title: Failure of monotherapy in primary monosymptomatic enuresis: a combined desmopressin and propiverine treatment regimen improves efficacy outcomes.
abstract: OBJECTIVE
  To evaluate, in a prospective study, the combination of the antimuscarinic propiverine and the antidiuretic hormone-agonist desmopressin in children and adolescents not responsive to previous monotherapy, as in primary monosymptomatic enuresis (PME), combined treatments are considered a second-line approach after the failure of monotherapy.
  
  
  METHODS
  The study included 122 children and adolescents (mean age 10.8 years, range 5-21) with PME and so far unresponsive to single or multiple monotherapy. Propiverine (body weight <30 kg, 15 mg/day; >or=30 kg, 20 mg/day) and desmopressin (0.4 mg/night) were administered over 3 months, followed by successive structured withdrawal programmes for propiverine and desmopressin, depending on the amount of loss of urine at night before treatment.
  
  
  RESULTS
  The re-evaluation of unresponsive patients, incorporating video-urodynamics, showed neurogenic detrusor overactivity, isolated detrusor sphincter dyssynergia and vesicorenal reflux in 12.3% (15/122) of patients, so far falsely treated as enuresis. In 107 of 122 patients the diagnosis of PME was confirmed. The primary efficacy outcome, continence at night, was achieved in 104 of 107 patients (97.2%). During the individual follow-up periods (3-12 months), 23 of 107 (21.5%) patients relapsed after withdrawal of both medications. Adverse events of moderate intensity were rare (3.7%).
  
  
  CONCLUSIONS
  Re-evaluation of patients after monotherapy has failed is justified, because other entities can be discovered in patients so far treated unsuccessfully for enuresis. The combination of propiverine and desmopressin is highly effective in children with PME. Our results support the case for further optimizing the inaugurated treatment algorithm of PME for treatment duration, dose-titration and structured withdrawal programmes, thus possibly further decreasing relapse rates.
authors.affiliation: Department of Urology and Paediatric Urology, Neunkirchen Hospital, Neunkirchen, Germany.
authors.forename: Saladin Helmut
authors.initials: SH
authors.lastname: Alloussi
authors.forename: Gerd
authors.initials: G
authors.lastname: Mürtz
authors.forename: Silvia
authors.initials: S
authors.lastname: Gitzhofer
authors.forename: Robert
authors.initials: R
authors.lastname: Eichel
authors.forename: Christoph
authors.initials: C
authors.lastname: Lang
authors.forename: Helmut
authors.initials: H
authors.lastname: Madersbacher
authors.forename: Gerhard
authors.initials: G
authors.lastname: Strugala
authors.forename: Schahnaz
authors.initials: S
authors.lastname: Alloussi
mesh_terms: D000293:Adolescent; D000328:Adult; D050034:Antidiuretic Agents / Q000627:therapeutic use*; D001561:Benzilates / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D003894:Deamino Arginine Vasopressin / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D006801:Humans; D018727:Muscarinic Antagonists / Q000627:therapeutic use*; D053206:Nocturnal Enuresis / Q000188:drug therapy*; D011446:Prospective Studies; D055502:Secondary Prevention; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D050034:Antidiuretic Agents; D001561:Benzilates; D018727:Muscarinic Antagonists; C015586:propiverine; D003894:Deamino Arginine Vasopressin