European Child & Adolescent Psychiatry

, Volume 27, Issue 8, pp 949–964 | Cite as

Standard urotherapy as first-line intervention for daytime incontinence: a meta-analysis

  • S. K. SchäferEmail author
  • J. Niemczyk
  • A. von Gontard
  • M. Pospeschill
  • N. Becker
  • M. Equit


According to the International Children’s Continence Society (ICCS) guidelines for the treatment of daytime urinary incontinence (DUI) in children and adolescents, the first-line intervention for all types of DUI is standard urotherapy (SU). Despite this recommendation there is still no meta-analysis available on the effectiveness of SU. The aim of this study is to provide a meta-analytic evaluation of the intervention. This meta-analysis is based on Odds Ratios (OR) and consists of 26 patient samples out of 19 studies (N = 1609), collected from well-established medical databases. Remission rates after SU are compared to spontaneous remission rates, which are matched to the individual follow-up period. The meta-analysis shows that SU is an effective treatment of DUI. Compared to a spontaneous remission rate of 15.40% per year, urotherapy increases the probability to recover by a factor of 7.27 (6.57 if corrected for publication bias). After exclusion of three outlying samples this effect can be generalized for all types of SU and all patient populations. Moderator analyses cannot identify variables which significantly influence the variance of effect sizes. However, RCTs seem to be associated with lower effects, even when the control group is not considered for effect size calculation. Based on the present meta-analysis, SU is an effective intervention for treating DUI in children and adolescents. Of 100 patients in 1 year, approximately 56 patients (54 if corrected for publication bias) remit after being treated with SU, while only 15 out of 100 remit spontaneously. However, to further quantify the effect size of SU in comparison to spontaneous remission rates and other treatments, additional RCTs are still needed.


Daytime urinary incontinence DUI Children Standard urotherapy Meta-analysis 



Confidence interval


Daytime urinary incontinence


Dysfunctional voiding


International Children’s Continence Society


Prior management of bowel symptoms


Odds ratio


Randomized controlled trial


Standard urotherapy


Transcutaneous electrical nerve stimulation


Underactive bladder


Urge incontinence


Voiding postponement



The authors would like to thank everyone who contributed to this meta-analysis with advice and fruitful comments on clinical or methodological aspects. In particular, they thank the anonymous reviewer for the valuable comments on earlier versions of this article. They also thank all researchers, who contributed to the meta-analysis by sending additional information on published and unpublished trials.

Compliance with ethical standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Supplementary material

787_2017_1051_MOESM1_ESM.pdf (88 kb)
Online Resource 1 List of references used in both meta-analyses (spontaneous remission rate and SU) (PDF 87 kb)
787_2017_1051_MOESM2_ESM.pdf (76 kb)
Online Resource 2 Modified version for single use in “Standard urotherapy as first-line intervention for daytime incontinence: a meta-analysis” (PDF 76 kb)


