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B. Hodgkinson, K. Josephs, D. Hegney,
School of Nursing, University of Queensland & the University of Queensland/ Blue
Care Research and Practice Development Centre
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.

This review seeks to answer the following question(s):
How effective are:
   1. simple behavioural interventions such as reward systems
   2. complex behavioural interventions
   3. alarms
   4. pharmaceuticals such as desmopressin and tricyclics
   5. and complementary interventions such as acupuncture and hypnosis
in managing primary nocturnal enuresis in children?
Inclusion criteria
The inclusion criteria for this review are as follows:
Types of studies
The purpose of this review is to examine the effectiveness of interventions to manage
primary NE. Therefore, the study designs of interest in this review are the randomised
controlled trial (RCT), pseudo-randomised controlled trials, controlled clinical trials
(CCT), interrupted time series (ITS) and controlled before and after trials (CBA).
Types of participants
Studies that examined children (as defined in the trial) aged up to and including the
age of 16 years, who suffered from a primary diagnosis of NE will be included.
Types of interventions
The Cochrane reviews that form the basis of this review have divided interventions
for management of NE in children into seven categories. These categories will also be
used in this review:
   1)      alarms
   2)        simple behavioural and physical interventions (such as fluid restriction,
        lifting and reward systems)
   3)       complex behavioural and educational interventions (use a number of
        different behavioural and educational interventions in combination such as dry
        bed training)
   4)      complementary and miscellaneous interventions
   5)      desmopressin
   6)      tricyclic and related drugs
   7)      drugs other than desmopressin and tricyclics
Types of outcome measures
Outcomes of interest to this review have been specified by the identified Cochrane
reviews and include:
   1)      change in the number of wet nights per week
   2)      number of participants failing to attain 14 consecutive dry nights (the
        accepted criterion for continence)
   3)      mean number of wet nights at follow-up
   4)      relapse (as defined by each trial)
Search strategy
A three step systematic search of the literature will be performed to identify all
available evidence.
Initially, Cochrane (including DARE) and other health technology assessment
websites will be searched for existing systematic reviews. It is already known that
seven systematic reviews directly related to NE in children are listed in the Cochrane
database and will form the basis of this review.
To update these systematic reviews a search for recent randomised controlled trials
and controlled trials (from 1990 to 2008) will be conducted in Pubmed, Embase, and
CINAHL databases.
Key search terms will be:
Subject headings: Nocturnal enuresis, randomized clinical trials as topic, controlled
clinical trials as topic.
Title/abstract: nocturnal enuresis, bedwetting, nighttime wetting, randomized
controlled trial, randomised controlled trial, interrupted time series, controlled before
and after, controlled clinical trial.
The searches will be limited to children aged ≥1year and ≤16 years.
Finally, reference lists of all retrieved articles will be searched for relevant trials.
These reviews and guidelines will be summarised and presented to an advisory panel
of nurse continence advisors and clinicians to ensure relevance to clinical practice.
Quantitative papers selected for retrieval will be assessed by two independent
reviewers for methodological validity prior to inclusion in the review using
standardised critical appraisal instruments from the Joanna Briggs Institute Meta
Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix
A). Any disagreements that arise between the reviewers will be resolved through
discussion, or with a third reviewer.
Quantitative data will be extracted from papers included in the review using the
standardised data extraction tool from JBI-MAStARI (Appendix B). The data
extracted will include specific details about the interventions, populations, study
methods and outcomes of significance to the review question and specific objectives.
Quantitative papers will, where possible be pooled in statistical meta-analysis using
JBI-MAStARI. All results will be subject to double data entry. Odds ratio (for
categorical data) and weighted mean differences (for continuous data) and their 95%
confidence intervals will be calculated for analysis. Heterogeneity will be assessed
using the standard Chi-square. Where statistical pooling is not possible the findings
will be presented in narrative form.
[1]     Glazener CM, Evans JH, Peto RE. Alarm interventions for nocturnal enuresis
in children. Cochrane Database Syst Rev. 2005(2):CD002911.
[2]     Caldwell PH, Edgar D, Hodson E, Craig JC. 4. Bedwetting and toileting
problems in children. Med J Aust. 2005 Feb 21;182(4):190-5.
[3]     Bower WF, Moore KH, Shepherd RB, Adams RD. The epidemiology of
childhood enuresis in Australia. Br J Urol. 1996 Oct;78(4):602-6.
[4]     Paediatric Society of New Zealand. Best practice evidence based guideline:
Nocturnal enuresis "Bedwetting". Wellington: New Zealand Guidelines Group; 2005.
[5]     Redsell SA, Collier J. Bedwetting, behaviour and self-esteem: a review of the
literature. Child Care Health Dev. 2001 Mar;27(2):149-62.
[6]      Glazener CM, Evans JH. Desmopressin for nocturnal enuresis in children.
Cochrane Database Syst Rev. 2002(3):CD002112.
[7]     Glazener CM, Evans JH. Simple behavioural and physical interventions for
nocturnal enuresis in children. Cochrane Database Syst Rev. 2004(2):CD003637.
[8]      Glazener CM, Evans JH, Cheuk DK. Complementary and miscellaneous
interventions for nocturnal enuresis in children. Cochrane Database Syst Rev.
[9]     Glazener CM, Evans JH, Peto RE. Drugs for nocturnal enuresis in children
(other than desmopressin and tricyclics). Cochrane Database Syst Rev.
[10] Glazener CM, Evans JH, Peto RE. Tricyclic and related drugs for nocturnal
enuresis in children. Cochrane Database Syst Rev. 2003(3):CD002117.
[11] Glazener CM, Evans JH, Peto RE. Complex behavioural and educational
interventions for nocturnal enuresis in children. Cochrane Database Syst Rev.
[12] Hjalmas K, Arnold T, Bower W, Caione P, Chiozza LM, von Gontard A, et al.
Nocturnal enuresis: an international evidence based management strategy. The
Journal of Urology. 2004 Jun;171(6 Pt 2):2545-61.
[13] Russel K, Kiddoo D. The Cochrane Library and nocturnal enuresis; an
umbrella review. Evidence-Based Child Health. 2006;1:5-8.