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No effect of basic bladder advice in enuresis: A randomized controlled trial
By M. Cederblad, A. Sarkadi, G. Engvall, and T. Nevéus
Journal of Pediatric Urology, Volume 11, Issue 3, June 2015, Pages 153.e1–153.e5
Good science is based on questioning why we do things the way we do. This study investigated the effect of “empathic doctoring advice”, such as daytime voiding and drinking advice for children with nocturnal enuresis. The results of the study confirm what we clinically suspect: daytime voiding and drinking recommendations do not influence the number of wet nights, nor do they improve the success of subsequent alarm therapy.
There are two firstline, evidence-based treatments available for nocturnal enuresis: desmopressin and the enuresis alarm. Prior to use of these therapies, international experts usually recommend that the children also be given basic bladder training during the daytime. The rationale behind this recommendation is that daytime bladder training or urotherapy, is a mainstay in the treatment of daytime incontinence caused by detrusor overactivity. Still, there is, as yet, no firm evidence that daytime bladder training is useful against nocturnal enuresis.
To explore whether basic bladder advice has any effect against nocturnal enuresis. Study design The study was prospective, randomized, and controlled. The evaluated intervention was bladder advice, given in accordance with ICCS guidelines and focused on regular voiding, sound voiding posture, and sufficient fluid intake. Forty children aged 6 years or more with previously untreated enuresis, but no daytime incontinence, were randomized (20 in each group) to receive either first basic bladder advice for 1 month and then alarm therapy (group A) or just the alarm therapy (group B). Based on power calculations, the minimum number of children required in each treatment arm was 15.
The basic bladder advice did not reduce the enuresis frequency in group A (p = 0.089) and the end result after alarm therapy did not differ between the two groups (p = 0.74) (see Table). Only four children in group A had a partial or full response to bladder training, and two of these children relapsed immediately during alarm therapy.
This was the first study to evaluate, in a prospective, randomized manner, the value of daytime basic bladder training as a treatment of enuresis. It was found that the treatment neither resulted in a significant reduction in the number of wet nights, nor did it improve the success of subsequent alarm therapy.
The recommendation that all children with enuresis be given bladder training as a firstline therapy can no longer be supported. Instead, we recommend that treatment of these children start with the enuresis alarm or desmopressin without delay. Number of wet nights out of 14 before, during, and after the study. BaselineAfter bladder adviceAfter alarm treatmentGroup A (n = 20)8-14, median 14 (11.9 ± 2.5)0-14, median 13.5 (10.5 ± 4.8)0-14, median 4.5 (5.6 ± 5.36)Group B (n = 20)8-14, median 14 (12.6 ± 2.3)0-14, median 2.5 (4.85 ± 5.38)