1. health and fitness
2. disease
3. incontinence

VOLUME 8 NUMBER 2 2003 ISSN: 0965-0288
Effective
Bulletin on the effectiveness
of health service interventions
for decision makers
This bulletin summarises
the research evidence
on the effects of
interventions for the
treatment of nocturnal
enuresis in children
Health Care
Treating nocturnal
enuresis in children
■ Nocturnal enuresis in
children (bedwetting)
affects many families.
Although it has a high rate
of spontaneous remission,
bedwetting may bring social
and emotional stigma, stress
and inconvenience to both
the child and their family.
■ A variety of interventions
are used to treat nocturnal
enuresis. These include
alarms, drugs such as
desmopressin, simple
behavioural methods such
as star charts, as well as
more complex multi-faceted
interventions.
■ Much of the available
research evaluating the
effects of interventions is of
poor quality and there are
few direct comparisons
between different types of
intervention.
■ Simple behavioural
interventions are widely
used as standard first-line
treatment, but they require
a high level of parental
involvement. Currently,
there is insufficient
evidence to support the use
of any particular
intervention.
■ The use of alarms has been
shown to reduce night-time
bedwetting both during
treatment and after
treatment stops. Before
embarking on alarm
treatment, families need to
be made aware of both the
time and the high level of
parental involvement
necessary to attain success.
■ Drug therapy such as
desmopressin reduces the
number of wet nights per
week compared with
placebo, but only for as long
as the drug is used. Drugs
could be used to reduce
bedwetting for a specific
purpose, such as nights
away from home. Children
and their families need to
be warned about possible
side effects of some of the
drugs.
CENTRE FOR REVIEWS AND DISSEMINATION
A. Background
Nocturnal enuresis (bedwetting) is
the involuntary loss of urine at
night, in the absence of physical
disease, at an age when a child could
reasonably be expected to be dry (by
consensus, at a developmental age of
five years).1,2 Although bedwetting
has a high rate of spontaneous
remission, it may bring social and
emotional stigma, stress and
inconvenience to both the child with
enuresis and their family.3 Children
who wet the bed may experience
parental disapproval, sibling teasing
and repeated treatment failure which
may lower self esteem.4,5
Prevalence and causes
Nocturnal enuresis affects many
families. Estimating the prevalence is
difficult, however, because there are
variations in methods of diagnosis
and in definitions.6,7 In the UK, the
most recent estimates suggest that
the prevalence of frequent
bedwetting (more than once a week)
is higher in boys and shows a steady
decline with age.8-10 Around one in
six of five-year-olds regularly wet the
bed compared to around one in
twenty 11-year-olds.8-10
The causes of primary nocturnal
enuresis, where a child has never
been dry at night, are unclear.
Genetic,2,11-13 physiological14,15 and
psychological16-19 factors, as well as
delay in maturation of the
mechanism for bladder control,20,21
have been suggested. Other factors
which may contribute to bedwetting
include: constipation, sleep apnoea
and upper airway obstructive
symptoms22 and diet or mild caffeine
drinks with diuretic effects (e.g.
cola).8
B. Management
of enuresis
A wide variety of interventions are
used to treat nocturnal enuresis.
These include enuresis alarms, drugs
2
Box 1 Interventions used to treat nocturnal enuresis
Behavioural interventions
■ Lifting: involves taking the child to the toilet during the night usually
before the time that bedwetting is expected, without necessarily
waking the child.
■ Waking: involves waking the child to allow them to get up and
urinate.
■ Reward systems (e.g. star charts): the child might receive a star for
every dry night, and a reward after a preset number of stars have
been earned.
■ Retention control training: attempting to increase the functional
bladder capacity by delaying urination for extended periods of time
during the day.
■ Stop-start training: teaching children to interrupt their stream of urine
in order to strengthen their pelvic floor muscles
■ Dry bed training: can include enuresis alarms, waking routines,
positive practice, cleanliness training, bladder training, and rewards.
Enuresis alarms
■ Enuresis alarms: wake the child in the night at the onset of wetting.
When a child begins to urinate, a sensor (either a bed pad or one
worn inside pyjamas) is moistened, and the alarm is triggered.
