Treatment Outcomes & Conclusion

Definitions of treatment outcome

Refractory enuresis and treatment of relapse

Conclusion

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Definitions of treatment outcome

As per guidelines outlined by the International Children’s Continence Society (ICCS), treatment with an enuresis alarm should be discontinued if no positive effects are observed within 6 - 8 weeks. In the event of progress during this time frame, the treatment should be discontinued when the child achieves a stretch of 14 consecutive dry nights. If the child fails to reach this milestone after 16 weeks, the treatment can be deemed partially successful if there is a reduction of ≥50% in the frequency of wet nights per week compared with the baseline measurements. Treatment can be tried again after 12 months. Otherwise, treatment is classified as unsuccessful if failure persists.^[91]

The ICCS has also developed standardised definitions for initial and long-term enuresis medical treatment outcomes for research purposes; for clinical purposes, treatment success is determined by the child and the family.^[20]

Initial response:

• no response – <50% reduction in baseline symptom frequency
• partial response – 50 - 99% reduction in baseline symptom frequency
• complete response – 100% reduction in baseline symptom frequency

Long-term outcomes:

• relapse – more than one symptom recurrence per month
• continued success – no relapse within 6 months after interruption of treatment
• complete success – no relapse within 2 years after interruption of treatment.

Refractory enuresis and treatment of relapse

Refractory enuresis is defined as no response to DDAVP therapy and alarm therapy.^[92] Factors that should be explored on history and referred appropriately are listed in Table 1.

A history should always be taken and examination performed prior to investigations. Bladder capacity and voiding pattern may be assessed using uroflow studies and post-void ultrasonography to guide the following line of therapy.

Table 1. Tabulated approach to treatment failure

Enquire about …	Possible causes	Investigations
Adherence to DDAVP and/or alarm therapy	Caregiver fatigue	History
	Slow response
	Adverse effects
Toilet indoors/outdoors	Fear to use the toilet	History
Night light
Family history of enuresis	Delayed maturation	History
Fluid intake at night	Excessive urine production	History
Constipation	Compression on bladder	History
	Bladder and bowel dysfunction
Frequency	Urinary tract infection	Urine dipstick
	OAB	Bladder diary
	Small-capacity bladder	Refer nephrology/urology
Daytime incontinence	CAKUT	Sonar, KUB
	Bladder capacity	VCU may be indicated
		Refer urology
Constant dribbling of urine	Female epispadias	Sonar, KUB
	Ectopic ureter (female)	VCU may be indicated
	Vesicovaginal fistula	Refer urology/nephrology
Secondary enuresis	Psychosocial stressor home or school	Refer psychology
Snoring	Obstructive sleep apnoea	Refer otorhinolaryngology
Polydipsia, polyuria	Diabetes mellitus	Urine dipstick
	Diabetes insipidus	Haemoglucotest
	Renal tubulopathy	Serum sodium
		Urine osmolality
		Refer nephrology
Neurodevelopmental disorders	Delayed maturation	Neurological examination
	Neurogenic bladder	Refer neurodevelopmental specialist[93]
Weight loss or poor growth	Chronic kidney disease	Blood pressure
		Serum creatinine
		Refer nephrology

DDAVP = desmopressin; OAB = overactive bladder; CAKUT = congenital anomalies of kidney and urogenital tract; KUB = kidney ureter bladder X-ray; VCU = voiding cystourethrogram.

Conclusion

NE, particularly MSE, significantly affects the quality of life of affected children, with a prevalence of 14.4% in SA. An updated guideline is proposed, expanding on the previous comprehensive 2017 guideline.^[1]

Recommended links

See pdf document for recommended links on page 15.

Declaration

• This publication is for educational and medical purposes only. The recommendations are based on scientific evidence and author consensus. Adherence is voluntary and does not replace physician judgement. The recommendations do not prescribe specific diagnostic or treatment protocols or serve as the sole standard of care.

Author contributions

• AA: inception, write-up, review, collaboration and submission.
• AB: write-up, review, suggestions and comments.
• FC: write-up, review, suggestions and comments.
• TdM: write-up, review, suggestions and comments.
• MF: write-up, review, suggestions and comments.
• JF: write-up, review, suggestions and comments.
• JJ: write-up, review, suggestions and comments.
• NL: write-up, review, suggestions and comments.
• JL: write-up, review, suggestions and comments.
• SL: write-up, review, suggestions and comments.
• HNL: write-up, review, suggestions and comments.
• SM: write-up, review, suggestions and comments.
• KM: write-up, review, suggestions and comments.
• EMM: write-up, review, suggestions and comments.
• SBAM: write-up, review, suggestions and comments.
• KLP: write-up, review, suggestions and comments.
• MBR: write-up, review, suggestions and comments.
• AvdM: write-up, review, suggestions and comments.
• IvH: write-up, review, suggestions and comments.
• CAZ: write-up, review, suggestions and comments.
• FA: writeup, expert review, suggestions and comments.
• AD: write-up, expert review, suggestions and comments.
• GHHS: write-up, expert review, suggestions and comments.

Funding

• None.

Conflicts of interest

• TdM: Nestle Nutrition Institute for lectures (unrelated to this guideline).
• SBAM: advisor for degarelix (Firmagon, Ferring Pharmaceuticals) (unrelated to this guideline).
• AD: departmental educational grant by Ferring Australia to update enuresis resource kit (unrelated to this updated guideline).

Click here for the pdf.

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  The South African Medical Journal_The South African guidelines on enuresis: 2024 update_November 2024; Vol. 114, No. 11