In newborns micturition occurs at frequent intervals and voiding may have an intermittent pattern, although bladder emptying efficiency is usually good. Between the age of 1 and 2, conscious sensation of bladder filling develops. By age 4, most children will be able to keep dry both day and night.
Original Description:
Original Title
The Management of Urinary Incontinence in Children (1)
In newborns micturition occurs at frequent intervals and voiding may have an intermittent pattern, although bladder emptying efficiency is usually good. Between the age of 1 and 2, conscious sensation of bladder filling develops. By age 4, most children will be able to keep dry both day and night.
In newborns micturition occurs at frequent intervals and voiding may have an intermittent pattern, although bladder emptying efficiency is usually good. Between the age of 1 and 2, conscious sensation of bladder filling develops. By age 4, most children will be able to keep dry both day and night.
The Management of Urinary Incontinence in Children
Samih Al-Hayek and Paul Abrams
Bristol Urological Institute, Southmead Hospital, Bristol, UK
Introduction The childhood period is characterized by marked development changes. Acquisition of toileting skills is part of normal development. However, achievement of urinary control is complex and yet to be fully understood. In newborns micturition occurs at frequent intervals and voiding may have an intermittent pattern, although bladder emptying efficiency is usually good. In over 80 percent of voids the bladder empties completely (1). Between the age of 1 and 2, conscious sensation of bladder filling develops. During the second and third year of life, there is progressive development towards a socially conscious continence and a more voluntary type of micturition control develops. Through an active learning process, the child acquires the ability to voluntarily inhibit and delay voiding until a socially convenient time, then actively initiate urination. This all depends on an intact nervous system. By age of 4, most children will be able to keep dry both day and night. That is influenced by family, social and environmental factors (2). Urinary incontinence in children affects the whole family. To properly manage it, a full appreciation of the problem, and thorough assessment of the child and the social circumstances is needed.
Definition The standardization of terminology committee of the International Continence Society (ICS) has set the terms and definitions to be used when describing any lower urinary tract dysfunction (LUTD) (3) and these can be used to describe LUTD in children, with few exceptions. Indeed, it is important that the same terminology is used in children and adults in order not to confuse patients, their families and their nursing and medical caregivers. Urinary incontinence is defined as the complaint of any involuntary leakage of urine. It is clear that this definition does not apply to infants and small children, and when reporting incontinence in children further explanation is needed. Urinary incontinence in children could be classified into two main categories: Nocturnal enuresis: can be primary or secondary Day and night incontinence: on the basis of urodynamics this could be subcategorized into: 1. Detrusor overactivity (during filling) 2. Dysfunctional voiding (where there is urethral overactivity during voiding in the absence of a neurological cause) 3. Detrusor underactivity
Nocturnal Enuresis (NE) Definition and classification Nocturnal enuresis (NE) can be defined as an involuntary voiding of urine during sleep, with a severity of at least three times a week, in children over 5 years of age in the absence of congenital or acquired defects of the central nervous system (4). It has been agreed that 5 years is appropriate, as it is around this time that a child normally has complete bladder control and has developed cognitive control over voiding. Nocturnal enuresis could be classified as primary or secondary: Primary or persistent nocturnal enuresis describes children who have never achieved a period of up to 6 months free of bedwetting. Secondary or onset nocturnal enuresis is the reemergence of loss of control (wetting) after a period of being dry. Secondary nocturnal enuresis appears to be associated with a higher incidence of stressful events, particularly parental separation, disharmony between parents, birth of a sibling, early separation of the child from parents and psychiatric disturbance in a parent (5-7). Both Jarvelin and Fergusson et al. argue that primary and secondary enuresis are aspects of the same problem (6, 8). They claim the two classifications share a common etiological basis.