■ Over-learning: may be initiated after successful alarm treatment
(e.g. achievement of 14 consecutive dry nights). Extra drinks are
given at bed-time to cause additional stress to the detrusor muscles in
the bladder. Alarm treatment is then continued until 14 consecutive
dry nights are once again achieved.
Pharmacological interventions
■ Drugs: include desmopressin and, less commonly, tricyclic drugs such
as imipramine, amitriptyline and nortriptyline.
such as desmopressin, simple
behavioural methods such as star
charts and more complex
behavioural methods including dry
bed training. Other less common
interventions include psychotherapy,
surgery, fluid deprivation and
complementary therapies. Box 1
describes the most commonly used
behavioural, alarm and
pharmacological interventions.
Treatment for children who wet the
bed is often carried out by health
professionals in general practice.
Bedwetting may be discovered when
a child is seen for a complaint other
than enuresis. Having established
that the child is at an age where one
could reasonably expect a dry bed
(i.e. at least five years old) and wants
EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children
to become dry,23 consensus is that a
thorough assessment should be
undertaken including a general
physical examination, urinalysis and
investigation of attitudes.8 In keeping
with the objectives of the National
Service Framework for Children, any
intervention should be centred on
the needs of the child.27 Although it
is yet to be subjected to rigorous
evaluation, the ‘three systems
approach’24 is advocated as a way to
understand, assess and select
appropriate treatment for nocturnal
enuresis.
The Enuresis Resource and
Information Centre (ERIC) has
produced guidelines on minimum
standards of practice in the
treatment of enuresis to assist
VOLUME 8 NUMBER 2
2003
managers and practitioners in the
planning, execution and evaluation
of enuresis services.25 ERIC also has
details of over 600 enuresis clinics in
the UK.26 Some clinics are based in
hospitals and others in health
centres (often run by school nurses)
Most but not all clinics are open to
clients without the need for a
professional referral.
C. Nature of the
evidence
This issue of Effective Health Care
summarises the research evidence
from randomised controlled trials
(RCTs) on the effects of interventions
for the treatment of nocturnal
enuresis in children. The bulletin is
based upon a series of systematic
reviews that have been carried out
by the Cochrane Incontinence
Group, and are available via the
Cochrane Library. The Cochrane
reviews are all based on a previous
systematic review originally
published in 1997 as part of the CRD
Outcome:
Report series.28 Further details of
review methods are available in the
Appendix.
Although over 100 RCTs have been
identified across the Cochrane
reviews, there are few direct
comparisons between different types
of intervention. The difficulty in
comparing interventions is
exacerbated by the lack of
uniformity in outcome measures and
the failure of some studies to
adequately assess baseline levels of
bedwetting. Many of the included
RCTs have methodological problems
such as small sample sizes and high
rates of attrition (drop-outs), leading
to low statistical power and potential
bias. In addition, many are poorly
reported. For example, many trial
authors give insufficient detail about
the method of randomisation or
inadequately report follow-up data.
In addition, strict inclusion/exclusion
criteria were imposed in many of the
trials. Consequently, the children
involved are not necessarily
representative of the wider
population of those who wet the
bed, either in the community or in
institutions.
D. Effects of
interventions
D1. Behavioural interventions
other than alarms Simple
behavioural interventions are widely
used as standard first-line treatment.
Twelve RCTs were included in a
Cochrane review assessing the
effects of simple behavioural
interventions.29 None of the RCTs
were of good methodological quality.
The review found that star charts,
whether with or without lifting or
waking, were associated with fewer
wet nights and lower failure rates
while on treatment, and longer-term
success after treatment. However,
each finding was based on a single
A number of the included RCTs
have recruited children by
advertising in the media, or from
enuresis clinics. Participating
families may have been especially
motivated to tackle the bedwetting.
