Enuresis treatment

Most of the comparisons between treatments have been made by means of meta-analyses conducted by the Cochrane Enuresis Collaborative.28,30,32-34 Unfortunately, most enuresis treatment studies have been so poorly designed they compromise the... 

Longstaffe, S., Moffatt, M.E. and Whalen, J.C. (2000) Behavioral and self-concept changes after six months of enuresis treatment a randomized, controlled trial. Pediatrics 105 935-940. 

Brodzikowska-Pytel A, Giembicki J. Hyponatremia as a complication of nocturnal enuresis treatment with desmopressin in a child. Pediatr Pol 1999 74 79-83. 

OPC-51803 is a highly selective V2R agonist and may prove useful for the treatment of CDI, urinary incontinence, enuresis and pollakiuria. It has a much higher bioavailability after oral application than desmopressin. 

List the treatment goals for a patient with urinary incontinence or pediatric enuresis. 

Considering that pharmacotherapy is inferior to select non-pharmacologic treatment modalities in pediatric enuresis, pharmacotherapy will be most valuable in patients who are not candidates for nonpharmacologic therapy due to nonadherence or who do not achieve the desired outcomes on nonpharmacologic therapy alone. 

The American Academy of Child and Adolescent Psychiatrists and the International Children s Continence Society (ICCS) have published practice guidelines for the assessment and treatment of pediatric enuresis.24,25... 

Obtain a thorough medication history, including use of prescription, non-prescription, and complementary and alternative drug products. Determine which, if any, treatments in the past had been helpful as judged by the patient and/or caregiver(s). Could any of the patient s current medications be contributing to enuresis ... 

Fritz G, Rockney R, Bernet W, et al. Practice parameter for the assessment and treatment of children and adolescents with enuresis. J Am Acad Child Adolesc Psychiatry 2004 43 1540-1550. 

Saint-John s-wort was used in ancient Greece and medieval Europe, where it was believed to ward off evil spirits. Its name derives from wort, the Old English word for herb, and the fact that it was harvested in Europe on the eve of St. John s day (June 24th) and burned to purify the air (Fleiligenstein and Guenther 1998). Traditional uses include treatment of depression, insomnia, enuresis, and anxiety. Modern use has focused on its antidepressant effects and possible antiviral effects for treatment of the human immunodeficiency virus (FIIV) (Fleiligenstein et al. 1998) (table 7.3). There has been some interest in its antiglioma effects as well (Couldwell et al. 1993). 

Phenobarbitone is used to treat epilepsy, migraine headache, dental infections, pregnancy vomiting, tetanus, enuresis, chorea, pre and post operative sedation, hypertension, anxiety states, neurosis, and in the treatment of drug and alcohol addiction. This drug is also called phenobarbital. 

Because it is stable, desmopressin is preferred for treatments especially if pressor effects are not desired. The primary indication for therapy is central diabetes insipidus, a disorder that results when ADH secretion is reduced and that is characterized by polydipsia, polyuria, and dehydration. Desmopressin is also used to reduce primary nocturnal enuresis, or bedwetting, in children. It is useful in people with mild hemophilia A or with some types of von Willebrand s disease, in which von Willebrand s factor is present at low levels. In these cases, desmopressin is given when excessive bleeding occurs or before surgery to help reduce bleeding indirectly by increasing the amounts of coagulation factors. 

Unlabeled Uses Relief of neuropathic pain, such as that experienced by patients with diabetic neuropathy or postherpetic neuralgia treatment of anxiety, bulimia nervosa, migraine, nocturnal enuresis, panic disorder, peptic ulcer, phantom limb pain... 

Multiple studies have been done of TCAs in the treatment of nocturnal enuresis, and all consistently show effect over placebo. Most notably, Rapoport et al. (1978) found a significant relationship between IMI plasma level and response to medication. Imipramine is the only medication with FDA approval for treatment of this condition. 

It should be noted that TCA dosages for the treatment of enuresis are often lower than those seen with the treatment of other disorders. It has been presumed that this level of dosing is efficacious because the TCAs are acting directly in the CNS, and the benefits seen not due to a peripheral anticholinergic side effect seen only at higher doses. 

St. John s wort has been used to treat a wide range of ailments for more than 2000 years, and is said to have been prescribed by Hippocrates himself. Apart from depression, St. John s wort is being promoted or used as a treatment for attention-deficit hyperactivity disorder (ADHD), anxiety, stress, obsessive-compulsive disorder, sleep problems, nocturnal enuresis, bacterial and viral infections such as HIV-AIDS, respiratory conditions, peptic ulceration, inflammatory arthritis, cancer, and skin wounds (Rey and Walter, 1998 Walter et ah, 2000). It is also said to increase libido, an application dating from the Middle Ages (Fletcher, 1996). No empirical evidence is currently available to support any of these uses. 

