of overdose (Moffatt 1997; Nield &Kamat 2004).

Antidiuretics

The synthetic anti diuretic hormone, desmopressin, has beenput forth as an effective medical alternative. It is a synthetic

version of vasopressin, which is the bodys natural antidiuretichormone (Moffatt 1997). The rationale for the use of thesedrugs is that there is evidence that children with nocturnalenuresis may not have the same nocturnal increase in vaso-pressin as children without enuresis. Desmopressin works by decreasing night-time urine production. It is efcacious,reducing the number of wet nights by about 50%. Desmo-pressin mainly reduces symptoms, rather than curing theproblem, as removal of the drug almost always results in thechild reverting to wetting behaviour (Glazener et al . 2004;Brown et al . 2008). The relapse rate is high, with most childrenreverting to wetting after the medication is stopped (Glazeneret al . 2004). Desmopressin typically has a more rapid onset of dry nights than the urine alarm (Sukhai et al . 1989). Like anti-depressants, it is a popular choice for intermittent use (Moffatt1997; Glazener et al . 2004). Although it produces fewer sideeffects than antidepressants, uids must be restricted once thedrug is taken, as there is a risk for seizures resulting fromwater intoxication, as well as electrolyte abnormalities (Nield& Kamat 2004). It is also quite expensive (Houts 2003; Brownet al . 2008).

Interventions with inconclusive evidence base

Retention control training

Retention control training (RCT) was born out of evidenceindicating that enuretic children had reduced bladder capacity.RCT expands bladder capacity by having the child drink a highamount of uids and delay urination as long as possible. Thethought is that the bladder will expand and the length of timebetween urination will increase. This technique is used to helpthe child gain control over the urination reex (Schroeder &Gordon 1991). RCT has had success rates of up to 50% (Friman2008). However, more recent studies found that increasingbladder capacity through holding exercises had a negligibleeffect on wetting behaviour and did not affect response to lateralarm therapy (Van Hoeck et al . 2007, 2008). Therefore, mostexperts no longer view it as an evidence-based treatment fornocturnal enuresis.

Cleanliness training

The goal of cleanliness training is focused on returning soiledbeds, linens,pyjamas and clothing to their pre-soiled state. Afterwetting, children are directed to remove wet bed linens andpyjamas, rinse off their body, put on dry pyjamas and make thebed with clean linens. This process is thought to punish thewetting and encourage the child to take responsibility for

keeping dry at night (Christophersen & Mortweet 2001). It is astandard procedure, which usually follows activation of theurine alarm. Despite its popularity, it has not been evaluatedindependently of other components so the extent of its contri-bution is unknown (Friman 2008).

Arousal therapy

Arousal therapy is a combination of urine alarm training andrewarding the child for awakening (Christophersen & Mortweet2001). It is a product of the theory that a child must be fully aroused from sleep to learn from the intervention. Upon acti-vation of the alarm, the parents must ensure that the child getsup, goes to the bathroom, urinates in the toilet, returns to bedand resets the alarm within 3 min of the alarm going off (Moffatt 1997). A sticker-system or other token economy isused, rewarding arousal with stickers and taking them away forfailure to arouse. Studies have found success rates rangingbetween 79% and 98%; however, this technique lacks random-ized controlled trials and it has not been examined indepen-dently of the urine alarm (Moffatt 1997).




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children whoreceivedthe urine alarm witha placebo medication(Sukhai et al . 1989; Bradbury 1997). Moffatt (1997) hypoth-esized that the medication postponed the wetting accidents tothe early morning hours when the child is able to be aroused

more easily and is perhaps more susceptible to conditioning. Arecent randomized controlled study found that the meannumber of dry nights increased for those participants in thedesmopressin plus urine alarm condition versus the urine alarmonly condition, but only in the rst 6 weeks of treatment whiledesmopressin was being administered (Ozden et al . 2008).Onceadministration of desmopressin ceased, no signicant differencein mean number of dry nights between the two groups wasfound.Thissuggests thatdesmopressin is effective only as long asit isbeingadministeredand,over time,urinealarm therapyalonemay have the same results as combined treatment. The need isclear for more randomized clinical trials that combine behav-ioural and medical interventions (Brown et al . 2008).

