Best practice in the management of primary nocturnal enuresis in children: a systematic review.
OBJECTIVE
Nocturnal enuresis is the involuntary loss of urine at night in a child of an age and physical health where they would be expected to be dry. The prevalence of this condition in Australia has been estimated at 18.9% in children 5 to 12 years of age, with up to 19% of boys and 16% of girls aged 5 years wetting the bed at least once per month. Up to the age of 13 years bedwetting is more common in boys and more common in girls after this age. Nocturnal enuresis has a spontaneous cure rate of approximately 14% however up to 3% of children remain enuretic as adults. Although this condition is pathologically benign, it can have serious social and psychological repercussions for the sufferer including affects on self esteem, school success, parental disapproval and even sexual activity in later life. Despite the volume of information available for the management of enuresis, the majority of research has been conducted outside Australia. Therefore, the purpose of this work was to produce management guidelines for nocturnal enuresis in children specific to Australian clinical practice.


METHODS
This review considered systematic reviews or concurrently controlled trials (randomised controlled trials (RCT), pseudo-randomised controlled trials, controlled clinical trials (CCT), interrupted time series (ITS) and controlled before and after trials (CBA)), for examining effectiveness of interventions to manage nocturnal enuresis in children up to the age of 16 years.


METHODS
A systematic search of the literature was performed to identify all available evidence. Cochrane and other health technology assessment websites were searched for existing systematic reviews. For recent randomised controlled trials and controlled trials (1990 to 2007) Pubmed, Embase, and CINAHL databases were searched. Reference lists of all retrieved articles were searched for relevant trials. These reviews and guidelines were summarised and presented to an advisory panel of nurse continence advisors and clinicians to ensure relevance to Australian clinical practice.


METHODS
Methodological quality of all studies was assessed by two reviewers using the JBI critical appraisal forms for experimental studies located within the JBI-MAStARI software. This tool was used to identify all sources of bias. Where disagreement existed between the two reviewers a third reviewer adjudicated.


RESULTS
Seven systematic reviews, eight new trials and two guidelines were used in the development of these guidelines.Briefly management recommendations include: CONCLUSIONS: Despite the high prevalence of nocturnal enuresis and the negative psychosocial sequelae that can arise from this condition, management is both readily available and effective.


CONCLUSIONS
The practice of managing nocturnal enuresis in children should start with addressing both daytime wetting and any evidence of constipation. Following this, less invasive behavioural therapies should be attempted. If these measures fail then the use of alarms with or without short-term administration of desmopressin could be attempted. Other interventions have yet to be proven to be definitively effective and should be considered with caution.It should be emphasized however, that the vast majority of children will become continent at some future time point, with or without the benefit of interventions.


CONCLUSIONS
While it is clear that some behavioural methods, alarms and desmopressin can be effective interventions, the evidence for other treatments is not so definitive. The observation however that even alarms and/or desmopressin do not work for all children suggests that research to establish the effectiveness of other interventions (especially behavioural and complementary treatments) should be performed in the form of large, carefully designed RCTs.
1. Senior Business Improvement Officer, Organisational Development Group, Blue Care 2. Clinical Researcher (Continence), UQ/ Blue Care Research and Practice Development Centre & Continence Advisor Blue Care. 3. Professor and Director of Research, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore.
Brent
B
Hodgkinson
Kay
K
Josephs
Desley
D
Hegney