The pharmacologic treatment of enuresis in children and adults with MR is a subject that has been more extensively studied than most other diagnoses. Enuresis causes significant anxiety for those experiencing it as well as for those who care for them. Approximately 20% of 5-year-old children wet the bed at least monthly, while by age 6 only 10% wet the bed. There is a 15% remission rate each year after age 6. 

Behavioral therapies are the treatment of choice for enuresis in both typically developing children and children with MR. No medical intervention should be undertaken before considering behavioral interventions, such as a star chart for dry nights, evening fluid restriction, bladder-stretching exercises (where children are asked to hold their urine for as long as they can, past the initial bladder spasm), and/or the buzzer-and-pad. However, some MR/DD patients will be unable to cooperate with such strategies and may need medical... 

A review of 18 controlled studies in otherwise typically developing children (Moffatt et ah, 1993) demonstrated that only about 24% of children were completely dry while on medication and that 94% relapsed after medication was discontinued. In the Swedish Enuresis Trial (SWEET), 399 children aged 6-12 years with primary enuresis participated in an open, multicenter trial of DDAVP (Tullus et ah, 1999). Subjects were observed for 4 weeks and had their DDAVP dose titrated over 6 weeks (20 0 pg), followed by a 1-year long-term treatment period. A total of 245 children (61%) experienced a 50% or more reduction in the number of wet nights, with resolution of enuresis in 77 children. The greatest therapeutic effect was observed in children 6-7 years of age. There were no studies on the effectiveness of DDAVP in children with MR. 

Tullus, K., Bergstron, R., Fosdal, I., Winnergard, I., and Hjalmas, K. (1999) Efficacy and safety during long-term treatment of primary monosymptomatic nocturnal enuresis with desmopressin. Acta Paediatr. 88 1274-1278. 

Historically, interventions for enuresis, as well as en-copresis, have often reflected intolerance, seeming harshness, and/or a poor understanding of child development (Glicklich, 1951). The vast majority of children over the age of 6 or 7 years as well as their parents will request treatment. Very occasional parents or children may be interested in intermittent treatment—for example, treatment may be desirable for overnight sleep-overs or for camping. Trials of interventions will be necessary to determine what approaches will work in such children and how much time is required for the intervention to be effective. 

Finally, there are children with intermittent minimal incontinence and so-called giggle incontinence (Niren-berg, 1991). Although it is seldom that these conditions require treatment, in such cases where children do request it the standard enuresis approach will generally suffice. Figure 51.4 provides an algorithm for DE interventions. 

Behrle, R.C. (1956) Evaluation of a conditioning device in the treatment of nocturnal enuresis. Pediatrics 17 849. 

Klauber, G.T. (1989) Clinical efficacy and safety of desmopressin in the treatment of nocturnal enuresis. / Pediatr 114 719-722. 

Norgaard, J.P., Rittig, S., and Djurhuus, J.C. (1989) Nocturnal enuresis an approach to treatment based on pathogenesis./ Pediatr 114 705-710. 

Enuresis 10-40 ag qhs/bid Headache nausea Hyponatremia and water intoxication at toxic doses Can be useful for acute situations (e.g., sleepaways) or as maintenance treatment DDAVP 0.1, 0.2 mg t nasal spray 10 Hg/ spray... 

One of the first controversies regarding the treatment with CMl of patients with OCD was whether the patients benefited from the drug s antidepressant effect or whether the improvement was actually the result of an antiobsessive effect. In an early study, Marks et al. (1980) reported on the efficacy of CMl in depressed patients with OCD. However, subsequent reports demonstrated that the antiobsessive efficacy of CMl is independent of its antidepressant activity (Ananth et al. 1981 Flament et al. 1985 Insel et al. 1982a Mavissakalian et al. 1985 S. A. Montgomery 1980 Thoren et al. 1980 Volavka et al. 1985 Zohar and Insel 1987). Depression is not a prerequisite for an antiobsessional response to CMl. In this regard, OCD resembles other nonaffective disorders, such as panic disorder, bulimia, enuresis, migraine, and chronic pain syndrome, in which antidepressants are effective in the absence of depression (D. L. Murphy et al. 1985). 

Tietjen DN, Husmann DA. Nocturnal enuresis a guide to evaluation and treatment. Mayo Clin Proc 1996 71 857-862. 

Schulman SL, Colish Y, von Zuben FC, et al. Effectiveness of treatments for nocturnal enuresis in a heterogeneous population. Clin Pediati 2000 39 359-364. 

At the present time, the TCAs are used primarily in depression that is unresponsive to more commonly used antidepressants such as the SSRIs or SNRIs. Their loss of popularity stems in large part from relatively poorer tolerability compared with newer agents, to difficulty of use, and to lethality in overdose. Other uses for TCAs include the treatment of pain conditions, enuresis, and insomnia. 

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