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Much has happened since the end of the era when enuresis was blamed on the parents or the children themselves. Still, there are large gaps in our knowledge and large parts of modern enuresis management guidelines are (still) not based on firm evidence. In this review I will question the following commonly made assumptions regarding enuresis evaluation and treatment: •It is important to subdivide enuresis according to the presence of daytime symptoms•Voiding charts are crucial in the primary evaluation of the enuretic child•All children with enuresis need to be screened for behavioral or psychiatric issues•Concomittant daytime incontinence needs to be successfully treated before addressing the enuresis•Concomittant constipation needs to be successfully treated before addressing the enuresis•Urotherapy is a first-line treatment against enuresisIn this review I will argue that much of what we do with these children is based more on experience and well-meant but poorly supported assumptions than on evidence. Some advice and therapies are probably ineffective whereas for other treatments we lack reliable predictors of treatment response. More research is obviously needed, but awaiting new results enuresis management could be substantially simplified.

Yosuke Morizawa, Katsuya Aoki, Shunta Hori, Daisuke Gotoh, Makito Miyake, Yasushi Nakai, Kazumasa Torimoto, Nobumichi Tanaka, Kiyohide Fujimoto Department of Urology, Nara Medical University, Kashihara, Nara, JapanCorrespondence: Kiyohide FujimotoDepartment of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, JapanTel +81-744-22-3051Fax +81-744-22-9282Email kiyokun@naramed-u.ac.jpPurpose: To determine the clinical efficacy of endoscopic transurethral incision (TUI) for boys with refractory daytime incontinence due to a posterior urethral valve with or without nocturnal enuresis.Patients and Methods: A total of 20 boys with daytime incontinence were assessed. Twelve boys underwent TUI (TUI+ group) and eight boys continued receiving oral drugs (TUI- group). The primary endpoint was the cure rate associated with TUI or NE in both groups.Results: Only two boys achieved daytime continence 6 months after TUI, but no boys were cured of nocturnal enuresis 6 months after TUI. The median time to daytime continence was significantly longer in the TUI+ than in the TUI- group (52 vs 27 months, respectively; log rank P = 0.041) and the median time to dry nights was significantly longer in the TUI+ than in the TUI- group (56 vs 36 months, respectively; log rank P = 0.021).Conclusion: TUI might be not effective in boys with refractory daytime incontinence.Keywords: pediatric, daytime incontinence, enuresis, TUI

Duplication of the urethra is a rare congenital anomaly in females which, if left unidentified, might cause refractory urinary incontinence. This video demonstrates its identification and treatment. A 5-year-old female was referred for primary refractory diurnal incontinence without any dry moment since birth. Initial clinical examination showed permanent urine leakage from an opening cranial to the clitoris. Ultrasound did not show any bladder or kidney abnormalities. A diagnostic cystoscopy under anesthesia revealed an accessory meatus located cranially to the orthotopic meatus and to the clitoris. Lying in dorsal decubitus under general anesthesia, catheters were inserted in respectively the orthotopic and accessory meatus. The accessory meatus and urethra were dissected away into the bladder dome from a circumferential skin incision. Defects were closed and bladder drainage per urethram was left in situ for 10 days. P ostoperative recovery was uncomplicated. Complete resolution of the incontinence was immediately achieved at catheter removal. Daytime and night-time continence are observed with 3 years follow-up. Urethral duplication is a rare finding in females but should be excluded during the workup of primary incontinence. In girls with isolated urethral duplication, resection of the accessory urethra is the best surgical option. [ABSTRACT FROM AUTHOR]