  1. 1.
    Swithinbank LV, Heron J, von Gontard A, Abrams P (2010) The natural history of daytime urinary incontinence in children: a large british cohort. Acta Paediatr 99:1031–1036. doi: 10.1111/j.1651-2227.2010.01739.x CrossRefPubMedGoogle Scholar
  2. 2.
    Joinson C, Sullivan S, von Gontard A, Heron J (2016) Early childhood psychological factors and risk for bedwetting at school age in a UK cohort. Eur Child Adolesc Psychiatry 25:519–528CrossRefPubMedGoogle Scholar
  3. 3.
    Joinson C, Heron J, von Gontard A, Butler U, Golding J, Emond A (2008) Early childhood risk factors associated with daytime wetting and soiling in school-age children. J Pediatr Psychol 33:739–750CrossRefPubMedGoogle Scholar
  4. 4.
    Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, Rittig S, Vande Walle J, 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(1863–1865):e13. doi: 10.1016/j.juro.2014.01.110 CrossRefGoogle Scholar
  5. 5.
    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 (2016) 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. Neurourol Urodyn 35:471–481. doi: 10.1002/nau.22751 CrossRefPubMedGoogle Scholar
  6. 6.
    Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W, Jørgensen TM, Rittig S, Walle JV, Yeung C-K, 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 176:314–324. doi: 10.1016/S0022-5347(06)00305-3 CrossRefPubMedGoogle Scholar
  7. 7.
    Chase J, Austin P, Hoebeke P, McKenna P, International Children’s Continence Society (2010) The management of dysfunctional voiding in children: a report from the standardisation committee of the international children’s continence society. J Urol 183:1296–1302. doi: 10.1016/j.juro.2009.12.059 CrossRefGoogle Scholar
  8. 8.
    von Gontard A, Niemczyk J, Wagner C, Equit M (2016) Voiding postponement in children—a systematic review. Eur Child Adolesc Psychiatry 25:809–820. doi: 10.1007/s00787-015-0814-1 CrossRefGoogle Scholar
  9. 9.
    Chang S-J, Van Laecke E, Bauer SB, von Gontard A, Bagli D, Bower WF, Renson C, Kawauchi A, Yang SS-D (2015) Treatment of daytime urinary incontinence: a standardization document from the international children’s continence society. Neurourol Urodyn. doi: 10.1002/nau.22911 CrossRefPubMedGoogle Scholar
  10. 10.
    Hellström A-L, Hjälmås K, Jodal U (1987) Rehabilitation of the dysfunctional bladder in children: method and 3-year followup. J Urol 138:847–849CrossRefPubMedGoogle Scholar
  11. 11.
    Kuwertz-Bröking E, von Gontard A (2015) S2 k-leitlinie: enuresis und nicht-organische (funktionelle) harninkontinenz bei kindern und jugendlichen. arbeitsgemeinschaft für wissenschaftliche und medizinische fachgesellschaftenGoogle Scholar
  12. 12.
    Hoebeke P (2006) Twenty years of urotherapy in children: what have we learned? Eur Urol 49:426–428. doi: 10.1016/j.eururo.2005.12.033 CrossRefPubMedGoogle Scholar
  13. 13.
    Sambach H, Equit M, El Khatib D, Schreiner-Zink S, Von Gontard A (2011) Therapieresistente Harninkontinenz und Enuresis. Monatsschr Kinderheilkd 159:565–571. doi: 10.1007/s00112-011-2383-9 CrossRefGoogle Scholar
  14. 14.
    Mulders M, Cobussen-Boekhorst H, De Gier R, Feitz W, Kortmann B (2011) Urotherapy in children: quantitative measurements of daytime urinary incontinence before and after treatment: according to the new definitions of the international children’s continence society. J Pediatr Urol 7:213–218. doi: 10.1016/j.jpurol.2010.03.010 CrossRefPubMedGoogle Scholar
  15. 15.
    Zivkovic V, Milica L, Stanković I, Marina V, Andjelka S (2011) The evaluation of combined standard urotherapy, abdominal and pelvic floor retraining in children with dysfunctional voiding. J Pediatr Urol 7:336–341CrossRefGoogle Scholar
  16. 16.
    Deeks JJ, Higgins JP, Altman DG (2008) Analysing data and undertaking meta-analyses. In: Fellow JPHSSV, Director SGF (eds) Cochrane Handb. Syst. Rev. Interv. Wiley, New York, pp 243–296Google Scholar
  17. 17.
    van Gool JD, de Jong TP, Winkler-Seinstra P, Tamminen-Möbius T, Lax H, Hirche H, Nijman RJ, Hjälmås K, Jodal U, Bachmann H, Hoebeke P, on behalf of the European Bladder Dysfunction Study (EU BMH1-CT94-1006) (2014) Multi-center randomized controlled trial of cognitive treatment, placebo, oxybutynin, bladder training, and pelvic floor training in children with functional urinary incontinence. Neurourol Urodyn 33:482–487. doi: 10.1002/nau.22446 CrossRefPubMedGoogle Scholar