Nocturnal enuresis can also be classified according to the presenting symptoms as mono- or non-monosymptomatic. Monosymptomatic nocturnal enuresis refers to those children who report no bladder or voiding problems associated with their wetting. Non-monosymptomatic nocturnal enuresis refers to bedwetting, which is associated with other symptoms such as urgency and frequency during the day, with or without daytime wetting (9). This classification helps in directing the treatment appropriately. Prevalence of NE The extent of bedwetting is widespread. But as expected, the frequency decreases with age (10). It has been argued that nocturnal enuresis is the most prevalent of all childhood problems. In the United Kingdom, estimates suggest around three quarters of a million children and young people over 7 years will regularly wet the bed. In the United States recent evaluations of prevalence suggest some 5 to 7 million children regularly experience primary nocturnal enuresis (11). In the literature, there is a wide variation in the reported prevalence. This may be due to the definition used for nocturnal enuresis related to the frequency of wet nights. Table I gives the percentage of children with any episodes of nocturnal enuresis based on surveys undertaken in Great Britain, Holland, New Zealand and Ireland (12-14).
Table I: Percent of children with enuresis in four surveys.
AGE (YEARS) BOYS % GIRLS % 5 13-19 9-16 7 15-22 7-15 9 9-13 5-10 16 1-2 1-2
Girls are more likely to experience secondary enuresis and associated daytime incontinence compared to boys, but less likely to have a family history or genetic predisposition to bedwetting (15-18). A recent survey of twin pairs in England and Wales found a significant difference between boys and girls in the development of nocturnal bladder control with 54.5% of girls and 44.2% of boys being dry at night (18, 19) As mentioned before, primary NE usually remits with age (14). The risk of remaining enuretic during adult life if not treated actively during childhood is about 3% (20).
Treatment of NE As it is not a life-threatening condition, most parents tend to delay consulting doctors regarding their children. In England and Scotland only about 50% of children with NE consult their doctors (21). It is usually the frequency of bed wetting and how much the family is bothered by the condition which drives the consultation. Fifteen percent (15%) of children with nocturnal enuresis wet every night, and most children wet more than once a week (12, 22). There may be a lack of awareness of the local health care providers (mainly general practitioners) about the available options in managing NE. A French survey of school children, most mothers of those children with NE had a rather tolerant attitude, but if the child had moderate to severe NE then two thirds of the mothers had consulted the doctor, mainly the general practitioner. However, most doctors suggested no solution or a wait-and- see approach (23). The management of nocturnal enuresis depends on the childs motivation to participate in treatment; confounding psychosocial factors should be addressed, and any intervention should be regularly reviewed. It is still not clear whether active treatment of nocturnal enuresis in childhood is able to reduce the number of adult enuretics.
A- General Measures The approach in treating primary and secondary NE is the same. Nevertheless, co-morbid psychiatric disorders in secondary NE should be taken into account. It is essential to explain the problem to the child and their parents. Education about the problem and a realistic discussion of the prognosis will help in achieving confidence in the treatment offered and will improve both compliance and the outcome (24). Asking the child and parents to keep a record of the wet and dry nights may play a role in engaging them in treatment. The family should be counseled to ensure that the child receives the optimal duration of sleep (24). General advice such as to eat, drink and void regularly during the day, abstain from drinking too much during the late afternoon and evening, and asking the child to void before bedtime (25). School teachers should also be informed about these therapeutic rules. A low calcium and sodium dietary content of the afternoon and evening meals may also be useful (26, 27). Regular family and child encouragement with positive attitude towards the child should be utilized with the explanation that bed-wetting does have a high chance of resolving spontaneously with up to 19% of children becoming dry within the next 8 weeks without any further treatment (28-30). B- Nonpharmacological Therapy treatment modalities such as fluid restriction, dry-bed training, retention control training, psychotherapy, acupuncture and hypnosis all have been used but there is still not enough evidence that they are effective (31-38). A randomized, controlled trial on laser acupuncture was compared to desmopressin treatment. The authors concluded that this treatment should be considered as an alternative, noninvasive, painless, cost-effective and short-term therapy for children with primary nocturnal enuresis in case of a normal bladder function and high nighttime urine production. Success rates (about 65%) indicated no statistically significant differences between the well- established desmopressin therapy and the alternative laser acupuncture (37). However, this is the only randomized, controlled trial available and included only 40 children. Comparison of treatment outcome and cure rates for different treatment modalities is difficult because of the inconsistent use of definitions, the inclusion of children with daytime symptoms and the variable follow-up periods in most studies. It is accepted that use of multiple treatment modalities achieves a significant reduction in the number of wet episodes and possible cure to start with. This will give the parent and the child confidence that the problem is treatable.