Number cured (achieving 14 consecutive dry nights)
Study
or sub-category
alarm
n/N
01 alarm vs control
Werry 1965
6/21
Sloop 1973
11/21
Sacks 1974
51/64
Jehu 1977
18/19
Bollard 1981a
12/15
Bollard 1981b
16/20
Wagner 1982
10/12
Lynch 1984
7/18
Bennett 1985
4/9
Wagner 1985
8/13
Houts 1986
9/12
Moffatt 1987
42/61
Ronen 1992
12/19
Subtotal (95% CI)
304
Total events: 206 (alarm), 9 (control)
2
Test for heterogeneity: Chi = 7.40, df = 12 (P = 0.83), I2 = 0%
Test for overall effect: Z = 9.20 (P < 0.00001)
02 delayed alarm vs control
1/18
Lynch 1984
7/13
Wagner 1985
31
Subtotal (95% CI)
Total events: 8 (alarm), 1 (control)
Test for heterogeneity: Chi2 = 0.20, df = 1 (P = 0.65), I2 = 0%
Test for overall effect: Z = 2.08 (P = 0.04)
03 unsupervised alarm vs control
Bollard 1981a
9/15
control
n/N
RR (fixed)
95% CI
Weight
%
RR (fixed)
95% CI
1/27
1/21
2/9
0/20
0/15
2/20
1/12
0/18
0/9
1/13
0/11
1/55
0/18
248
6.50
7.43
26.07
3.63
3.72
14.87
7.43
3.72
3.72
7.43
3.86
7.82
3.81
100.00
7.71 [1.00, 59.25]
11.00 [1.56, 77.76]
3.59 [1.05, 12.25]
38.85 [2.50, 602.54]
25.00 [1.61, 387.35]
8.00 [2.11, 30.34]
10.00 [1.51, 66.43]
15.00 [0.92, 244.51]
9.00 [0.55, 146.11]
8.00 [1.16, 55.20]
17.54 [1.14, 269.84]
37.87 [5.39, 266.00]
23.75 [1.51, 373.78]
12.55 [7.32, 21.53]
0/18
1/13
31
33.33
66.67
100.00
3.00 [0.13, 69.09]
7.00 [1.00, 49.16]
5.67 [1.11, 28.99]
0/15
100.00
19.00 [1.20, 299.63]
0.001 0.01
0.1
favours control
1
10
100
1000
favours alarm
Figure 1 Comparison: alarm vs control – number cured during treatment
2003
VOLUME 8 NUMBER 2
EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children
3
Outcome:
Numbers remaining cured (achieving 14 dry nights and not relapsing)
Study
or sub-category
Treatment
n/N
01 alarm vs control
Sloop 1973
7/21
Bollard 1981a
8/15
Bollard 1981b
10/20
Wagner 1982
5/12
Wagner 1985
6/13
Subtotal (95% CI)
81
Total events: 36 (Treatment), 1 (Control)
Test for heterogeneity: Chi2 = 0.52, df = 4 (P = 0.97), I2 = 0%
Test for overall effect: Z = 4.37 (P < 0.0001)
Control
n/N
RR (fixed)
95% CI
RR (fixed)
95% CI
1/21
0/15
0/20
0/12
0/13
81
33.33
16.67
16.67
16.67
16.67
100.00
7.00 [0.94, 52.04]
17.00 [1.07, 270.41]
21.00 [1.31, 335.74]
11.00 [0.67, 179.29]
13.00 [0.81, 209.42]
12.67 [4.06, 39.52]
02 delayed alarm vs control
Wagner 1985
2/13
0/13
100.00
5.00 [0.26, 95.02]
03 unsupervised alarm vs control
Bollard 1981a
4/15
0/15
100.00
9.00 [0.53, 153.79]
0.001 0.01
0.1
1
favours control
Figure 2
10
100
1000
favours alarm
Comparison: alarm vs control – numbers remaining cured after treatment
small trial. Of the two trials
addressing retention control training,
one was too small to provide
meaningful information, and the
other had a very high (80%) dropout rate. Another small trial showed
that there might be some benefits
associated with cognitive therapy
compared with star charts, but these
findings will need to be confirmed in
larger trials.
A feature of the included RCTs was
high dropout or non-adherence
rates. Families reported that waking
the child at night was disruptive
and stressful, suggesting that some
of these simple behavioural
interventions are not suitable for all.
A number of RCTs have assessed the
effects of complex behavioural
treatment programmes such as dry
bed training. In the 1997 systematic
review undertaken by CRD,28
complex behavioural treatment
programmes such as dry bed
training were not found to be more
effective than alarm treatment. An
update is nearing completion and
will be available as a Cochrane
review later this year.30
D2. Alarms Fifty-three RCTs were
included in a Cochrane review
assessing the effects of alarm
interventions for nocturnal
enuresis.31 The methodological
quality of many of the RCTs was
poor. Many were too small to be
4
Weight
%
likely to find statistically significant
differences, even where some
difference may exist, and often only
one small trial compared alarms with
another method. In these
circumstances, no conclusions can
be drawn.
