Best practice in the management of primary nocturnal enuresis in children

Primary nocturnal enuresis (NE) 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. [1]. Children with primary NE have never experienced a dry period of at least six months while children with secondary NE are now incontinent but have experienced a previous dry period for at least six months. [2] The prevalence of primary NE 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. [1] Up to the age of 13 years bedwetting is more common in boys but more common in girls after this age. [3, 4] Nocturnal enuresis has a spontaneous cure rate of approximately 14% per annum however up to 3% of children remain enuretic as adults. [2] 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. [2, 5] To date seven Cochrane systematic reviews have been identified that assess single interventions for the management of NE in children. [1, 6-11] The treatment of NE with simple behavioural and physical interventions (e.g. star charts and rewards) [7], alarms [1], complex behavioural and educational interventions (e.g. dry bed training, counseling and education) [11], complementary and miscellaneous interventions (e.g. hypnosis, acupuncture) [8], and pharmaceutical interventions [6, 9, 10], have all met with mixed levels of success. Despite the volume of literature, the question arises as to what is the most effective treatment algorithm for the treatment of primary NE in children? Practice guidelines are presently available [2, 4, 12] along with an umbrella review [13]; However, these documents require updating. Furthermore, many of these guidelines suggest that alarms, with desmopressin as a second line therapy, be considered the treatment of choice in mono-symptomatic NE. However, this is unlikely to be effective in all cases and therefore other interventions need to be investigated. Therefore, the purpose of this systematic review is to update the literature base to 2008, summarise the findings of all available trials (all research with concurrent controls), and to present the findings in a simple format (e.g. Best Practice Information Sheet) with a treatment algorithm.