Primary monosymptomatic nocturnal enuresis is a common condition that can impair the child's psychosocial development. Affected children and parents should be educated about the potential associated problems with enuresis nocturna, associated comorbidities, and the need for treatment. Primary monosymptomatic nocturnal enuresis must be differentiated from non-monosymptomatic nocturnal enuresis.
Nocturnal enuresis is approximately twice as common in boys than girls [7, 8]. In our retrospective analysis, enuresis was found to be more common (60%) in boys than in girls. Similarly, in the study of Oge et al [9] and Ozkan et al [10] enuresis was reported to be detected more frequently in boys than in girls.
In our study, the rate of positive family history was 46.3%. There are studies reporting that children of parents who experience NE are more likely to experience NE [11]. In the study of Oge et al [9], among enuretics and non-enuretics, family history was 40.7% and 9.5%, respectively. In the study of Ozkan et al [10], it was 42% for siblings only and 66% for other family members. Many mothers and fathers did not have enough information about his own and his relatives enuresis history. The answers of families who did not provide clear information were calculated as negative family history. Therefore, we think that this rate may be higher than the detected rate.
When we look at the diseases detected while questioning the anamnesis of the patients, it was seen that the patients followed up with familial mediterranean fever (FMF) were the highest (14.1%, n:17) patient group who presented with the complaint of nocturnal urinary incontinence. No article was found in the literature regarding the relationship between colchicine treatment and enuresis nocturna, but a case of bowel and bladder incontinence developing after colchicine treatment was reported in a case report of an adult patient [12]. Also, detrusor instability has been reported after colchicine treatment, which prevents transmitter release from nerve cells [13]. Only 5 of 17 patients with FMF in our series had a positive family history. This result made us think that colchicine may have an effect on bladder function.
In our patients, the second most common (11.6%) disease after FMF was epilepsy and constipation-encopresis. In Per Edvardsen's study [14]; based on experimental results, the possible etiology of enuresis, the relationship between this disorder and epilepsy, and the emotional changes alleged to occur in enuretic patients were discussed. In another study, the rate of epilepsy in children with NE (2.1%) compared to children without epilepsy (% 0.3) was found to be significantly higher [15].
The relationship between constipation and bladder dysfunction is known, and there are studies reporting its relationship with enuresis [16, 17]. Borgström et al [18] found that fecal disimpaction did not alleviate nocturnal enuresis in children with enuresis and also constipated children. He states that intestinal problems should be addressed, but the child should not be given false hope that this approach alone will dry them out at night. They speculate that evidence-based treatments such as enuresis alarm and desmopressin may be less effective in children with enuresis and constipation unless their intestinal disorders are properly addressed first.
In the study of Durmuş et al [19] it was observed that allergic diseases were observed to be statistically significantly more common in patients with MSE compared to the group without enuresis. In our series, allergic diseases were found to be the third most frequent (8.3%) among the accompanying diseases.
In their study, Balaban et al [20] found that half of the children with NE had significantly higher tonsillar hypertrophy compared to the control group. Another study found a high incidence of attention deficit and hyperactivity disorder (ADHD) and NE symptoms in children with adenoid hypertrophy. Adenotonsillectomy was found to be effective in the improvement of these symptoms [21]. There is no report to compare with in our study. However, when the past surgeries of the patients are questioned, it is seen that the patients who underwent adenoidectomy are the most common. This situation made us think that adenoidectomy may not contribute to the improvement of NE in contrast to the studies reported above. It was found that orchiopexy surgery was performed as a different finding with the second frequency. We think that this is coincidental and has nothing to do with NE.
According to the ICCS, the enuretic child does not need blood tests, radiology or urodynamic evaluation in the absence of certain symptoms (such as voiding difficulties, excessive thirst). The most important comorbid conditions to consider are psychiatric disorders, constipation, urinary tract infections, and snoring or sleep apnea. The first-line treatment modalities in monosymptomatic enuresis are desmopressin or enuresis alarm. If both of these treatments fail, alone or in combination, anticholinergic therapy is a possible next step. Antidepressant therapy may be considered by the specialist if the child is not responding to initial therapy [6].
The literature states that the physical examination of an enuretic child may usually be completely normal or may present findings unrelated to enuresis. It has been reported that in the absence of urinary system complaints in the patient's history, the child can be treated without being initially examined by a doctor [6]. However in our study, it was found that although there was no urinary system pathology, there may be secondary diseases that often accompany. Therefore, the evaluation and treatment of these patients should be do by a specialist physician.
In our study, abnormal findings were found in 117 (13.9%) of the patients with urinary incontinence only in the urinary system USG performed at night. We should state again that these patients did not have any additional complaints such as urgency or difficulty in voiding at their application. Hydronephrosis and increased bladder wall thickness (BWT) were found most frequently (BWT > 4mm). We think that ultrasonography scanning is important in MNE.
Evaluation of bladder capacity is crucial for the diagnosis and monitoring of treatment of specific subtypes of lower urinary tract symptoms. The ICCS recommends the use of frequency /volume charts for this assessment, which must be performed for at least 48 hours to achieve objective results of maximum voiding volume (MVV) [22]. This is quite time consuming and covers the entire weekend for both parents and children. Reliable results can be difficult to obtain, especially in families with low motivation.
In our series, when the highest bladder volume was evaluated in the voiding diary, it was observed that almost more than half of the patients (54.2%) recorded results equivalent to the expected bladder capacity. We think that very productive results can be obtained when the importance of the voiding diary is emphasized to the family.
Uroflowmetry is an alternative non-invasive method for assessing bladder capacity. In the first UFM evaluation performed in our series, it was observed that bladder capacity was measured below the EBC in 547 (65%) patients. We think that physiological bladder filling did not occur with the large amount of fluid consumption in a short time before the UFM, and that the anxiety caused by urinating in the hospital environment in children was effective on the results in UFM. It has been recognized that repetition is needed to improve the accuracy, reliability, and correct interpretation of uroflowmetry [23].
In a study, the hypothesis advocated was that uroflowmetry and 48-hour frequency/volume chart could be used interchangeably when assessing bladder capacity in children with different types of urinary system dysfunction [24]. As a result of the study, both methods were comparable in evaluating maximum bladder capacity for MNE[24[. Hoffmesster et al [25] in their study on frequency/volume charts and uroflowmetry used as measurement methods to evaluate bladder capacity, stated that if the capacity measured by uroflowmetry is between 200 and 450 ml, this corresponds to the correct result. Therefore, in the clinic, uroflowmetry volumes were interpreted as usable for treatment decisions, since the current deviation values would not lead to an abnormal treatment.
We also found that a voiding diary measurement, which was explained correctly to the family, gave more accurate results than the first UFM performed in the laboratory. Therefore, we think that voiding diary may be more reliable in cases where UFM cannot be replicated.
Advice on drinking and voiding habits, use of enuresis alarms, and desmopressin are common treatment options in the treatment of enuresis nocturna [6]. In most cases, MNE can be successfully treated with nocturnal alarm or desmopressin. For desmopressin therapy to be successful, the patient must meet the requirements for response (non MNE) and fully comply with treatment and recommendations regarding administration and food/fluid intake. A surprisingly high proportion of patients initially believed to be resistant to desmopressin are in fact successfully treated with desmopressin monotherapy under specialist care. We applied behavioral therapy, desmopressin acetate to our patients, and combined therapy with anticholinergics in treatment-resistant cases. After the first 3 months of treatment, our dryness rate was satisfactory. We think that the active participation of the family and the child in the treatment process and informing about the disease are important in the success of the treatment.