Pediatric Nephrology

, Volume 32, Issue 5, pp 843–851 | Cite as

Monosymptomatic nocturnal enuresis in pediatric patients: multidisciplinary assessment and effects of therapeutic intervention

  • Simone N. Fagundes
  • Adrienne Surri Lebl
  • Leticia Azevedo Soster
  • Guilherme Jorge Sousa e Silva
  • Edwiges Ferreira de Mattos Silvares
  • Vera H. Koch
Original Article



Few studies manage patients with isolated monosymptomatic enuresis (MNE) with multidisciplinary evaluation and pre- and long-term post-intervention monitoring.


This was a prospective study of MNE patients, aged 6–16 years, diagnosed by multidisciplinary assessment. Of the 140 initial applicants (58.6%) with MNE, 82 were included in the study and randomized for therapeutic intervention in three treatment groups, namely: alarm, desmopressin and alarm + desmopressin. Therapeutic response was evaluated 12 months after treatment withdrawal.


Of the 82 patients [mean age 9.5 (SD ± 2.6) years, n = 62 males (75.6%)], 91.1% had a family history of nocturnal enuresis (NE) in first-/second-degree relatives, 81.7% had constipation and 40.7% had mild-to-moderate apnea. Prior to randomization, management of constipation and urotherapy led to remission in seven of the 82 patients; 75 patients were randomized to intervention. There were 14/75 (18.7%) dropouts during the intervention, especially in the alarm group (p = 0.00). Initial complete/partial response was achieved in 56.6% of the alarm group, 70% of the desmopressin group and 64% in the combined group (p = 0.26). Continued success occurred in 70% of the alarm group, 84.2% of the desmopressin group and 100% of the combined group (p = 0.21). Recurrence occurred in 3/20 (15%) patients in the alarm group and 1/19 (5.2 %) patients of the desmopressin group. Post-intervention Child Behavior Checklist (CBCL) and PedsQL 4.0 scores showed significant improvement.


The three therapeutic modalities were effective in managing MNE with low relapse rates; the alarm group showed the highest dropout rate. Therapeutic success was associated with improvement of behavioral problems and quality of life scores.


Nocturnal monosymptomatic enuresis Children Adolescents Treatment Alarm Desmopressin 



We thank Dr JW Varni for permission to use the Peds QL 4.0 questionnaires and the MAPI Institute for their support, Dr Clarice Tanaka and Rita Pavione from the Department of Physical Therapy, Speech Therapy and Occupational Therapy, University of São Paulo Medical School.

Compliances with ethical standards


Financial support for this study was provided by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) Grant # 2011/17589-1.