Purpose This article is a standardization document of the International Children's Continence Society (ICCS); it represent a consensus of ICCS on the management of pediatric daytime urine incontinence (DUI). Materials and Methods This document was designed and written by a multi-disciplinary core group of authors appointed by the ICCS' board. Results Based on evidence of studies and the experience of experts, the treatment guideline of DUI is assembled in this standardization document. Guidelines and the algorithm of management include non-pharmacological treatment (urotherapy), as well as the pharmacological therapy and other modalities that are presented for DUI in general, as along with recommendations for individual conditions. Conclusion The final document is not a systematic literature review. It includes relevant research when available as well as experts' opinion on the current understanding of daytime incontinence in children. This document illustrates that specific treatment of DUI based on an exact diagnosis is effective. The mainstay of treatment is urotherapy, but a combination of treatment modalities is often necessary. Neurourol. Urodynam. 36:43-50, 2017. © 2015 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Aims To investigate the relevance of enuresis subtyping for selection of treatment modality and for long-term outcome in a large consecutive patient cohort. Materials and Methods We included all patients referred for urinary incontinence during a 5-year period but excluding recurrent urinary tract infections (UTI). Type and severity of incontinence, prior history, results of examinations performed, number of visits, and effect of all treatments provided, were included in a clinical database. Results Seven hundred twenty children aged 4-16 years (mean 8.5 ± 2.2 years, 239 girls) were included in the analysis (42% with monosymptomatic (MNE), 55% with non-MNE, and 3% with isolated daytime incontinence). Initial evaluation revealed only few underlying causes (one neurological and eight anatomical). Investigations showed significant differences between MNE and non-MNE patients as both maximal voided volume and nocturnal urine volume was lower in non-MNE patients ( P < 0.001). Follow-up for average 1,587 days (3.4 years) was performed in 660 (92%) patients. A higher number of visits and a longer treatment period were needed for non-MNE patients (on average 4.7 ± 2.8 visits) than MNE patients (3.1 ± 1.6 visits, P < 0.001). The most common treatment regimen that resulted in dryness in both MNE (40%) and non-MNE (36%) was the alarm system. Interestingly, of the 539 patients who initially were referred due to desmopressin resistance 177 (33%) of these were dry on desmopressin monotherapy. Conclusions The study indicated that MNE and non-MNE are two distinct disease entities with different optimal treatments and showed that the latter patients are more difficult and time-consuming to manage. Neurourol. Urodynam. 33:475-481, 2014. © 2013 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Much has happened since the end of the era when enuresis was blamed on the parents or the children themselves. Still, there are large gaps in our knowledge and large parts of modern enuresis management guidelines are (still) not based on firm evidence. In this review I will question the following commonly made assumptions regarding enuresis evaluation and treatment: •It is important to subdivide enuresis according to the presence of daytime symptoms•Voiding charts are crucial in the primary evaluation of the enuretic child•All children with enuresis need to be screened for behavioral or psychiatric issues•Concomittant daytime incontinence needs to be successfully treated before addressing the enuresis•Concomittant constipation needs to be successfully treated before addressing the enuresis•Urotherapy is a first-line treatment against enuresis In this review I will argue that much of what we do with these children is based more on experience and well-meant but poorly supported assumptions than on evidence. Some advice and therapies are probably ineffective whereas for other treatments we lack reliable predictors of treatment response. More research is obviously needed, but awaiting new results enuresis management could be substantially simplified., Competing Interests: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2022 Nevéus.)

Abstract: Purpose: This document represents the consensus guidelines recommended by the ICCS on how to evaluate and treat children with nonmonosymptomatic nocturnal enuresis (NMNE). The document is intended to be clinically useful in primary, secondary and tertiary care. Materials and methods: Discussions were held by the board of the ICCS and a committee was appointed to draft this document. The document was then made available to the members of the society on the web site. The comments were vetted and amendments were made as necessary to the document. Results: The main scope of the document is the treatment of NMNE with drugs other than desmopressin-based therapy. Guidelines on the assessment, and nonpharmacologic and pharmacologic management of children with NMNE are presented. Conclusions: The text should be regarded as an expert statement, not a formal systematic review of evidence-based medicine. It so happens that the evidence behind much of what we do in the care of enuretic children is quite weak. We do, however, intend to present what evidence there is, and to give preference to this rather than to experience-based medicine, whenever possible. [Copyright &y& Elsevier]

Aim Parents of children suffering from non-monosymptomatic enuresis (nm E) report their child wetting itself during intensive playing. As children with enuresis are characterized by reduced bladder control (measured as prepulse inhibition ( PPI) of startle reflex), the hypothesis suggests that intensive playing leads to further decrease in control and consecutive wetting. Two questions are important: Does PPI change while concentrating? Is this difference more explicit in children with daytime incontinence? Methods Forty-four healthy children, 40 children with nm E and 37 with monosymptomatic enuresis ( mE) were examined. PPI was measured while watching DVD and while playing Nintendo's Wii®, and calculated as percentage of the native startle response. Results All probands showed a relevant decrease in PPI: in relaxed state, the PPI of the controls was 54%; when concentrating, it fell to 34.5% (p = 0.014). The decrease in PPI in mE was from 66% to 51% (p = 0.008), and the decrease in PPI in nm E was from 29% to 21% (p = 0.125). Conclusion While the decrease in PPI when playing was smallest in the group with nm E, overall PPI level was by far the lowest. The findings confirm the aetiology of enuresis through impaired 'sensori-motor gating' in children with nm E and provide a neurophysiologic correlate for wetting while playing. [ABSTRACT FROM AUTHOR]