Conclusions and future directions

Because nocturnal enuresis impairs adjustment and well-beingfor children and adolescents concurrently, and predicts futurepsychopathology, it is imperative that the most effective treat-ments be utilized (Liu et al . 2000; Redsell & Collier 2000). Suc-cessful treatment for the disorder can result in improvements inself-concept and self-esteem, attitude and behaviour (Moffattet al . 1987; Hagglof et al . 1998; Longstaffe et al . 2000). The lit-

erature on the treatment of nocturnal enuresis is well estab-lished, demonstrating the superior efcacy of the urine alarm,either alone or as a key element in a multi-component treat-ment programme. Combination treatments, including medica-tion or behavioural components with the urine alarm, appearpromising and merit further investigation.

Although both the psychological and medical elds acknowl-edge the efcacy of the basic urine alarm to treat the disorder,there appears to be insufcient interdisciplinary exchange of ideas, despite some consistency of empirical ndings. Themedical literature tends to maintain a primary focus on man-aging symptoms, with a secondary focus on pharmacologicalinterventions, medication dosages and physical/anatomicalissues related to the disorder. The psychological literature tendsto centre around behavioural interventions and psychosocialcharacteristics of children who suffer from the disorder. Thefocus tends to be on eliminating the disorder by using strategiesinvolving external resources (e.g. parents, alarms). The morerecent use of combination (alarm with medication) treatmentsis a promising step in integrating psychological and medicalapproaches, in that symptoms are reduced rapidly with

medication, and the alarm effects the elimination of symptomsover a somewhat longer time span.

The US and international literatures have been bifurcated;researchers have conducted comparable studies and reached the

same general conclusions, but without the benet of interna-tional discourse and a global dissemination of knowledge.Research in the area would progress more rapidly if there weregreater communication among researchers, rather than con-ducting entirely parallel paths of inquiry. Databases, such as theCochrane Collaboration, an organization that conducts system-atic reviews of interventions in health care for a global audienceto enhance health-related decision making, and the NationalInstitute for Health and Clinical Excellence, an organization inthe UK that provides guidance for the public and healthcareprofessionals on the treatment and prevention of various ill-nesses, seem to be a promising new direction for creating aworldwide database that combines literatures across elds andlocations (Cochrane Collaboration n.d., para. 1; National Insti-tute for Health and Clinical Excellence n.d., para. 1).

Of interest is that outcome literature seems to be reporteddifferently by the psychological versus medical elds (Houtset al . 1994). In the psychological literature, outcomes arereported as the percentage of children who ceased bedwettingentirely over the long term. In the medical literature, outcome isreported in terms of reductions in wetting frequencies.Thus,thepsychologicalapproach emphasizes thegoal of treatment being acure, whereas the medical approach emphasizes management

but not elimination of the problem. In practice, medications areaimed primarily at reducing the amount of times the child wetsandgenerally do notcure thedisorder, as seen by thehighrelapserates once medication is stopped (Wagner 1987; Moffatt 1997).

Future research might address limitations in work to date.The most glaring limitation is that many empirical studies wereconducted with small sample sizes, calling into question thevalidity of ndings (e.g. Sukhai et al . 1989; Nawaz et al . 2002;Ozden et al . 2008). Randomized clinical trials using adequatesample sizes would improve the knowledge base, as would sys-tematic examination of patient characteristics that might serveas moderators and/or mediators of treatment effectiveness (e.g.age, gender, race and ethnicity, socioeconomic status, parentmotivation). Comprehensive meta-analyses, such as those pro-vided by the Cochrane Collaboration and the National Institutefor Health and Clinical Excellence, should continue to be per-formed so as to combine the ndings and maximize samplesizes of the existing literatures across all elds and locations.Furthermore, the examination and study of enuresis from theperspective of monosymptomatic versus polysymptomaticforms shows the potential for a greater understanding of the




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disorder. For example, the three systems approach is one thatseeks to better conceptualize the clinical heterogeneity of enure-sis by classifying children based on their symptomology andindividual functioning so as to provide the most appropriate

treatment intervention (Butler & Holland 2000).Because nocturnal enuresis is not uncommon in adults, espe-

cially during periods of distress, exploration of ways of extend-ing the paediatric literature to treatment of adults is warranted(McDonald & Trepper 1977). Furthermore, although daytimeincontinence may have a different aetiology than nocturnalenuresis, and thus may be less amenable to psychological treat-ments, the harmful psychosocial sequelae of daytime wettingare sufcient to justify evaluation of behavioural treatments(Christophersen & Mortweet 2001).