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. 1.
    Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W, Jørgensen TM, Rittig S, Walle JV, Yeung CK, Djurhuus JC (2006) The standardization of terminology of lower urinary tract function in children and adolescents: report from the standardisation committee of the international children’s continence society. J Urol 176:314–324CrossRefPubMedGoogle Scholar
  2. 2.
    Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, Rittig S, Walle JV, von Gontard A, Wright A, Yang SS, Nevéus T (2014) The standardization of terminology of lower urinary tract function in children and adolescents: update report from the standardization committee of the international children’s continence society. J Urol 191:1863–1865CrossRefPubMedGoogle Scholar
  3. 3.
    Neveus T, Eggert P, Evans J, Macedo A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L, International Children’s Continence Society (2010) Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the international children’s continence society. J Urol 183:441–447CrossRefPubMedGoogle Scholar
  4. 4.
    Butler RJ, Heron J (2008) The prevalence of infrequent bedwetting and nocturnal enuresis in childhood. A large British cohort. Scand J Urol Nephrol 42:257–264CrossRefPubMedGoogle Scholar
  5. 5.
    Neveus T (2011) Nocturnal enuresis-theoretic background and practical guidelines. Pediatr Nephrol 26:1207–1214CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    von Gontard A, Niemczyk J, Weber M, Equit M (2015) Specific behavioral comorbidity in a large sample of children with functional incontinence: report of 1,001 cases. Neurourol Urodyn 34:763–768CrossRefGoogle Scholar
  7. 7.
    Yeung CK, Sihoe JD, Sit FK, Bower W, Sreedhar B, Lau J (2004) Characteristics of primary nocturnal enuresis in adults: an epidemiological study. BJU Int 93:341–345CrossRefPubMedGoogle Scholar
  8. 8.
    Schaumburg HL, Kapilin U, Blåsvaer C, Eiberg H, von Gontard A, Djurhuus JC, Rittig S (2008) Hereditary phenotypes in nocturnal enuresis. BJU Int 102:816–821CrossRefPubMedGoogle Scholar
  9. 9.
    Caldwell PH, Nankivell G, Sureshkumar P (2013) Simple behavioural interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 7:CD003637Google Scholar
  10. 10.
    Perrin N, Sayer L, While A (2013) The efficacy of alarm therapy versus desmopressin therapy in the treatment of primary mono-symptomatic nocturnal enuresis: a systematic review. Prim Health Care Res Dev 19:1–11Google Scholar
  11. 11.
    Leebeek-Groenewegen A, Blom J, Sukhai R, Van Der Heijden B (2001) Efficacy of desmopressin combined with alarm therapy for monosymptomatic nocturnal enuresis. J Urol 166:2456–2458CrossRefPubMedGoogle Scholar
  12. 12.
    Nascimento Fagundes S, Azevedo Soster L, Lebl AS, Rodrigues Pereira RP, Tanaka C, Pereira RF, Ferreira de Mattos Silvares E, Koch VH (2016) Impact of a multidisciplinary evaluation in pediatric patients with nocturnal monosymptomatic enuresis. Pediatr Nephrol 31:1295–1303CrossRefPubMedGoogle Scholar
  13. 13.
    Berry RB, Brooks R, Gamaldo CE, Harding SM, Marcus CL, Vaughn BV; for the American Academy of Sleep Medicine (2012) The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, version 2.0. American Academy of Sleep Medicine, Darien.
  14. 14.
    Santos EOL, Silvares EFM (2006) Enuretical children and referred children for university mental health services: a comparative study of their parents’ perception. Psicol Reflex Crit 19:277–282CrossRefGoogle Scholar
  15. 15.
    Achenbach TM, Rescorla LA (2001) Manual for the ASEBA school—age forms and profiles. University of Vermont, Research Center for Children, Youths, and Families, BurlingtonGoogle Scholar
  16. 16.
    Klatchoian DA, Len CA, Terreri MT, Silva M, Itamoto C, Ciconelli RM, Varni JW, Hilário MO (2008) Quality of life of children and adolescents from São Paulo: reliability and validity of the Brazilian version of the pediatric quality of life inventory version 4.0 generic core scales. J Pediatr 84:308–315CrossRefGoogle Scholar
  17. 17.
    Marschall-Kehrel D, Harms TW (2009) Structured desmopressin withdrawal improves response and treatment outcome for monosymptomatic enuretic children. J Urol 182[4 Suppl]:2022–2026Google Scholar
  18. 18.
    Young GC, Morgan RTT (1972) Overlearning in the conditioning treatment of enuresis. Behav Res Ther 10:147–151CrossRefPubMedGoogle Scholar
  19. 19.
    Butler RJ (2004) Childhood nocturnal enuresis: developing a conceptual framework. Clin Psychol Rev 24:909–931CrossRefPubMedGoogle Scholar
  20. 20.
    Fai-Ngo Ng C, Wong SN, Hong Kong Childhood Enuresis Study Group (2005) Comparing alarms, desmopressin, and combined treatment in Chinese enuretic children. Pediatr Nephrol 20:163–169CrossRefPubMedGoogle Scholar
  21. 21.
    Ahmed AF, Amin MM, Ali MM, Shalaby EA (2013) Efficacy of an enuresis alarm, desmopressin, and combination therapy in the treatment of saudi children with primary monosymptomatic nocturnal enuresis. Korean J Urol 54:783–790CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Deshpande AV, Caldwell PH, Sureshkumar P (2012) Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics). Cochrane Database Syst Rev 12:CD002238Google Scholar
  23. 23.
    Naseri M, Hiradfar M (2012) Monosymptomatic and non-monosymptomatic nocturnal enuresis: a clinical evaluation. Arch Iran Med 15:702–706PubMedGoogle Scholar