  18. 18.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. doi: 10.1371/journal.pmed.1000100 CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Maternik M, Krzeminska K, Zurowska A (2015) The management of childhood urinary incontinence. Pediatr Nephrol 30:41–50. doi: 10.1007/s00467-014-2791-x CrossRefPubMedGoogle Scholar
  20. 20.
    Sureshkumar P, Bower W, Craig JC, Knight JF (2003) Treatment of daytime urinary incontinence in children: a systematic review of randomized controlled trials. J Urol 170:196–200. doi: 10.1097/01.ju.0000072341.34333.43 CrossRefPubMedGoogle Scholar
  21. 21.
    Field AP, Gillett R (2010) How to do a meta-analysis. Br J Math Stat Psychol 63:665–694. doi: 10.1348/000711010X502733 CrossRefPubMedGoogle Scholar
  22. 22.
    Development Core Team R (2015) R: a language and environment for statistical computing. R Foundation for Statistical Computing, ViennaGoogle Scholar
  23. 23.
    Viechtbauer W (2010) Conducting meta-analyses in R with the metafor package. J Stat Softw 36:1–48CrossRefGoogle Scholar
  24. 24.
    Higgins JPT, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558. doi: 10.1002/sim.1186 CrossRefPubMedGoogle Scholar
  25. 25.
    Higgins JPT, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560. doi: 10.1136/bmj.327.7414.557 CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Viechtbauer W, Cheung MW-L (2010) Outlier and influence diagnostics for meta-analysis. Res Synth Methods 1:112–125. doi: 10.1002/jrsm.11 CrossRefPubMedGoogle Scholar
  27. 27.
    Cook RD, Weisberg S (1982) Residuals and influence in regression. Chapman and Hall, New YorkGoogle Scholar
  28. 28.
    Wells G, Shea B, O’connell D, Peterson J, Welch V, Losos M, Tugwell P (2013) The Newcastle-Ottawa Scale (NOS) for assessing the quality if nonrandomized studies in meta-analyses. 2009. Accessed 19 Oct 2009
  29. 29.
    Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, Henry D, Altman DG, Ansari MT, Boutron I et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Cochrane Deutschland, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften - Institut für Medizinisches Wissensmanagement Bewertung des Biasrisikos (Risiko systematischer Fehler) in klinischen Studien: ein Manual für die LeitlinienerstellungGoogle Scholar
  31. 31.
    Duval S, Tweedie R (2000) Trim and fill: a simple funnel-plot–based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56:455–463CrossRefPubMedGoogle Scholar
  32. 32.
    Rosenthal R (1995) Writing meta-analytic reviews. Psychol Bull 118:183CrossRefGoogle Scholar
  33. 33.
    Fergusson D, Horwood L, Shannon F (1986) Factors related to the age of attainment of nocturnal bladder control: an 8-year longitudinal study. Pediatrics 78:884–890PubMedGoogle Scholar
  34. 34.
    Crimmins C, Rathbun S, Husmann D (2003) Management of urinary incontinence and nocturnal enuresis in attention-deficit hyperactivity disorder. J Urol 170:1347–1350. doi: 10.1097/01.ju.0000084669.59166.16 CrossRefPubMedGoogle Scholar
  35. 35.
    Arfwidsson C, Doroszkiewicz M, Antonsson H, Jansson I, Lundh A, Ståklint M, Sillén U (2009) Effect of transcutaneous neuromodulation on overactive bladder symptoms in children. J Pediatr Urol 5:99–100. doi: 10.1016/j.jpurol.2009.02.181 CrossRefGoogle Scholar
  36. 36.
    Caldwell PHY, Nankivell G, Sureshkumar P (2013) Simple behavioural interventions for nocturnal enuresis in children. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD003637.pub3 CrossRefPubMedGoogle Scholar
  37. 37.
    Deshpande AV, Caldwell PH, Sureshkumar P (2012) Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics). Cochrane Libr. doi: 10.1002/14651858.CD002238.pub2 CrossRefGoogle Scholar
  38. 38.
    Glazener C, Evans JH, Peto RE (2004) Complex behavioural and educational interventions for nocturnal enuresis in children. Cochrane Libr. doi: 10.1002/14651858.CD004668 CrossRefGoogle Scholar
  39. 39.
    Freeman KA, Riley A, Duke DC, Fu R (2014) Systematic review and meta-analysis of behavioral interventions for fecal incontinence with constipation. J Pediatr Psychol 39:887–902. doi: 10.1093/jpepsy/jsu039 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Department of PsychologySaarland UniversitySaarbrückenGermany
  2. 2.Department of Child and Adolescent PsychiatrySaarland University HospitalHomburgGermany

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