Despite compelling evidence of theefcacy of theurine alarm,this treatment approach is relatively unknown to parents andused less commonly by physicians than medication, a less efca-cious approach (Houts 2003). Houts (2003) argues that thistrend existsbecause behavioural treatments for enuresis have nocorporate backing, as do pharmaceutical treatments. Thus, phy-sicians are more familiarwith medications because of the effortsof pharmaceutical companies to promote them. Houts alsoargues that the issue of managed care hinders the disseminationof behavioural interventions for enuresis, as insurance compa-nies routinely pay for prescription medications and often ques-tionnon-medicalservices.Theseissuesappeartobeparticularly salient in the USA. It seems that the international medical com-

munities, primarily in the UK and Europe, have viewed treat-ment with the urine alarm as the rst choice option for the pastseveral years, as evidenced by the literature and standardizationdocumentsput forth by theInternationalChildrensContinenceSociety (e.g. Neveus et al . 2006, 2010).

With this in mind, the continuation of the dissemination of the efcacy of the urine alarm must be prioritized as a nextstep in addressing this common yet debilitating disorder of childhood.

References

American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders: 4th edn, Text Revision (DSM-IV-TR).

American Psychiatric Association, Washington, DC, USA.American Psychological Association (2005) Policy statement on

evidence-based practice in psychology. Available at: http://www.apa.org/pi/families/resources/ebp-statement.pdf (accessedfrom 18 February 2010).

Azrin, N. H., Sneed, T. J. & Foxx, R. M. (1974) Dry-bed training:rapid elimination of childhood enuresis. Behaviour Research and Therapy , 12, 147156.

Bradbury, M. (1997) Combination therapy for nocturnal enuresiswith desmopressin and an alarm device. Scandinavian Journal of Urology and Nephrology. Supplementum, 183, 6163.

Brown, R. T., Antonuccio, D. O., DuPaul, G. J., Fristad, M. A., King,C. A., Leslie, L. K. & Vitiello, B. (2008) Childhood Mental Health

Disorders: Evidence Base and Contextual Factors for Psychosocial,Psychopharmacological, and Combined Interventions. AmericanPsychological Association, Washington, DC, USA.

Butler, R. J. & Gasson, S. L. (2005) Enuresis alarm treatment.Scandinavian Journal of Urology and Nephrology , 39, 349357.

Butler, R. J. & Heron, J. (2008) The prevalence of infrequentbedwetting and nocturnal enuresis in childhood: a large Britishcohort. Scandinavian Journal of Urology and Nephrology , 42,257264.

Butler, R. J., Heron, J. & The ALSPAC Study Team (2006) Exploringthe differences between mono- and polysymptomatic nocturnalenuresis. Scandinavian Journal of Urology and Nephrology , 40,313319.

Butler, R. J. & Holland, P. (2000) The three systems: a conceptual way of understanding nocturnal enuresis. Scandinavian Journal of Urology and Nephrology , 34, 270277.

Christophersen, E. R. & Mortweet, S. L. (2001) Treatments That Workwith Children: Empirically Supported Strategies for Managing Childhood Problems. American Psychological Association,Washington, DC, USA.

Cochrane Collaboration (n.d.) Welcome rst-time visitors! Availableat: http://www.cochrane.org/index_newcomers.htm (accessed from3 June 2009).

Friman, P. C. (2008) Evidence-based therapies for enuresis andencopresis. In: The Handbook of Evidence-Based Therapies for Children and Adolescents: Bridging Science and Practice (eds R. G.

Steele, T. D. Elkin & M. C. Roberts), pp. 311333. Springer Press,New York, NY, USA.

Glazener, C. M. A., Evans, J. H. C. & Peto, R. E. (2004) Treatingnocturnal enuresis in children: review of evidence. Journal of Wound, Ostomy, and Continence Nursing , 31, 223234.

Glazener, C. M. A., Evans, J. H. C. & Peto, R. E. (2009) Complex behavioral and educational interventions for nocturnal enuresis inchildren. Cochrane Database of Systematic Reviews, 1, 199.

Hagglof, B., Andren, O., Bergstrom, E., Marklund, L. & Wendelius, M.(1998) Self-esteem in children with nocturnal enuresis and urinary

Key messages

The urine alarm continues to be the most effective treat-ment for primary nocturnal enuresis in children.

Recent literature has shown the benet of combining theurine alarm with both behavioural and pharmaceuticalcomponents when treating children with primary noctur-nal enuresis.

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2010 Blackwell Publishing Ltd, Child: care, health and development , 37 , 2,153160


8/9

incontinence: improvement of self-esteem after treatment.European Urology , 33, 1619.

Houts, A. C. (2003) Behavioral treatments for enuresis. In:Evidence-Based Psychotherapies for Children and Adolescents (edsA. E. Kazdin & J. R. Weisz), pp. 389406. Guilford Press, New York,NY, USA.