Do alarms work? The review’s main
findings were that alarm treatment
was more effective during treatment
than control interventions (see
Figure 1). In terms of success rates
once treatment was completed (see
Figure 2), about half the children
remained dry after using alarms,
compared with almost none of those
who received no treatment or
waiting list control.
Which type of alarm is best? Most
of the alarms evaluated were of the
type that woke the child
immediately by means of a bell or
buzzer. Insufficient evidence was
found to draw conclusions about the
relative effectiveness of different
types of alarm. There was some
limited evidence that an immediate
alarm was better than a delayed
alarm, and that one which woke the
child rather than the parents had
better results. Children were
reported to prefer a body-worn alarm
to a bed pad and alarm.
Are alarms better than other
behavioural interventions? The
Cochrane review included eight
RCTs comparing alarms with a
EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children
variety of simple behavioural
interventions including star charts,
rewards, wakening, lifting and stopstart training (pelvic floor muscle
training).31 Most of the trials
comparing behavioural interventions
with alarms tended to favour alarms.
In one small trial, alarms were found
to be better than stop-start training
in terms of wet nights per week both
during and after treatment. There
were no statistically significant
differences between alarms and
methods such as lifting, wakening or
rewards in four other small trials,
although all trials favoured alarms in
respect of a reduction in the mean
number of wet nights. There was not
enough evidence to conclude
whether supplementing alarm
treatment with behavioural
interventions improved the
effectiveness of the alarm.
Are alarms better than drugs? The
Cochrane review included 18 RCTs
that involved comparisons between
alarms and drugs either alone or in
combination.31 Limited evidence
suggested that alarms were better
than drug treatment. Although
desmopressin appeared to have a
more immediate effect, alarms were
more effective by the end of a
course of treatment (RR 0.71, 95% CI
0.50 to 0.99) and after treatment
stopped (RR 0.27, 95% CI 0.11 to
0.69). Alarms were also found to be
better than tricyclics both during
VOLUME 8 NUMBER 2
2003
Outcome:
Number of wet nights per week during treatment
Study
or sub-category
N
Desmopressin
Mean (SD)
N
01 10 mcg vs placebo
Aladjem 1982
15
1.52(2.15)
Kjoller 1984
13
2.49(2.52)
Subtotal (95% CI)
28
2
Test for heterogeneity: Chi = 1.68, df = 1 (P = 0.20), I2 = 40.4%
Test for overall effect: Z = 4.01 (P < 0.0001)
02 20 mcg vs placebo
Folwell 1997
Tuvemo 1978
Segni 1982
Post 1983 B
Kjoller 1984
Terho 1984
Janknegt 1990
Rushton 1995
Skoog 1997
Sener 1998
Schulman 2001a
Schulman 2001b
31
18
20
20
12
54
22
49
33
31
44
109
3.24(2.51)
1.60(1.82)
2.20(1.34)
4.90(1.92)
2.45(1.84)
2.16(2.00)
3.40(2.50)
3.96(2.37)
4.00(1.15)
1.10(1.39)
4.00(1.33)
4.00(1.57)
03 40 mcg vs placebo
Post 1983 A
52
3.90(2.34)
Janknegt 1990
22
3.80(2.20)
Martin 1993
22
2.16(2.25)
Skoog 1997
33
3.50(1.44)
Yap 1998
34
2.50(2.70)
Schulman 2001a
48
3.50(1.73)
Subtotal (95% CI)
211
Test for heterogeneity: Chi2 = 3.11, df = 5 (P = 0.68), I2 = 0%
Test for overall effect: Z = 7.63 (P < 0.00001)
04 60 mcg vs placebo
Skoog 1997
33
3.50(1.15)
Schulman 2001a