Enuresis alarm In a recent Cochrane review, C.M. Glazener et al. found that the enuresis alarm is the most effective means of facilitating arousal from sleep and remains the most effective way to treat monosymptomatic nocturnal enuresis (39). They reviewed the results of 53 trials, involving 2862 children and found that most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use. Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment. There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioral interventions. Similarly, body- worn alarms were as effective as bedside ones. Relapse rates were lower when overlearning was added to alarm treatment usually done by giving extra fluids at bedtime after successfully becoming dry for a considerable period of about 14 consecutive nights to strengthen the bladder control. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (39). Forsythe and Buttler have summarized the history and progress of the enuretic alarm over a period of 50 years and came to the same conclusion (40). The systematic review by Mellon and McGrath reported 78% dry children which was significantly better than no treatment (41). Alarm therapy has been shown in a meta-analysis to have a 43 percent lasting cure rate (42, 43) which means that is more effective than other forms of treatment (44).Interestingly, the use of alarm has been found to increase the functional bladder capacity, without any change in nocturnal urine production or vasopressin secretion, which may explain why children after successful treatment are often able to sleep without nocturia (45, 46).
Alarms are usually suitable for children aged over 7 years who wants to be dry and can take responsibility for the alarm with the familys help. The key to success is not the stimulus intensity of the alarm triggering but the childs preparedness to awake and respond to the signal.
Relapse may develop but this often responds to further alarm therapy. Failure does not preclude future successful treatment in an older more motivated child.
Several factors may affect the efficacy of alarm use (Box 1) with potential difficulties (Box 2).
Box I: Factors which might affect the alarm use.
Factors which improve the efficacy of the alarm(2): Optimal motivation of the child and family, A higher frequency of wet nights and longer duration of use. In a successfully treated child, alarm therapy should be continued for at least a month after sustained dryness.
Reduced efficacy is associated with(2): Lack of concern shown by the child, Lack of supervision, inconsistent use Family stress Abnormal scores on behavioral check lists Psychiatric disorder in the child, failure to awaken in response to the alarm, unsatisfactory housing conditions, and more than one wetting episode per night.
Box II: Some difficulties when using the alarm. Common problems with using the alarm (47): Alarm treatment is slow in the beginning so it should be continued at least 6 to 8 weeks before it is judged. Compliance remains a problem. Dropout rates are rarely disclosed in reported studies. Family members may find this method too disruptive. Lots of encouragement is needed. The child may consider it as a punishment. Further explanation to the child may help. The alarm may fail to go off or go off for no reason which may cause disturbance to the child and family. The child may not wake up to the alarm. Then a family member should then take the responsibility to do so. It is not necessary for the child to be fully awakened. Proper guidance and instructions would resolve many of the above difficulties. Arousal training Van Londen et al. first described this procedure with a group of 41 children. He concluded that arousal training is a fast, simple and effective form of bibliotherapy for nocturnal enuresis with nonclinical children between 6 and 12 years of age (48). They reported a response rate of 100%, 98% (14 consecutive dry nights) compared to 73% with alarm monotherapy, which is an unusually high rate. Arousal training entails reinforcing appropriate behavior (waking and toileting) in response to alarm triggering. The parents act as therapists. They reward the operant behavior-pattern following the urine alarm. The instructions involve (2): setting up the alarm before sleep when the alarm is triggered the child must respond by turning it off within 3 minutes the child completes voiding in the toilet, returns to bed and resets the alarm when the child reacts in this fashion he is rewarded with 2 stickers when the child fails to respond in this way the child pays back one sticker Reward and positive reinforcement Although star charts for dry beds has been traditionally used by many parents and health professionals, they tend to be largely unsuccessful. That could be due to the way they are introduced to the child with a reward for positive outcome, but the child has little or no control on the outcome (dry night). It was even reported that rewards for actions the child wishes to engage in will decrease and undermine intrinsic motivation, by