Houts, A. C., Berman, J. S. & Abramson, H. (1994) Effectiveness of psychological and pharmacological treatments for nocturnalenuresis. Journal of Consulting and Clinical Psychology , 62, 737745.

Institute of Medicine (2001) Crossing the Quality Chasm: A New Health System for the 21st Century . National Academy Press,Washington, DC, USA.

Liu, X., Sun, Z., Uchiyama, M., Li, Y. & Okawa, M. (2000) Attainingnocturnal urinary control, nocturnal enuresis, and behavioralproblems in Chinese children aged 6 through 16 years. Journal of the American Academy of Child and Adolescent Psychiatry , 39,15571564.

Longstaffe, S., Moffatt, M. E. K. & Whalen, J. C. (2000) Behavioraland self-concept changes after six months of enuresis treatment: arandomized, controlled trial. Pediatrics, 105, 935940.

McDonald, J. E. & Trepper, T. (1977) Enuresis: an historical, cultural,and contemporary account of etiology and treatment. Psychology in the Schools, 14, 308314.

Mellon, M. W. & McGrath, M. L. (2000) Empirically supportedtreatments in pediatric psychology: nocturnal enuresis. Journal of Pediatric Psychology , 25, 193214.

Moffatt, M. E. K. (1997) Nocturnal enuresis: a review of the efcacy of treatments and practical advice for clinicians. Journal of Developmental and Behavioral Pediatrics, 18, 4956.

Moffatt, M. E. K., Kato, C. & Pless, I. B. (1987) Improvements inself-concept after treatment of nocturnal enuresis: randomizedcontrolled trial. Journal of Pediatrics, 110, 647652.

National Institute for Health and Clinical Excellence (n.d.) AboutNICE. Available at: http://www.nice.org.uk/aboutnice/ (accessedfrom 26 January 2010).

Nawaz, S., Grifths, P. & Tappin, D. (2002) Parent-administeredmodied dry-bed training for childhood nocturnal enuresis:evidence for superiority over urine alarm conditioning whendelivery factors are controlled. Behavioral Interventions, 17,247260.

Neveus, T., von Gontard, A., Hoebeke, P., Hjalmas, K., Bauer, S.,Bower, W. & Djurhuus, J. C. (2006) The standardization of terminology of lower urinary tract function in children andadolescents: report from the Standardisation Committee of theInternational Childrens Continence Society. Journal of Urology ,176, 314324.

Neveus, T., Eggert, P., Evans, J., Macedo, A., Rittig, S., Tekgul, S. &Robson, L. (2010) The evaluation of and treatment formonosymptomatic enuresis: a standardization document from theInternational Childrens Continence Society. Journal of Urology ,183, 441447.

Nield, L. S. & Kamat, D. (2004) Enuresis: how to treat and evaluate.Clinical Pediatrics, 43, 409415.

Ozden, C., Ozdal, O. L., Aktas, B. K., Ozelci, A., Altinova, S. &Memis, A. (2008) The efcacy of the addition of short-termdesmopressin to alarm therapy in the treatment of primary nocturnal enuresis. International Urology and Nephrology , 40,583586.

Redsell, S. A. & Collier, J. (2000) Bedwetting, behaviour andself-esteem: a review of the literature. Child: care, health and development , 27, 149162.

Schroeder, C. S. & Gordon, B. N. (1991) Assessment and Treatment of Childhood Problems: A Clinicians Guide. Guilford Press, New York,NY, USA.

Sukhai, R. N., Mol, J. & Harris, A. S. (1989) Combined therapy of enuresis alarm and desmopressin in the treatment of nocturnalenuresis. European Journal of Pediatrics, 148, 465467.

Van Hoeck, K. J., Bael, A., Van Dessel, E., Van Renthergem, D.,Bernaerts, K., Vandermaelen, V. & van Gool, J. (2007) Do holdingexercises or antimuscarinics increase maximum voided volume inmonosymptomatic nocturnal enuresis? A randomized controlledtrial in children. Journal of Urology , 178, 21322136.

Van Hoeck, K. J., Bael, A., Lax, H., Hirche, H., Bernaerts, K.,Vandermaelen, V. & van Gool, J. (2008) Improving the cure rateof alarm treatment for monosymptomatic nocturnal enuresis by increasing bladder capacity a randomized controlled trial inchildren. Journal of Urology , 179, 11221127.

Wagner, W. G. (1987) The behavioral treatment of childhoodnocturnal enuresis. Journal of Counseling and Development , 65,262265.




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treatment of primary noctural enuresis in children

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