48
3.00(1.73)
Subtotal (95% CI)
81
2
Test for heterogeneity: Chi = 0.00, df = 1 (P = 1.00), I2 = 0%
Test for overall effect: Z = 7.08 (P < 0.00001)
05 combined dose vs placebo
Birkasova 1978
22
2.10(2.25)
06 dose titration vs placebo
Rushton 1995
49
3.77(2.52)
Schulman 2001b
99
3.20(1.69)
Subtotal (95% CI)
148
2
Test for heterogeneity: Chi = 1.52, df = 1 (P = 0.22), I2 = 34.3%
Test for overall effect: Z = 6.25 (P < 0.00001)
Placebo
Mean (SD)
WMD (fixed)
95% CI
4.40(1.94)
3.84(2.13)
62.07
37.93
100.00
-2.88 [-4.31, -1.45]
-1.35 [-3.17, 0.47]
-2.30 [-3.42, -1.18]
31
18
20
20
12
54
22
47
36
25
47
38
4.86(1.95)
3.97(2.20)
4.20(1.79)
5.80(1.14)
3.84(2.13)
4.02(1.83)
5.30(1.80)
4.90(1.64)
5.00(1.20)
5.10(2.00)
4.50(1.37)
5.00(1.54)
4.29
3.09
5.59
5.61
2.12
10.27
3.24
8.14
17.46
6.29
17.45
16.45
-1.62 [-2.74, -0.50]
-2.37 [-3.69, -1.05]
-2.00 [-2.98, -1.02]
-0.90 [-1.88, 0.08]
-1.39 [-2.98, 0.20]
-1.86 [-2.58, -1.14]
-1.90 [-3.19, -0.61]
-0.94 [-1.75, -0.13]
-1.00 [-1.55, -0.45]
-4.00 [-4.92, -3.08]
-0.50 [-1.05, 0.05]
-1.00 [-1.57, -0.43]
52
22
22
36
34
47
213
5.00(1.91)
5.30(1.80)
3.68(2.25)
5.00(1.20)
4.50(2.10)
4.50(1.37)
17.27
8.25
6.58
29.47
8.81
29.62
100.00
-1.10
-1.50
-1.52
-1.50
-2.00
-1.00
-1.33
36
47
83
5.00(1.20)
4.50(1.37)
56.09
43.91
100.00
-1.50 [-2.05, -0.95]
-1.50 [-2.13, -0.87]
-1.50 [-1.92, -1.08]
22
5.50(2.20)
100.00
-3.40 [-4.71, -2.09]
47
36
83
4.90(1.82)
5.00(1.54)
32.13
67.87
100.00
-1.13 [-2.01, -0.25]
-1.80 [-2.40, -1.20]
-1.58 [-2.08, -1.09]
-10
-5
0
5
[-1.92,
[-2.69,
[-2.85,
[-2.13,
[-3.15,
[-1.63,
[-1.67,
-0.28]
-0.31]
-0.19]
-0.87]
-0.85]
-0.37]
-0.99]
10
favours placebo
Comparison: Desmopressin vs placebo
(RR 0.73, 95% CI 0.61 to 0.88), and
after treatment stopped (RR 0.58,
95% CI 0.36 to 0.94). Insufficient
reliable evidence was found to
support the practice of
supplementing alarm treatment with
drug interventions.
Acceptability of alarms Most
alarms wake the child immediately
using a bell or buzzer but then
require nightwear, and perhaps
bedding, to be changed. High
dropout rates in some of the trials
included in the Cochrane review
suggest that there were problems
with adherence, often reflecting the
unacceptability of the intervention.
Potential difficulties, such as the
time needed to attain success and
the disruption to the family, need to
be discussed before embarking on
alarm treatment. In two trials, non-
2003
WMD (fixed)
95% CI
17
12
29
favours desmopressin
Figure 3
Weight
%
VOLUME 8 NUMBER 2
adherence or dropout was attributed
to the equipment being too difficult
or complicated to use. A small
number of RCTs included in the
review involved alarms that
delivered electric shocks to the
children’s skin. The use of these
alarms was clearly unacceptable to
parents and children, and they
sometimes caused side effects such
as skin burns and ulceration.
D3. Drugs Three Cochrane reviews
have assessed the effects of drug
therapy on nocturnal enuresis in
children.32-34 One of these reviews
covers the less commonly used
drugs and is currently being updated
and will be available later this year.34
Forty-one RCTs were included in a
Cochrane review assessing the
effects of desmopressin.32 The review
found that there was clear evidence
that desmopressin (in a variety of
doses and forms) was better at
reducing the number of wet nights
per week during treatment
compared to placebo (see Figure 3).