decreasing the childs sense of self-determination and competence (49). For most children the dry night is a reward in itself. A better way of using this method is to start rewarding what is controllable. For example, rewarding regular daytime voiding, waking up to go to the toilet, voiding before sleep and waking quickly to an alarm triggering. Cognitive restructuring Butler suggested three cognitive processes: auto-suggestion, restructuring beliefs and visualization. Few studies have, however, investigated cognitive change directly. Normalized voiding Normalized voiding involves increasing daytime fluid intake, increasing the frequency of micturitions during the day with voiding regularly at predetermined times (every 2-3 hours) with avoidance of postponing urination. This is usually used in combination with other treatment modalities. It is an attempt to normalize voiding, because many of the children postpone voiding. Although it seems appealing, this approach has not been examined on its own.
Positive practice The aim of positive practice is to develop an alternative response to bedwetting. Following a wet bed, the child is encouraged to practice the following, both immediately and prior to bedtime the next night (2): the child is encouraged to lie in bed with the lights off, count to 50, go to the toilet and attempt to urinate, and repeat this few times. Bollard and Nettelbeck have reported success rate of 83% (50). It may be clear that this can only be attempted in motivated children and good parental support. Retention control training This is to help the child increase his bladder capacity and the ability to retain urine. The child will be asked to have a drink, when he or she indicates the need to void, they will be asked to hold and will be praised if they do. Using a enuresis alarm will increase the methods effect. Scheduled waking The aim is to encourage arousability from sleep. As originally described, there are two aspects: hourly waking on the first night and scheduled waking thereafter (51). With the hourly waking on one night only, the child is: woken each hour with a minimal prompt, asked to void in the toilet, and praised for having kept the sheets dry. On subsequent nights, scheduled waking involved waking the child 3 hours after sleep and encouraging him or her to void. For every dry night the waking time is brought forward by a half hour until it is timed to occur one hour after going to sleep. Bollard & Nettelbeck found this procedure was 100% effective when combined with the alarm in 12 children (50).
Dry bed training This was first described by Azrin et al. in 1974 (51) with high success rate. Adjustments have been made to make the procedure easier, but it is still considered a complex, time-consuming and demanding procedure (52-54). The procedure incorporates (2): the enuresis alarm positive practice (practice of waking) cleanliness training (encouraging the child to take responsibility for removing of wet night clothes and sheets, re-making the bed and resetting the alarm) waking schedules - to improve arousability from sleep as described above and involving: For the first night, waking the child each hour, praising a dry bed, encouraging the child to decide at the toilet door whether he or she needed to void, and on returning to bed the child is encouraged to have a further drink. On the second night, the child is woken and taken to the toilet 3 hours after going to sleep. For each dry night the waking time is brought forward by 30 minutes. If wet on any night the waking time stays at the time of the previous evening. The waking schedule was discontinued when the waking time reached 30 minutes following the child going to sleep. The waking schedule is resumed if the child begins wetting twice or more in any week, stating again 3 hours after sleep. social reinforcement and increased fluid intake. Final message for nonpharmacological treatment In a recent Cochrane review, 13 trials were assessed, involving 702 children of whom 387 received a simple behavioral intervention. In single small trials, reward systems (e.g., star charts), lifting and waking were each associated with significantly fewer wet nights, higher cure rates and lower relapse rates compared to controls. There was not enough evidence to evaluate retention control training (bladder training). Cognitive therapy may have lower failure and relapse rates than star charts, but this finding was based on one small trial only. This makes the evidence behind using these methods shaky. However, simple methods could be tried as first-line therapy before considering alarms or drugs, because these alternative treatments may be more demanding and may have adverse effects (52). The same group have reviewed 16 trials involving 1,081 children which included a complex or educational intervention for nocturnal enuresis. A complex intervention, such as dry bed training (DBT) or full-spectrum home training (FSHT) including an alarm, was better than no-treatment control groups, but there