  24. 24.
    Yeung CK, Sreedhar B, Sihoe JD, Sit FK, Lau J (2006) Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int 97:1069–1073CrossRefPubMedGoogle Scholar
  25. 25.
    Rawashdeh YF, Hvistendahl GM, Kamperis K, Hansen MN, Djurhuus JC (2002) Demographics of enuresis patients attending a referral centre. Scand J Urol Nephrol 36:348–353CrossRefPubMedGoogle Scholar
  26. 26.
    Van Herzeele C, Evans J, Eggert P, Lottmann H, Norgaard JP, Vande Walle J (2015) Predictive parameters of response to desmopressin in primary nocturnal enuresis. J Pediatr Urol 11:200.e1-8CrossRefPubMedGoogle Scholar
  27. 27.
    Fergusson DM, Horwood LJ (1994) Nocturnal enuresis and behavioral problems in adolescence: a 15-year longitudinal study. Pediatrics 94:662–668PubMedGoogle Scholar
  28. 28.
    Vaz GT, Vasconcelos MM, Oliveira EA, Ferreira AL, Magalhães PG, Silva FM, Lima EM (2012) Prevalence of lower urinary tract symptoms in school-age children. Pediatr Nephrol 27:597–603CrossRefPubMedGoogle Scholar
  29. 29.
    Mota DM, Barros AJ, Matijasevich A, Santos IS (2015) Prevalence of enuresis and urinary symptoms at age 7 years in the 2004 birth cohort from Pelotas, Brazil. J Pediatr (Rio J) 91:52–58CrossRefGoogle Scholar
  30. 30.
    Azevedo Soster L, Alves R, Fagundes SN, Koch VH, Bruni O (2016) Sleep disturbances associated with sleep enuresis: a questionnaire study. Eur J Paediatr Neurol 20:282–285CrossRefPubMedGoogle Scholar
  31. 31.
    Glazener CMA, Evans JHC, Peto RE (2005) Alarm interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2:CD002911Google Scholar
  32. 32.
    Glazener CM, Evans JH (2002) Desmopressin for nocturnal enuresis in children. Cochrane Database Syst Rev 3:CD002112Google Scholar
  33. 33.
    Silvares EFM, Pereira RF (2012) Adesão em saúde e psicoterapia: conceituação e aplicação na enurese noturna. Psicologia USP, São Paulo 23:539–557CrossRefGoogle Scholar
  34. 34.
    Baeyens D, Lierman A, Roeyers H, Hoebeke P, Walle JV (2009) Adherence in children with nocturnal enuresis. J Pediatr Urol 5:105–109CrossRefPubMedGoogle Scholar
  35. 35.
    Van Herzeele C, Alova I, Evans J, Eggert P, Lottmann H, Nørgaard JP, Vande Walle J (2009) Poor compliance with primary nocturnal enuresis therapy may contribute to insufficient desmopressin response. J Urol 182[4 Suppl]:2045–2049CrossRefPubMedGoogle Scholar
  36. 36.
    Ferrara P, Del Volgo V, Romano V, Scarpelli V, De Gara L, Miggiano GA (2015) Combined dietary recommendations, desmopressin, and behavioral interventions may be effective first-line treatment in resolution of enuresis. Urol J 12:2228–2232PubMedGoogle Scholar
  37. 37.
    Toktamis A, Demirel Y, Ozkan KU, Garipardiç M, Gözüküçük A, Nur N (2008) Prevalence and associated factors of day wetting and combined day and night wetting. Urol Int 81:54–59CrossRefPubMedGoogle Scholar
  38. 38.
    Rocha MM, Costa NJ, Silvares EFM (2008) Changes in parents’ and self-reports of behavioral problems in Brazilian adolescents after behavioral treatment with urine alarm for nocturnal enuresis. Int Braz J Urol 34:749–757CrossRefPubMedGoogle Scholar
  39. 39.
    Van Hoecke E, De Fruyt F, De Clercq B, Hoebeke P, Vande Walle J (2006) Internalizing and externalizing problem behavior in children with nocturnal and diurnal enuresis: a five-factor model perspective. J Pediatr Psychol 31:460–468CrossRefPubMedGoogle Scholar
  40. 40.
    HiraSing RA, van Leerdam FJ, Bolk-Bennink LF, Koot HM (2002) Effect of dry bed training on behavioural problems in enuretic children. Acta Paediatr 91:960–964CrossRefPubMedGoogle Scholar
  41. 41.
    Longstaffe S, Moffatt ME, Whalen JC (2000) Behavioral and self-concept changes after six months of enuresis treatment: a randomized, controlled trial. Pediatrics 105:935–940PubMedGoogle Scholar
  42. 42.
    Kilicoglu AG, Mutlu C, Bahali MK, Adaletli H, Gunes H, Metin Duman H, Toz HI, Uneri OS (2014) Impact of enuresis nocturna on health-related quality of life in children and their mothers. J Pediatr Urol 10:1261–1266CrossRefPubMedGoogle Scholar
  43. 43.
    Lopes M, Ferraro A, Koch VH (2014) Health-related quality of life of children and adolescents with CKD stages 4–5 and their caregivers. Pediatr Nephrol 29:1239–1247CrossRefPubMedGoogle Scholar
  44. 44.
    Üçer O, Gümüş B (2014) Quantifying subjective assessment of sleep quality, quality of life and depressed mood in children with enuresis. World J Urol 32:239–243CrossRefPubMedGoogle Scholar

Copyright information

© IPNA 2016

Authors and Affiliations

  • Simone N. Fagundes
    • 1
  • Adrienne Surri Lebl
    • 1
  • Leticia Azevedo Soster
    • 2
  • Guilherme Jorge Sousa e Silva
    • 1
    • 3
  • Edwiges Ferreira de Mattos Silvares
    • 3
  • Vera H. Koch
    • 1
    • 4
  1. 1.Department of Pediatrics - Instituto da CriançaUniversity of São Paulo Medical SchoolSão PauloBrazil
  2. 2.Pediatric Sleep Laboratory, Instituto da Criança Hospital das ClinicasUniversity of São Paulo Medical SchoolSão PauloBrazil
  3. 3.Clinical Psychology Department of São Paulo UniversitySão PauloBrazil
  4. 4.Pediatric Nephrology Unit, Instituto da Criança Hospital das ClinicasUniversity of São Paulo Medical SchoolSão PauloBrazil

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