FISIOPATOLOGIA ENURESIS PDF

Language: English Portuguese. To compare the results of the standard urotherapy alone and associated with pelvic floor muscle training alone, and in combination with oxybutynin in treatment of nonmonosymptomatic nocturnal enuresis. The assessment tools used were playful bladder diary, and a hour bladder diary, before and after treatment. After 2 years, patients were assessed by telephone using a standardized questionnaire.

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Language: English Portuguese. To compare the results of the standard urotherapy alone and associated with pelvic floor muscle training alone, and in combination with oxybutynin in treatment of nonmonosymptomatic nocturnal enuresis. The assessment tools used were playful bladder diary, and a hour bladder diary, before and after treatment.

After 2 years, patients were assessed by telephone using a standardized questionnaire. The data of children from the three groups were homogeneous at baseline. After week treatment, all children showed improved symptoms and signs of nonmonosymptomatic nocturnal enuresis, but the differences were not significant among the groups.

After 2 years, the three groups showed maintenance of treatment results, but no differences among them. All treatment modalities were effective regarding improved enuresis and lower urinary tract symptoms, but the sample was not large enough to show differences among groups.

Approximately 0. Its cause is defined as immaturity of the nervous systems. When the child presents enuresis associated with LUTS, such as increased voiding frequency, incontinence, urgency, nocturia, hesitancy, straining, weak stream, intermittency and dysuria, is defined as non-monosymptomatic nocturnal enuresis NMNE ; when enuresis is not associated with LUTS it is defined as monosymptomatic.

Conservative treatments are recommended as first line, although authors warn that this guideline is not a systematic review, but it is based on good practices due to the lack of scientific evidence in this filed.

Urotherapy is defined by ICCS, and divided into two modalities: standard therapy, including information about lower urinary tract function, behavioral modification, lifestyle advice, registration of symptoms and voiding habits, and regular support by caregivers.

The other modality of urotherapy consists of specific interventions, including pelvic floor muscle training PFMT. Only three studies were found in the literature on conservative treatment of NMNE; two are retrospective and the third is a randomized controlled trial.

A more recent retrospective study investigated the effects of 6-month PFMT in treatment of NMNE, and found a significant improvement in the associated symptoms of enuresis, urinary incontinence, dysuria, urgency, urge incontinence, and holding maneuvers.

Antimuscarinic drugs are employed in the treatment of LUTS with encouraging results, 3 as reported by Campos et al. The PFMT group showed better results in the reduction of incontinence episodes. Although the studies to date have shown encouraging results with conservative treatments, several therapeutic modalities were used at the same time, and no individual conclusion can be drawn about how much each modality can contribute to the management of NMNE.

To analyze the results of behavioral therapy, urotherapy, and urotherapy combined with oxybutynin; compare the efficacy of three treatment modalities; and verify the influence of time in each modality, in nonmonosymptomatic enuresis patients.

This clinical trial was registered under the number CAAE: The inclusion criteria were children with nocturnal enuresis and LUTS assessed by a hour bladder diary , aged 5 to 10 years, no previous bladder surgery, availability to attend treatment sessions, and no urinary tract infection, confirmed by laboratory tests.

The exclusion criteria comprised unsigned informed consent, presence of neurogenic bladder, and prior urotherapy. A playful diary was used as primary tool to evaluate the effect of treatment in NMNE. The data were collected 7 days before treatment and later, monthly, until completing 12 weeks of treatment. The playful bladder diary consisted of coloring every day a sun for dry nights, or a cloud for wet nights Figure 1. The child was instructed to color the figures alone, but the assistance of parents was allowed in case of doubts.

A hour bladder diary was used as an inclusion criterion to screen patients with LUTS, and as secondary assessment tool. Two years after the end of treatment, the participants were assessed by telephone about LUTS, using a specific questionnaire. The children were encouraged to avoid soft drinks at night and, if possible, drink them only on weekends.

Juices were allowed during the day, and caffeinated drinks were allowed only in the morning. Besides the standard urotherapy, Groups II and III performed PFMT and were instructed to perform a proper pelvic floor muscle contraction, without contracting the hip muscles or gluteus. In a supine position, they performed 2 series of 10 maximal effort pelvic floor muscle contractions, totaling up 20 contractions per session.

Electromyography biofeedback was used to assist participants and provide motivation. Montreal, Canada. All participants were instructed to repeat the same series of ten maximal effort pelvic floor muscle contractions, as learned during the intervention, three times a day, at home. Does your child leak, or wet, their underwear during the day? Information about the presence, or not, of incontinence.

Does your child leak while sleeping? Information about the presence, or not, of enuresis. Information about the presence, or not, of encopresis.