was not enough evidence about the effects of complex interventions alone if an alarm was not used. An alarm on its own was also better than DBT on its own, but there was some evidence that combining an alarm with DBT was better than an alarm on its own, suggesting that DBT may augment the effect of an alarm. There was also some evidence that direct contact with a therapist might enhance the effects of an intervention (53). C- Pharmacotherapy Pharmacological treatment for nocturnal enuresis can have either a full, partial or no response. A full response has been defined as a reduction in wet nights of at least 90%, to allow for the occasional accidental wetting, partial response is defined as a reduction in wet nights of 50-90%; less than 50% reduction in wet nights is considered to be nonresponse (55, 56). A lasting cure is defined as a full response, still present 6 months or longer after discontinuation of pharmacotherapy. With a follow-up of at least 6 months, response can become a lasting cure (>90% reduction) or a lasting improvement (50-90% reduction). This definition of full response means that a child could still be wet 2 or 3 times per month, and many would not regard this as a full response! Desmopressin (dDAVP) Desmopressin (dDAVP) is an analogue of vasopressin created by deaminating the cysteine residue at position 1 and substituting D-arginine for L-arginine at position 8. These changes result in significantly increased antidiuretic activity but loss of the vasopressor activity. The half-life of dDAVP is 1.5-3.5 hours. The normal circadian variation in urine production, with a nocturnal rise in vasopressin, is absent in a significant proportion of patients with monosymptomatic nocturnal enuresis (MNE) (24). When NE is a significant problem for the child and the child is older than 6 years, treatment for enuresis should be offered. Initial treatment will usually be the enuresis alarm or desmopressin. Desmopressin is easy to administer and the clinical effects appear immediately. The usual dose is 0.2-0.4 mg orally or 20 -40 g intranasally at bedtime. A small group of children who do not respond to desmopressin in ordinary dosage will become dry when the dose is doubled (57). Desmopressin can also be helpful in children who have failed to respond to, or who have withdrawn from alarm therapy, or for whom alarm therapy is unacceptable. Also, it is useful when the child would like to attend an overnight school trip or stay at a friends house (28). Placebo-controlled studies have shown that the antidiuretic drug dDAVP is significantly more effective than placebo (58). Patients on desmopressin were 4.6 times more likely to achieve 14 consecutive dry nights compared with placebo (59). However, there was no difference after treatment was finished. Kruse et al. found that the best results were obtained in older children who respond to 20 g. dDAVP and who do not wet frequently (60). A better response to desmopressin has been found in children with larger bladder capacities (25). Relapse after short-term treatment is rather the rule, whereas long-term treatment may yield better cure rates (61). Intermittent therapy appears to decrease the number of relapses (62). It has recently been shown that the chances of permanent cure may increase by adopting a structured withdrawal program. This implies a gradual discontinuation of the drug (over an 8-week period) and positive reinforcement of dry nights without medication. At week 10 with complete cessation of medication, 75% of children remained dry (63). Although several studies have shown that dDAVP is a well-tolerated and safe drug, even during long-term usage, one has to be aware that dDAVP is a potent antidiuretic drug and that there have been reports on severe water retention with hyponatremia and convulsions, but these are infrequent (64-68). Combined treatment with alarm and desmopressin Combined treatment is superior to alarm alone especially for nonresponders of each individual treatment. Both treatments are started at the same time: the rapid action of dDAVP is believed to facilitate the childs adaptation to the alarm. Leebeek reported a temporary, positive effect on enuresis using desmopressin combined with alarm therapy. However, both treatment modalities had a low long-term success rate of 36-37% (69, 70). Compared with either therapy alone, the combination has been found to be particularly effective in children with high wetting frequencies and behavioral problems. Combination with full-spectrum therapy may even yield higher success rates (71, 72). Van Kampen et al. reported their results of full-spectrum therapy in 60 patients: they were treated for 6 months with a combination of alarm, bladder training, motivational therapy and pelvic floor muscle training: 52 patients became dry (71). Antimuscarinic drugs Antimuscarinic drugs are mainly used for patients with overactive bladder symptoms (OAB) which might lead to daytime incontinence. They might therefore be of use for the subset of enuretic patients