Review of panel discussions.

Dr. A. von Gontard of the Department of Child Psychiatry, University of Cologne, Germany presented the German approach to children with nocturnal enuresis. The approach is based on empirical data and “guidelines” of professional medical associations (www.awmf.de), which provide information, support and counseling to the patient and family; discontinue ineffective treatments; address comorbid behavioral and emotional disorders; and treat diurnal incontinence, encopresis and constipation. A baseline calendar chart is completed for 4 weeks. Alarm treatment is the first line approach with the most effective long-term results, and desmopressin acetate is prescribed as a second line therapy. Consequently, an alarm is used for 16 weeks with an attempt to achieve 14 consecutive dry nights. If this is ineffective, then arousal training and desmopressin are prescribed. Desmopressin is discontinued after a maximum of 4 weeks. In select cases imipramine is used with close surveillance for cardiac side effects. The Italian approach to enuresis was presented by Dr. G. A. Manzoni from the Ospedale di Circolo di Varese. In Italy there is a multidisciplinary medical association, the Club Italiano Enuresi Notturna, which is composed of pediatricians, pediatric urologists, pediatric neuropsychiatrists, pediatric nephrologists, urologist/urodynamists, gynecologists and sexologists. The aims of this organization are to perform scientific research, and convey information to other physicians and the public. There are 40 first level centers at university and teaching hospitals and 300 second level centers distributed throughout Italy. Manzoni quoted several important Italian studies pertaining to the epidemiology and pathogenesis of enuresis. In a multicenter epidemiological study of 6,892 children 6 to 14 years old the prevalence of enuresis was 9.4% at age 6 years and 2.3% at age 11 years with a slight male predominance.1 Approximately two-thirds of the subjects had primary enuresis. The pathogenesis of enuresis in some cases is hypercalciuria, and subtypes of enuresis have been developed based on a multicenter study.2–4 In a study of 450 enuretic patients 40% had nocturnal hypercalciuria (NH). Of patients with nocturnal polyuria 43% had NH, whereas of those without polyuria only 34% had NH. Consequently, NH appeared to have an important role in enuresis and was associated with low levels of vasopressin and nocturnal polyuria. In children with nocturnal enuresis associated with diurnal incontinence the combination of oxybutynin chloride and desmopressin was more successful than oxybutynin alone for controlling nocturnal enuresis.5 There is a toll-free telephone number for Club Italiano Enuresi Notturna, and they receive more than 5,000 telephone calls a year. Their treatment strategy for monosymptomatic nocturnal enuresis is to use desmopressin tablets or nasal spray. In contrast, if the enuretic child also has diurnal incontinence, then oxybutynin or tolterodine is prescribed. Nonresponders use the enuretic alarm. Dr. Sang Won Han of the Division of Urology and Center for Child and Adolescent Health, Yonsei University College of Medicine, in Seoul Korea presented the Korean approach to nocturnal enuresis. The prevalence of enuresis in Korea is estimated to be 31% at age 5 years, 20% at age 7 years and 4% to 5% at age 12 years. Ten years ago Koreans did not consider bedwetting to be a serious medical condition. They thought that a child with bedwetting needed more discipline, and they used to punish the child if he or she wet the bed. Currently, if the parent of a bedwetter seeks therapy they have 3 options. The first option is a folk remedy, which involves use of gingko nut, leaf of persimmon or pumpkin. Option 2 is treatment by an herb doctor who uses acupuncture or drugs extracted from various plants, deer antlers, etc. Approximately 15% of patients select this option but the results have not been reported. The third option is to see a physician. In 1999 the Korean Enuresis Study Group was organized and is composed of pediatric urologists, pediatricians and pediatric psychiatrists. Through the efforts of this group, a significant proportion of patients previously considered to have uncomplicated nocturnal enuresis have been diagnosed with voiding dysfunction. Two basic approaches are used. Primary care physicians classify enuretic children into desmopressin responders and nonresponders. Pediatric urologists or nephrologists classify these children as those with or without voiding dysfunction. Traditionally, Korean women void in a squatting position but as their lifestyle has become more westernized, they are more likely to sit to void. However, most of the toilets in public spaces are still of the squatting type. There are no urodynamic data regarding the differences between the sitting and squatting positions. However, theoretically, the squatting position makes it easier to void because the pelvic floor is more easily relaxed. In children with enuresis a voiding and drinking diary as well as uroflowmetry with or without residual volume measurement is standard. In addition, cystometry offers invaluable information for the treatment of enuresis. If the cystometry is abnormal, a voiding cystourethrogram (VCUG) is also obtained. In recent years videourodynamics have been performed frequently. Treatment includes the combined efforts of urotherapy with day and night alarm, pharmacotherapy and at times psychological support. In some children pelvic floor magnetic stimulation is recommended. Han displayed a specially designed magnetic chair for children, and found that magnetic stimulation was most effective for enuresis if the child also had daytime frequency. He recommended that if an enuretic child has voiding dysfunction, urotherapy and control of constipation should be initial therapy followed by anticholinergic medication. If success was only partial then desmopressin was given. If there was no voiding dysfunction then either desmopressin or alarm therapy was recommended. Dr. C. K. Yeung from the Division of Pediatric Surgery, Chinese University of Hong Kong, Prince of Wales Hospital in Hong Kong presented the Hong Kong perspective. He noted that the prevalence of enuresis in Hong Kong is less than that in other countries. In a survey of 16,500 children only 2.5% had enuresis. In a telephone survey of 8,500 adults 1.9% were enuretic with a slight male predominance. Yeung et al presented the results of urodynamics in children with refractory nocturnal enuresis.6 The first group had normal daytime urodynamics but significant bladder instability after 0022-5347/04/1716-2672/0 Vol. 171, 2672–2679, June 2004 THE JOURNAL OF UROLOGY Printed in U.S.A. Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION DOI: 10.1097/01.ju.0000124582.64954.04