However, after treatment stopped,
the limited evidence available
suggested that this improvement
was not sustained.
Another Cochrane review of 54
RCTs found that treatment with
tricyclic or related drugs
(imipramine, amitriptyline,
viloxazine, clomipramine and
desipramine but not mianserin) was
associated with a reduction of about
one wet night per week while on
treatment.33 For example, imipramine
was better at reducing the number
of wet nights per week during
treatment compared to placebo
(WMD -1.19, 95% CI -1.56 to -0.82).
EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children
5
However, although about a fifth of
the children became dry while on
treatment (86/400 achieved 14 dry
nights on imipramine compared to
22/413 on placebo), this effect was
not sustained after treatment
stopped (6/192 on imipramine
compared to 7/209 on placebo).
■ Simple behavioural interventions
are widely used as standard first
line treatment, but they require a
high level of parental
involvement. Currently, there is
insufficient evidence to support
the use of any particular
intervention.
Insufficient reliable evidence was
found comparing desmopressin with
tricyclics or other related drugs.
Likewise, there was a lack of reliable
evidence comparing desmopressin or
tricyclics with simple and complex
behavioural interventions.
■ The use of an alarm intervention
has been shown to reduce nighttime bedwetting in a majority of
children both during treatment
and after treatment stops. Overlearning (giving children extra
fluids at bedtime after
successfully becoming dry using
an alarm) may reduce the relapse
rate. Before embarking on alarm
treatment, families need to be
made aware of both the time and
the high level of parental
involvement necessary to attain
success.
Acceptability of drugs The British
National Formulary (BNF) currently
suggests that drug therapy is not
usually appropriate for children
under seven years of age and is
reserved for when alternative
measures have failed.35 Fluid
overload is potentially the most
serious complication with
desmopressin. It is associated with
over-drinking at bedtime and its
symptoms include headache, nausea,
hyponatraemia, cerebral oedema and
convulsions. Tricyclics have
significant adverse effects, including
cardiotoxic and hepatotoxic effects
in overdose. Minor side effects
related to their anticholinergic
actions include postural
hypotension, dry mouth,
constipation, perspiration,
tachycardia, nausea, lethargy and
insomnia. The BNF recommends that
the possible side effects of the
various drugs should be considered
and that any prescription should not
be continued for longer than three
months without stopping for a full
re-assessment.35
E. Implications
■ Much of the available research on
the effects of interventions used
to treat nocturnal enuresis in
children is of poor quality and
there are few direct comparisons
between different types of
intervention.
6
■ Drug therapy such as
desmopressin reduces the
number of wet nights per week
compared with placebo, but only
for as long as the drug is used.
However, drugs could be used as
a way to reduce the frequency of
wetting for a specific purpose
such as nights away from home
(e.g. for holidays or staying with
friends). Children and their
families need to be informed
about possible side effects of
some of the drugs.
■ Future research must be of higher
methodological quality, involve
comparisons between those
interventions used most
commonly in practice, be
undertaken in appropriate
settings and include follow-up
periods of longer duration.
Appendix on methods
The bulletin is based upon a series of
systematic reviews that have been
carried out by the Cochrane
Incontinence Group. Full details of
review methods are available on the
Cochrane Library.
Relevant trials were identified from
the Group’s specialised register of
EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children
controlled trials which is described
under the Incontinence Group’s
details in The Cochrane Library.
The register contains trials identified
from MEDLINE, CINAHL, the
Cochrane Central Register of
Controlled Trials (CENTRAL) and
handsearching of journals and
relevant conference proceedings. In
addition, the cited references from
the included trials were searched.
No language or other restrictions
were imposed on any of these
searches and non-English language
papers were translated where
necessary.
Studies were assessed using the
methods of the Cochrane
Collaboration.36 All randomised or
quasi-randomised trials of
interventions for the treatment of
non-organic nocturnal enuresis in
children were included (as defined
by the trialists, usually up to age 16).
Two reviewers screened the studies
independently for eligibility. Where
the trials have been published in
more than one publication, only the
primary source has been referenced.
Two reviewers independently
assessed the quality of the eligible
trials, and extracted data using a
standard form. Primary outcomes of
interest were: the number of wet
nights per week during treatment
and at follow up; the number of
children who were cured during
treatment (defined as achieving 14
consecutive dry nights) or who
relapsed at follow up; and any
adverse events.