who have restricted bladder capacity due to detrusor overactivity at night, a pattern found at nocturnal cystometry in 30% or more of enuretic children (19). Because it is difficult to perform a nighttime cystometry in children, antimuscarinic drugs may be used in children who have more than 2 wetting episodes per night and who do not respond to dDAVP. They could also be used in combination with alarm or dDAVP (73, 74). Tricyclic antidepressants The mechanism by which imipramine helps NE is not clear. The therapeutic effect does not appear to be mediated via its antidepressant effect; a suggested mechanism of action is reduced detrusor activity and increased bladder capacity due to anticholinergic and smooth muscle relaxant effects and sympathomimetic or central noradrenergic mechanisms. Due to major cardiotoxic side effects, even in therapeutic doses, and the possibility of death with overdose, they cannot be generally recommended for treatment of this nonlethal disorder (75). Only in selected cases (like adolescent boys with attention deficit hyperactivity disorder and persistent nocturnal enuresis) should it be considered (76).
Other medications Carbamazepine is chemically related to imipramine. It can reduce prostaglandin E2-like activity in inflammation. It has been recently tried in NE with 30-day treatment periods of either placebo or carbamazepine (200 mg) tablets, in a randomized, double-blind, crossover design. There was 1 week washout period between medications. The patients or their parents received a calendar sheet to record wet and dry nights and offered subjective opinions concerning changes in sleep patterns, occurrence of nocturia and appearance of side effects. The difference in response to placebo and carbamazepine was statistically significant. Indomethacin had also been investigated (77-79). However, these are still pilot studies with a small number of patients preventing their use from being recommended at present. D- Refractory NE About one third of children do not respond to treatment with alarm and/or dDAVP. There is a role for anticholinergics especially if the child voids more frequently than his/her peers or has urgency and daytime incontinence. Treatment success is usually noted between 1-2 months. Treatment should be continued for 6-12 months, but good clinical evidence is lacking for efficacy. On the other hand, some of these children may have functional incontinence. They should be given a strict voiding regimen and a combination of dDAVP with the alarm (80). If all the above do not work, then absorptive nocturnal hypercalciuria may be responsible for the nocturnal enuresis in some of these patients. With an appropriate (low-calcium) diet these patients became desmopressin responders (81).
Day and Night Incontinence If the development process of bladder control is not completed, the child may have urinary incontinence. This can be with no obvious cause (functional) but occasionally is secondary to causes such as congenital or neurological. Urinary incontinence in children may be due to disturbances of the filling phase, the voiding phase or a combination of both. Those who have incontinence they usually have other symptoms such as frequency, urgency and infection. The use of urodynamics investigations (82, 83) helped to classify those children into different categories: Detrusor overactivity (during filling) Dysfunctional voiding (where there is urethral overactivity during voiding in the absence of a neurological cause) Detrusor underactivity
Prevalence of Day and Night Incontinence Most have looked at childrens incontinence as either diurnal or nocturnal, and less often at the subcategories of daytime incontinence. This makes it difficult to have a representative picture of the prevalence of the different types. Overall, the prevalence varies from 1% to 10%, but in general for 6- to 7-year-old children, the prevalence is somewhere between 2% and 4%, and rapidly decreases during the following years (10-16 yrs): it is more common in girls than in boys (82-84). This prevalence obviously depends on the criteria used to define incontinence. Sureshkumar et al. in a population based survey of over 2000 new entrant primary school children (age 4-6 years) in Sydney, Australia, noted an overall prevalence of daytime wetting of 19.2% when considering at least one daytime wetting episode in the prior 6 months, with a further 16.5% having experienced more than one wetting episode and only 0.7% experienced wetting on a daily basis (85). Children with daytime or mixed wetting were found to suffer from urgency in 50.7% of the cases, with 79.1% wetting themselves at least once in 10 days (15). Urgency as a symptom seems to peak at age 6-9 years and diminish towards puberty, with an assumed spontaneous cure rate for daytime wetting of about 14% per year (86, 87). Swithinbank et al. have found a prevalence of day wetting of 12.5% in children age 10-11 years, which decreases to 3.0% at age 15-16 years but this included "occasional" wetting (88).