OBJECTIVE: • To evaluate the clinical significance of congenital obstructive lesions of the posterior urethra in boys with refractory primary nocturnal enuresis. PATIENTS AND METHODS: • VCUG was performed in 43 consecutive boys who visited our department from April 2004 to April 2009 who were unresponsive to conservative treatment. 20 patients of the 43 patients, underwent TUI. VCUG and UDS were performed before and 3–4 months after TUI. • In UDS, the maximum flow rate (Q max ), maximum bladder capacity, and post-voiding residual urine volume were determined using uroflowmetry (UFM), and the detrusor pressure (P det ) at Q max was determined in a pressure flow study (PFS). • Clinical outcome was evaluated 3–4 months and 6 months after TUI. RESULTS: • In VCUG performed 3–4 months after TUI, improvement was observed in urethral morphology in all patients. In preoperative PFS, two patterns were observed: 13 patients(65%) had a synergic pattern (SP) in which the P det increased with increasing urinary flow rate simultaneously with the initiation of voiding and seven (35%) had a dyssynergic pattern (DP) in which the P det was not coincident with the initiation of voiding, but was higher immediately before voiding than at Q max . TUI was effective only in the SP group: symptomatic improvement was observed in 87.5% of patients with daytime incontinence and 77% of patients with nocturnal enuresis 6 months after TUI. • In the DP group, no effect was observed (0%). With regard to changes in UDS parameters, a significant decrease ( P= 0.0004) was observed in the P det at Q max and a significant increase ( P = 0.036) was observed in the maximum bladder capacity in the SP group, whereas no significant differences were noted in any parameters in the DP group. CONCLUSION: • Two voiding urodynamic patterns with different clinical outcomes of TUI were detected among patients with congenital posterior urethral obstruction, the underlying disease of refractory primary nocturnal enuresis in boys. [ABSTRACT FROM AUTHOR]

Aim: Few studies have looked at the prevalence of daytime incontinence in a longitudinal cohort of children. This study set out to determine the prevalence of daytime incontinence and relationships between daytime incontinence and bedwetting, faecal incontinence and urgency in a large cohort of British children. Methods: Parents of children taking part in the Avon Longitudinal Study of Parents and Children (ALSPAC) were asked questions concerning the child’s daytime wetting, bedwetting and faecal incontinence at different time points, 4.5, 5.5, 6.5, 7.5 and 9.5 years. The difference between the sexes for these different conditions was compared. Results and limitations: Data were available for 10 819 of the 13 973 children who entered the study. The prevalence of any daytime incontinence declined from 15.5% at 4.5 years to 4.9% at 9.5 years, and was mainly described as infrequent. Daytime incontinence was more common in girls than boys and frequent (DSM-IV) incontinence was more commonly related to urgency, bedwetting and faecal incontinence than infrequent incontinence. Conclusions: Daytime incontinence is relatively common among children of primary school age and frequent incontinence more commonly coexists with other conditions, such as bedwetting and urgency. This study suggests the need for treatment to focus on children with frequent incontinence. [ABSTRACT FROM AUTHOR]

Urethral duplication is a complex and rarely seen anomaly with three anatomic variants: epispadiac (dorsal), hypospadiac (ventral) and Y-type. Here we report an 11-year-old male patient with hypospadiac urethral duplication who presented with daytime urinary incontinence and dribbling, urethral stricture and possible obstructive uropathy. After endoscopic treatment of the stricture in the ventral (dominant) urethra, urethral reconstruction was done anastomosing the ventral (dominant) and dorsal (non-dominant atretic urethra) in a dismembered fashion. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

(Introduction) In tethered cord syndrome, the lower end of the spinal cord is moored to the caudal tissue, causing various neuropathies. Bladder dysfunction often appears early. We herein evaluated children with daytime urinary incontinence in whom tethered cord syndrome was eventually diagnosed. (Method) Eighteen children (9 males and 9 females) with daytime urinary incontinence were enrolled between March 2011 and October 2017. The causes of their urinary incontinence were investigated using spinal MRI and changes in clinical symptoms before and after untethering surgery. (Results) The average age at the first visit was 6.3 years (range: 4-9 years). Urodynamic testing and a voiding cystourethrogram (VCUG) were performed in all cases of refractory daytime incontinence, and all patients with abnormal findings on either test underwent spinal MRI. The diagnosis based on spinal MRI findings was filum lipoma in eight, occult tethered cord syndrome in four, low set conus in four, conus lipoma in one, and sacral meningeal cyst in one, patient. The average observation period after untethering surgery was 66.3 months (range: 22-116 months). All the patients achieved a cure postoperatively. Four patients were treated for nocturnal enuresis by oral medication, and three patients required urological management via clean, intermittent catheterization. (Conclusions) When treating children with daytime continence, one should consider the possibility of tethered cord syndrome, the diagnosis of which can be aided by urodynamic assessment of bladder function.