A fixed effect model was used to
calculate the pooled estimates and
the 95% confidence intervals.37
References
1. World Health Organisation.
Nonorganic enuresis. The ICD-10
classification of mental and
behavioural disorders: Clinical
descriptions and diagnostic
guidelines. Geneva: WHO, 1992.
2. American Psychiatric Association.
Functional enuresis. Diagnostic and
VOLUME 8 NUMBER 2
2003
statistical manual of mental
disorders. 3rd (revised) ed.
Washington: American Psychiatric
Association, 1980.
3. Fitzwater D, Macknin ML.
Risk/benefit ratio in enuresis
therapy. Clin Pediatr (Phila)
1992;31:308-10.
4. Warzak WJ. Psychosocial
implications of nocturnal enuresis.
Clin Pediatr (Phila) 1992;Spec No:
38-40.
5. Hagglof B, Andren O, Bergstrom E,
et al. Self-esteem before and after
treatment in children with
nocturnal enuresis and urinary
incontinence. Scand J Urol Nephrol
1997;31:79-82.
6. de Jonge GA. Epidemiology of
enuresis: a survey of the literature.
In: Kolvin I, MacKeith RC, Meadow
SR. (eds) Bladder control and
enuresis. London: William
Heinemann Medical Books, 1973.
7. Krantz I, Jylkas E, Ahlberg BM, et al.
On the epidemiology of nocturnal
enuresis-a critical review of
methods used in descriptive
epidemiological studies on
nocturnal enuresis. Scand J Urol
Nephrol 1994;Supp.163:75-82.
8. Blackwell C. A guide to enuresis: A
guide to treatment of enuresis for
professionals. Bristol: ERIC, 1989.
9. Rona R, Li L, Chinn S. Determinants
of nocturnal enuresis in England
and Scotland in the ‘90s. Dev Med
Child Neurol 1997;39:667-681.
10. Swithinbank L, Brookes S, Shepherd
A, et al. The natural history of
urinary symptoms during
adolescence. Br J Urol 1998;81:
90-93.
15. Norgaard JP, Djurhuus JC. The
pathophysiology of enuresis in
children and young adults. Clin
Pediatr (Phila) 1993;Spec No:5-9.
16. Rutter M, Yule W, Graham P.
Enuresis and behavioural deviance.
Some epidemiological
considerations. In: Kolvin I,
MacKeith RC, Meadow SR. (eds)
Bladder control and enuresis.
London: William Heinemann
Medical Books, 1973.
17. Shaffer D. Enuresis. In: Rutter M,
(ed) Child psychiatry: modern
approaches. Oxford: Blackwell
Scientific Publications, 1977.
18. Devlin JB. Prevalence and risk
factors for childhood nocturnal
enuresis. Ir Med J 1991;84:118-20.
19. Moffatt ME. Nocturnal enuresis:
psychologic implications of
treatment and nontreatment.
J Pediatr 1989;4:697-704.
20. Jarvelin MR. Developmental history
and neurological findings in
enuretic children. Dev Med Child
Neurol 1989;31:728-36.
21. Koff SA. Cure of nocturnal
enuresis: why isn’t desmopressin
very effective? Pediatr Nephrol
1996;10:667-70.
22. Maizels M, Gandhi K, Keating B, et
al. Diagnosis and treatment for
children who cannot control
urination. Curr Probl Pediatr
1993;23:402-50.
23. Butler RJ, Redfern EJ, Holland P.
Children’s notions about enuresis
and the implications for treatment.
Scand J Urol Nephrol 1994;163:39-47.
11. Bakwin H. Enuresis in twins. Am J
Dis Child 1971;121:222-5.
24. Butler R, Holland P. The three
systems: A conceptual way of
understanding nocturnal enuresis.
Scand J Urol Nephrol 2000;34:
270-277.
12. Bakwin H. The genetics of enuresis.
In: Kolvin I, MacKeith RC, Meadow
SR. (eds) Bladder control and
enuresis. London: William
Heinemann Medical Books, 1973.
25. Morgan R. Guidelines in the
minimum standards of practice in
the treatment of enuresis. Bristol,
UK: Enuresis Resource and
Information Centre, 1993.