Treatment of Day and Night Incontinence Overactive bladder (OAB) The treatment of OAB involves a multimodal approach. Behavioral modification is important and in some children may be all that is necessary. Others will require the addition of antimuscarinic medication. In some children, the addition of biofeedback is useful. It is important to treat other underlying and potentially complicating conditions such as constipation and UTIs (2). Dysfunctional voiding Treatment is aimed at optimizing bladder emptying and inducing full relaxation of the urinary sphincter and pelvic floor, prior to and during voiding. Strategies include pelvic floor muscle awareness and timing training, repeated sessions of biofeedback, visualization of pelvic floor activity and relaxation, clean intermittent self- catheterization for large post-void residual volumes of urine, and antimuscarinic drug therapy if detrusor overactivity is present. If the bladder neck is implicated in increased resistance to voiding, -blocker drugs may be introduced (89-91). Recurrent urinary infections and constipation should be treated and prevented during the treatment period. A review of interventions for children with dysfunctional voiding revealed 17 studies; eight evaluating biofeedback or pelvic floor muscle awareness training, five reporting -blockade pharmacotherapy, two relating to electrical stimulation and one each describing clean intermittent catheterization and the use of anticholinergic medication. Only one study was randomized, none were controlled and five were retrospective. As with overactive bladder, the natural history of untreated dysfunctional voiding is not well delineated, and thus the optimum duration of therapy is not well described. Detrusor underactivity (DUA) Treatment is aimed at optimizing bladder emptying after each void. Clean intermittent (self- ) catheterization is the procedure of choice to promote complete bladder emptying, in combination with treatment of infections and constipation (which may be extreme in these patients). Intravesical electrostimulation has been described, but at this time it is not recommended as a routine procedure for children. Giggle incontinence Since the etiology of giggle incontinence is not known it is difficult to determine the appropriate form of treatment. Positive results have been reported with conditioning training, methylphenidate and imipramine (75, 92-94). Others have tried antimuscarinic agents and -sympathomimetics. There is no acceptable evidence that any form of treatment is superior to no intervention.
Conclusion Although some studies have been conducted on possible treatment for daytime incontinence, most lack proper randomization, long-term follow-up or good number of participants. This was confirmed by the Cochrane review for the period between 1996 and 2001: the authors identified only five trials that compared two or more interventions using a randomized controlled design (95). Of these five studies, four evaluated pharmacotherapy. Of the four pharmacotherapy studies, two evaluated the use of terodiline, one evaluated the use of imipramine and the remaining abstract the use of oxybutynin versus biofeedback (96-98). The remaining study evaluated the use of alarm therapy for daytime incontinence (99). Terodiline is no longer available due to its adverse effect profile, imipramine is not the first choice for daytime incontinence due to its side effects, and alarm therapy is not felt to be a useful therapy for daytime incontinence. Therefore only one study in over 30 years was felt to be of high quality. This review highlights the need for properly designed studies to assess the impact of the various forms of therapy on daytime incontinence. The limited number of identified randomized controlled trials does not allow a reliable assessment of the benefits and harms of different methods of management in children. Further work is required in this difficult clinical area.
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