Non-Pharmaceutical Therapies for Enuresis
Alternative treatment / complementary therapies Urotherapy Alarm therapy Pelvic floor muscle training Biofeedback Alternative Treatment / Complementary Therapies Minimal advances in this area have been observed. No efficient or direct comparative data are available for any alternative therapies. There are no measurable outcomes data or placebo-controlled data available. Various forms of acupunctu
Alternative treatment / complementary therapies
Alternative Treatment / Complementary Therapies
Minimal advances in this area have been observed. No efficient or direct comparative data are available for any alternative therapies. There are no measurable outcomes data or placebo-controlled data available. Various forms of acupuncture, acupressure, chiropractic therapies and psychotherapies have been trialled. Hypnotherapy has one study indicating efficacy above placebo but below imipramine and alarm therapies (unfortunately not all medical diagnoses were excluded, as they were largely unknown at the time of the study).[43]
Medicinal herbs are regularly used in naturopathic and homeopathic therapies, but no data are available to identify the biochemical action that may constitute cholinergic, antidiuretic and other properties, so no recommended therapies can be brought to the fore in these guidelines.[44,45] These therapies can be seen as complementary. Acupressure has been proven safe in children,[46] while herbal medication still needs several randomised controlled trials to be proven safe for use.
Urotherapy
Urotherapy is part of the conservative adjustments and behavioural modifications that patients and parents can make with support from various health professionals.[20] It is explicitly indicated if dysfunctional voiding is part of the enuresis problem.
Bladder control can be improved in the following three domains:
- increasing the capacity of the bladder
- decreasing urine output at night time
- heightening awareness of the unconscious sensation of bladder filling.
The following techniques can be used:[47]
- increase daytime fluid intake
- reduce night-time fluid intake
- avoid caffeine and drinks with a high sugar content
- empty the bladder regularly
- pre-bedtime voiding
- functional awareness training
- daily bowel movements.
Urotherapy includes the following components:[48]
- demystification and educational information
- scheduled voiding habits
- lifestyle advice, e.g. drinking habits
- voiding posture
- registration of voiding habits and symptoms using a bladder diary or app
- support and feedback from the caregiver.
An improvement took place in >70% of cases when urotherapy was used before initiating pharmacological or alarm therapy.[47]
Alarm therapy
Enuresis alarms, consisting of a moisture sensor and an arousal alarm, work by conditioning the child to wake, get up and void or inhibit bladder contraction in response to a moisture sensor.[30,49] The alarm can be auditory or vibrating in nature (electric shock options are not recommended).[50] The child associates the alarm with a full bladder and will eventually awaken before voiding, breaking the bedwetting cycle.[49] Alarm therapy improves arousal and can increase bladder reservoir function.[49]
Alarm therapy has been reported to achieve impressive success rates of 60 - 80% in various studies; however, there is a 50% relapse rate once it is discontinued.[30,49] Alarm therapy is similarly effective in reducing wet nights compared with DDAVP, as demonstrated in a meta-analysis of randomised trials.[50] Adverse effects of alarm therapy are uncommon and include alarm failure and false alarms.[50] The child’s inability to wake up when the alarm goes off is the most common cause of failure.[49]
Alarm therapy is best suited for children with at least two episodes per week of monosymptomatic NE and with normal or small-capacity bladders.[30,49] This treatment modality needs to be demonstrated to the child and family for best results, and it should be used continuously with minimal interruption.[30] Response to treatment can take 2 - 3 months. This treatment therefore best suits motivated families who agree to active therapy, where immediate improvement is not a priority.[30,49] Withdrawal of alarm therapy is suggested after 2 weeks of consecutive dry nights.[30,49]
The device is often bought commercially, with an average cost between ZAR400 and ZAR4 000. Wireless options are available. Sensor options include pads under the sheets or in the child’s underwear.[49] The alarm has several variations available on the market: a buzzer, a bell, a vibration, or even a visual signal, e.g. light.[50] The alarms can be set to different intensities and tones and operate intermittently or at various intervals.[50] Reviews suggest that an immediate alarm performs better, and that children prefer a bodyworn alarm to a bed pad.[50]
Pelvic floor muscle training
The use of pelvic floor muscle training (PFMT) is based on the hypothesis that daytime and night-time enuresis in children may be due to pelvic floor muscle imbalance between contraction and relaxation and overactivity. Even though PFMT may have a role in NE management, there is no standard exercise protocol (number of repetitions, duration of contraction and relaxation, and length of treatment course). In randomised trials, PFMT increased bladder capacity, but it was not associated with improved enuresis or an improved response rate to subsequent treatment with an enuresis alarm.[54,55] A systematic review of simple behavioural and physical interventions for NE in children found contradicting results of PFMT and concluded that it had no additional effect to standard urotherapy.[25] We believe, based on the literature, that PFMT cannot be used as a single first-line therapy for MSE in children, although it can be one component of multimodal therapy programmes.
Biofeedback[56-58]
Biofeedback is an interactive, non-invasive subset of urotherapy that targets the pelvic floor muscles. It assists in teaching children how to control their lower urinary tract and relax their pelvic floor when voiding. It has been proven effective in treating children with functionally small bladder capacities. This method allows children to retain larger volumes for more extended periods without leakage.
The South African Medical Journal_The South African guidelines on enuresis: 2024 update_November 2024; Vol. 114, No. 11