![]() By doing this I do not mean neither to polemize or criticize the experts nor distance myself from my contribution to the current guideline documents but, hopefully, to underline fields needing more research and to suggest ways that-pending that research-enuresis management may be simplified, at least outside the university setting. The aim of this review is to scrutinize some of the central assumptions underlying modern enuresis management. These assumptions are not by any means unreasonable, just not properly tested. Much of what we now do is (still) based not on firm evidence but on experience and assumptions. ![]() The new prevailing strategy for the management of children with enuresis is surely a great step forward compared with the views of several decades ago, but there are still problems. Anticholinergics and tricyclic antidepressants are recommended as second- and third-line therapies, respectively ( 5). For other enuretic children, and for those still wet after urotherapy, either desmopressin or the enuresis alarm are recommended. Likewise, treatment of concomittant constipation is recommended ( 9). This is recommended to be the first-line therapy at least for children with NMNE ( 5, 7). Instead the recommendation is often given that the LUT function of these children be “normalised” by the institution of regular drinking ( 10) and voiding habits and correct voiding posture: i.e., basic urotherapy ( 5, 6). Neither is psychotherapy advocated as a primary (or indeed secondary) therapy. Nowadays, children with enuresis are expected to be taken seriously and the wait-and-see attitude is no longer accepted, at least for children aged six years or more. The need to screen all enuretic children for behavioral issues and signs of neuropsychiatric disorders is also underlined ( 4, 13). Signs of constipation are also actively sought for ( 7), using the Rome IV criteria ( 12). Based on the anamnesis and the voiding charts the children are subdivided into monosymptomatic and nonmonosymptomatic groups, the latter having concomittant daytime lower urinary tract (LUT) symptoms and/or a daytime micturition frequency that is regarded as abnormal ( 11). The children are instructed to complete voiding charts, recording daytime voiding frequency and voided volumes as well as nocturnal urine production ( 10). Now, the evaluation of the enuretic child is heavily focused on the bladder and on urine production. ![]() The recommended strategy for managing these children has changed accordingly, as reflected by international guidelines ( 5– 10). And the link between enuresis and psychiatric/psychological issues is due to on the one hand poor self esteem, casued by the wetting ( 3), and on the other an overrepresentation of children with neuropsychiatric disorders such as attention-deficit/hyperactivity disorder (ADHD) ( 4). Enuresis is familial in the majority of cases and caused by various combinations of nocturnal polyuria, nocturnal detrusor overactivity and high arousal thresholds ( 2). Until the 1980s the evaluation of bedwetting children was focused on behavior, early trauma and other psychological factors, and therapy-if any therapy was advocated-was usually psychotherapy in various forms.īut since the seminal work in the late 80s by the Aarhus group we know more ( 1). More research is obviously needed, but awaiting new results enuresis management could be substantially simplified.Įnuresis used to be viewed as a purely psychiatric disorder. Some advice and therapies are probably ineffective whereas for other treatments we lack reliable predictors of treatment response. In this review I will argue that much of what we do with these children is based more on experience and well-meant but poorly supported assumptions than on evidence. Urotherapy is a first-line treatment against enuresis.Concomittant constipation needs to be successfully treated before addressing the enuresis.Concomittant daytime incontinence needs to be successfully treated before addressing the enuresis.All children with enuresis need to be screened for behavioral or psychiatric issues.Voiding charts are crucial in the primary evaluation of the enuretic child.It is important to subdivide enuresis according to the presence of daytime symptoms.In this review I will question the following commonly made assumptions regarding enuresis evaluation and treatment: ![]() Still, there are large gaps in our knowledge and large parts of modern enuresis management guidelines are (still) not based on firm evidence. Much has happened since the end of the era when enuresis was blamed on the parents or the children themselves. Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
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