Does your child defecate every day? Information about the presence, or not, of constipation. Does your child have a sudden desire to void? Information about the presence, or not, of urgency. How many times your child urinate during the day?

Information about the presence, or not, of urinary frequency. Does your child cross legs or squat when fell desire to pass urine? Information about the presence, or not, of holding maneuvers. A pilot study was carried out for power calculation, and the three groups were compared according to number of colored suns at the playful bladder diary. Sixteen patients were required for each group. Due to the lack of normal distribution of the variables, non-parametric tests were used.

Mann-Whitney test was used to compare baseline measures. To compare outcomes before and after the intervention in each group, a Kruskal-Wallis test was used. To compare treatment outcomes among the three groups, variables were transformed into ranks and repeated-measures analysis of variance ANOVA was used. After treatment, the number of participants presenting dry nights and symptoms was transformed into percentage, so as to follow the ICCS recommendation of treatment outcome. Out of 62 eligible children 38 participated in this study.

Fourteen patients were excluded because they could not attend sessions once a week, eight children refused to participate, and two caregivers refused to fill in the bladder diaries.

Thus, the 38 remaining patients included in this study were divided into three groups: Group I had 12 subjects 8 girls and 4 boys; median age 9. No differences were found in relation to age, sex and baseline symptoms, assessed by the two bladder diaries among the three groups.

The results of the playful bladder diary are showed in figure 3 , and the results of 48 hours bladder diary is showed in table 1. At the end of 12 weeks of treatment, children were classified according to the ICCS recommendation for therapeutic success.

Only those showing no enuresis were considered as complete success of treatment, and the results are showed in table 2. There was no significant difference among the groups as to number of children presenting complete success. Two years after the end of the treatment, the results of questions made over the telephone are summarized in table 3.

The three groups showed no significant difference in the initial phase. After 12 weeks of treatment, there was a significant difference in relation to the treatment time 0. The results showed that standard urotherapy alone or in combination with PFMT alone, or also in combination with oxybutynin, is effective in treatment of NMNE. The only study found in literature investigating the effect of standard urotherapy in children with monosymptomatic enuresis and NMNE was conducted by Mulders et al.

This study corroborates the findings of improvement LUTS in response to this treatment. Pelvic floor muscle training is a specific urotherapy intervention, and is known to improve LUTS symptoms in adults. Although the benefits of PFM rehabilitation in adults have been well described, little is known about this modality of treatment for children with LUTS.

The results of this study showed that PFMT had no additional effect to standard urotherapy, probably because this modality also has a positive impact on the pelvic floor muscle function, 7 relaxing them while leading to a proper bladder empting.

Furthermore, reduced caffeine intake is known to improve LUTS symptoms. Antimuscarinic drugs comprise a class that effectively and safely treats children with LUTS.

In this study, the group with standard urotherapy associated with PFMT and oxybutynin had better results in the reduction of enuresis, but they were not significant. This study is limited to assessment tools. If an invasive evaluation were used, such as an urodynamic study, more variables would be collected and differences among the treatments would be detected. In addition, the hour bladder diary was initially used as an inclusion criterion, and assessed again only 2 years after the end of treatment.

If assessed right after the end of treatment, it would probably give relevant information. Even so, the results of this follow-up assessment will help future research, by showing that, even with the end of intervention, the changes provided by treatment continued to improve LUTS of these children.

The three treatment modalities used in this study showed encouraging results when used alone; thus, it is believed that the combination of these therapies would provide greater benefits in the treatment of NMNE. All treatment modalities were effective in the treatment of nonmonosymptomatic nocturnal enuresis, and this corroborates the previous studies, but a larger sample size is needed to be able to detect differences among groups treated with combined treatments.

Only duration of treatment was significant for improvement of non-monosymptomatic enuresis. National Center for Biotechnology Information , U. Journal List Einstein Sao Paulo v. Einstein Sao Paulo. Published online Jun Find articles by Renata Martins Campos. Find articles by Claudia Rosenblatt Hacad. Find articles by Maria Carolina Ramos Perissinotto. Author information Article notes Copyright and License information Disclaimer.

Received May 28; Accepted Dec Copyright notice. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract Objective To compare the results of the standard urotherapy alone and associated with pelvic floor muscle training alone, and in combination with oxybutynin in treatment of nonmonosymptomatic nocturnal enuresis. Results The data of children from the three groups were homogeneous at baseline. Conclusion All treatment modalities were effective regarding improved enuresis and lower urinary tract symptoms, but the sample was not large enough to show differences among groups.

Objective To analyze the results of behavioral therapy, urotherapy, and urotherapy combined with oxybutynin; compare the efficacy of three treatment modalities; and verify the influence of time in each modality, in nonmonosymptomatic enuresis patients.

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