Summary Introduction Urotherapy is considered the treatment of choice for children suffering daytime urinary incontinence (DUI). Urotherapy intends to improve bladder dysfunction for children with DUI. For children with refractory DUI, an intensive inpatient bladder training program exists, which focuses on relearning, concentration on, and awareness of the bladder. Children's motivation and adherence are key determinants of a successful training outcome. It is hypothesized that motivation endurance throughout the treatment process may be enhanced by a serious game training tool, which could make the training more appealing and rewarding. Objective The study explores intrinsic motivation in children receiving bladder training for DUI and whether using a serious game improves their intrinsic motivation. Study design In this pragmatic study, 50 children were allowed to choose among receiving bladder training with (intervention group) or without the application of a serious game (control group). At 4, 8, and 12 weeks of training, children and parents were asked to complete the Intrinsic Motivation Inventory (IMI). Children also completed the Pediatric Urinary Incontinence Quality of Life Tool (PinQ) before the start of the training and 6 months thereafter. At 6-month follow-up, patients were ask to participate in two focus groups, wherein the children discussed how they used the serious game and which improvements they would prefer. Results Children who received standard bladder training with the addition of a serious game did not differ in terms of intrinsic motivation from children who underwent standard bladder training only. Training results were equal in both the groups, with 80% good or improved. Incontinence-related quality of life (QoL) improved accordingly. Discussion In contrast to the study expectations, this game did not increase intrinsic motivation. Findings on training and QoL results are consistent with those of previous studies in both interventions. Although a randomized design could have yielded more valid results than this preference-based approach, the latter is more congruent with clinical practice. In contrast to existing bladder diary apps, this game offers a combination of child-friendly instructions, explanation of bladder (dys)function, and keeping a bladder diary. Mobile devices are playing an increasingly important role in health care; therefore, an urotherapy app can be a complementary therapeutic tool. Conclusion Most children find it attractive to combine bladder training with a serious game. However, no added value was found regarding intrinsic motivation and training results. All children with persistent DUI in this cohort were highly motivated to complete an intensive bladder training program. Start page game; Luts & the 'Leaky Cauldrons'. [ABSTRACT FROM AUTHOR]

Summary Background Daytime incontinence and enuresis are common problems in otherwise healthy children, and negatively influence their social lives and self-esteem. Motivation for treatment is often a real clinical problem. Children's experiences of their incontinence treatments have not been previously described. Objective The aim of this study was to describe children's experiences of the Voiding School intervention as a treatment for their incontinence. Study design A qualitative, descriptive focus-group study with a purposive sample was conducted at a Finish university hospital in 2014. Children aged 6–12 years participated in the Voiding School at an outpatient clinic. The intervention included two 1-day group visits 2 months apart. The educational content was based on the International Children Continence Society's standards for urotherapy. The education was delivered with child-oriented teaching methods. At the end of the second visit, 19 children were interviewed in five groups. Data were analysed with inductive content analysis. Results The children described incontinence as an embarrassing problem, which they had to hide at any cost. They had experienced bullying and social isolation because of it. Normal outpatient visits emphasized adult-to-adult communication, which made the children feel like outsiders. The children perceived the Voiding School as a nice and child-oriented experience. Making new friends was especially important to younger boys who felt that the Voiding School day was too long and issue-oriented. In the Voiding School, videos and ‘learning by doing’ helped the children to understand the basis of given advice, and they were able to learn new habits, which gave them control over the incontinence; this helped them to become ‘the boss of the bladder’. Sharing experiences and improvements in their incontinence with their peers supported the children's self-esteem and encouraged them to do new things, such as staying overnight with friends. These experiences helped them to acquire control over the problem (Summary Figure). Discussion According to the children's experiences, normal outpatient visits were only appointments for adults, and not very useful for children. In the Voiding School, they were respected as being the main person, and their views were listened to. The results underlined the importance of a child-oriented approach to patient education with regard to children, and provided encouragement to further develop the intervention. Conclusion Child orientation, peer support, learning by doing, and understanding the cause and effect helped children to gain control over their bladders. Based on the children's experiences, this could be achieved by a voiding school. Summary Figure The themes arising from the children's expressions during the interviews. Summary Fig [ABSTRACT FROM AUTHOR]

To evaluate a possible relationship between urinary tract infections (UTI) and diurnal incontinence (DIC), we studied 251 girls aged 4 years or more who were referred with a history of recurrent UTI and/or DIC. During follow up (mean 35 months), 110 girls (44%) had both UTI and DIC, 50 (20%) only infections, and 41 (16%) only DIC whereas 50 (20%) had neither infection nor DIC. In 110 girls with infections occurring with intervals of at least 6 and 12 months, DIC was definitively initiated by infection on 32 (19%) occasions. Most girls were continent before the infection occurred. When the girls remained free of infection for 6 or 12 months respectively, the frequency of DIC remained unchanged. In conclusion, no support for the concept of DIC leading to UTI was obtained, whereas the reverse was found in some cases and suggested in others. [ABSTRACT FROM AUTHOR]