13. Eiberg H, Berendt I, Mohr J.
Assignment of dominant inherited
nocturnal enuresis (ENUR1) to
chromosome 13q. Nat Genet
1995;10:354-6.
26. Enuresis Resource and Information
Centre. ERIC Online (Website), Date
accessed: June 2003
(URL:http://www.eric.org.uk).
14. Djurhuus JC, Norgaard JP, Rittig S.
Monosymptomatic bedwetting.
Scand J Urol Nephrol
1992;Supp.141:7-19.
2003
VOLUME 8 NUMBER 2
27. Department of Health. Getting the
right start: National Service
Framework for Children. Emerging
findings. London: Department of
Health, April 2003.
28. NHS Centre for Reviews and
Dissemination. A Systematic Review
of the Effectiveness of Interventions
for Managing Childhood Nocturnal
Enuresis. CRD Report 11. York:
University of York, 1997.
29. Glazener CMA, Evans JE. Simple
behavioural and physical
interventions for nocturnal
enuresis in children. (Cochrane
Review) The Cochrane Library,
Issue 3. Oxford: Update Software,
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30. Glazener C, Evans J. Complex
behavioural interventions for
nocturnal enuresis in children.
(Cochrane Review) The Cochrane
Library, Issue 3. Oxford: Update
Software, 2003.
31. Glazener CM, Evans JH, Peto R.
Alarm interventions for nocturnal
enuresis in children (Cochrane
Review). The Cochrane Library,
Issue 3. Oxford: Update Software,
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32. Glazener CMA, Evans JHC.
Desmopressin for nocturnal
enuresis in children. (Cochrane
Review) The Cochrane Library,
Issue 3. Oxford: Update Software,
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33. Glazener C, Evans J, Peto R.
Tricyclic and related drugs for
nocturnal enuresis in children
(Cochrane Review). The Cochrane
Library, Issue 3. Oxford: Update
Software, 2003.
34. Glazener C, Evans J. Drugs for
nocturnal enuresis in children
(other than desmopressin and
tricyclics) (Cochrane Review). The
Cochrane Library, Issue 3. Oxford:
Update Software, 2003.
35. British Medical Association, Royal
Pharmaceutical Society of Great
Britain. British National Formulary.
London: British Medical
Association, Royal Pharmaceutical
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36. Clarke M, Oxman AD. Analysing
and presenting results. Cochrane
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37. Berlin JA, Laird NM, Sacks HS, et al.
A comparison of statistical methods
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EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children
7
Effective
Health Care
This bulletin is based on
systematic reviews carried out by
Cathryn Glazener and Johnathan
Evans of the Cochrane
Incontinence Group, with
additional review work carried out
by Rachel Peto of the Centre for
Reviews and Dissemination,
University of York.
The bulletin was written and
produced by staff at the Centre for
Reviews and Dissemination,
University of York.
The Effective Health Care bulletins are
based on systematic review and
synthesis of research on the clinical
effectiveness, cost-effectiveness and
acceptability of health service
interventions. This is carried out
by a research team using established
methodological guidelines, with
advice from expert consultants for
each topic. Great care is taken
to ensure that the work, and
the conclusions reached, fairly
and accurately summarise the
research findings. The University of
York accepts no responsibility for any
consequent damage arising from the
use of Effective Health Care.
Acknowledgements
Effective Health Care would like to
acknowledge the helpful assistance
of the following who commented on
the text:
■ Mark Baker, Yorkshire Cancer
Network
■ Richard Butler, East Leeds PCT
■ Penny Dobson, Enuresis Resource
and Information Centre
■ Alison Evans, University of Leeds
■ Johnathan Evans, Nottingham
City Hospital NHS Trust
■ Cathryn Glazener, University of
Aberdeen
■ Adrian Grant, University of
Aberdeen
■ Molly Haig, Enuresis Resource
and Information Centre
■ Steve Holmes, Mendip PCT
■ Dee Kyle, Bradford South and
West PCT
■ Colin Pollock, Regional
Directorate of Public Health
(Yorkshire & Humber)
■ June Rogers, Knowsley PCT
■ Stephen Singleton,
Northumberland HA
■ Colin Waine, Sunderland HA
■ Sheila Wallace, University of
Aberdeen
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EFFECTIVE HEALTH CARE Treating nocturnal ensuresis in children
VOLUME 8 NUMBER 2
2003