Day wetting

Day wetting
- Treatment review
Anne Wright, MD, Consultant
Evelina Children's Hospital
St Thomas' Hospital
ERIC Birmingham - 2014
Søren Rittig, MD, DMSc, Prof.
Department of Paediatrics
Aarhus University Hospital
Dag wetting - causes
Daytime incontinence
Neurogenic causes
Myelomeningocele
Cerebral palsy
Degenerative CNS ds
Sacral agenesia
Myelitis
Introduction – what is it?
Structurel/anatomic
causes
Posterior urethral valve
Ectopic ureter
Urogenital sinus
Phimosis/labia agg
Functional causes
Other causes
Urge incontinence/OAB
Dysfunctionel voiding
Underactive bladder
Vaginal reflux
Giggle incontinence
‘Voiding postponement’
Day wetting in children

Epidemiology – Gothenborg (N= 4000, 7 yrs)

At school start: 3.8% boys and 6% girls

Urge (25%) and frequency were risk factors for UTI

Less than 40% had seeked their GP!
Introduction – how frequent is it?
Childhood incontinence
- Management strategy
Priority list
Management strategy – priority list
Step 4: Neuromodulation for nonneurogenic LUTD
• Well established effect in adults and children over last
two decades
• Different to direct electrostimulation (direct
stimulation of a nerve/muscle to produce an
immediate effect used mostly in neurogenic disorders)
• Mechanism of action not well understood
– Thought to modulate innervation of bladder, sphincter and
pelvic floor
– Alters existent transmission pattern
– Restore natural balance and coordination of sacral reflexes
Neuromodulation
Neuromodulation in children; different
modes
• NON-INVASIVE
• INVASIVE
• Transcutaneous
electrical
neurostimulation/TENS
• Percutaneous tibial
nerve stimulation /
PTNS
• Sacral
neuromodulation/SNM/
Interstim
– Parasacral
Neuromodulation
Neuromodulation
Sacral neuromodulation
TEMPORARY STIMULATOR;
External to see if there is
beneficial effect
PERMANENT STIMULATOR;
Surgically implanted if initial
trial is successful
Neuromodulation
How effective is neuromodulation in
childhood OAB : TENS ?
TENS
– 7 studies of TENS in OAB
– Only 2 are randomised controlled trials
•
•
•
Lordeˆlo P, Soares PV, Maciel I, et al. Prospective study of transcutaneous parasacral
electrical stimulation for overactive bladder in children: Long-term
results. J Urol 2009;182:2900–4.
Hagstroem S, Mahler B, Madsen B, et al. Transcutaneous electrical nerve
stimulation for refractory daytime urinary urge incontinence. J Urol
2009;182:2072–8.
– Small numbers
– Anything from 2 hours/day (home-based) to 20minutes 3x/week
(clinic-based)
– Variable settings; average 10Hz/200µs/variable mA
– 47-84% resolution of symptoms (61/62% in RCT)
– 10-25% relapse rate
– Drop out rates 11-22% (combination of discomfort and motivation)
– Minimal side effects with good compliance
Neuromodulation
Two studies: TENS vs oxybutynin
in OAB
• One randomised cross-over n= 43
– Oxybutynin 5mg tds/TENS 20Hz/200µs
– Soomro NA et al J Urol 166:146, 2001
• One group comparison n=28
– Oxybutynin (0.3mg/kg/day)plus sham TENS
– Placebo plus TENS (30mins 3x/wk )
– Quintiliano F et al. Oral presentation ICCS 2014
• Both studies found that TENS and oxybutynin were equivalent in efficacy
with regards to symptom control.
– First study found that only oxybutynin altered urodynamic parameters with no
sig difference between side effects
– Second study found no side effects associated with TENS and improved
constipation. Significant side effects occurred with oxybutynin including dry
mouth, hyperthermia and facial flushing
Neuromodulation
How effective is neuromodulation in childhood
OAB:PTNS ?
PTNS
– 3 studies. Non-randomised
De Gennaro M, Capitanucci ML, Mastracci P, et al. Percutaneous tibial nerve
neuromodulation is well tolerated in children and effective for treating
refractory vesical dysfunction. J Urol 2004;171:1911–3.
Hoebeke P, Renson C, Petillon L, et al. Percutaneous electrical nerve stimulation
in children with therapy resistant nonneuropathic bladder sphincter
dysfunction: A pilot study. J Urol 2002;168:2605–8.
Capitanucci ML, Camanni D, Demelas F, et al. Long-term efficacy of percutaneous
tibial nerve stimulation for different types of lower urinary tract dysfunction
in children. J Urol 2009;182:2056–61.
–
–
–
–
–
30minutes/week for 12 weeks
Small numbers
17-44% resolution of symptoms
Relapse rate not known
Drop out rates: 3-20% (combination of needle fear
and motivation)
Neuromodulation
How effective is Implanted SNM ?
• 4 studies in non-neurogenic LUTD, none of
which define exact nature of dysfunction (DES)
• Difficult to extract results with regards to
LUTD
• Inconclusive
Neuromodulation
Mirabegron; a new drug for OAB
• New class of bladder
relaxant
• ß 3 agonist which causes
detrusor muscle relaxation
during storage without
impairing detrusor
contraction during
micturition
• Licensed and approved by
NICE 2013 for
anticholinergic –resistant
OAB
Pooled analysis of 3 international
studies (3542 adult patients)
• Significant
improvement in
symptoms of OAB
–
–
–
–
Incontinence episodes
Frequency
Urgency
MVV
• Adverse effects (>3 %)
Adjusted mean change from baseline of
incontinence episodes/24 hours of mirabegron
vs placebo
Nitti V et al Int J Clin Prac July 2013
– hypertension
– Nasopharyngitis
– UTI
Combination Treatment with Mirabegron and Solifenacin in Patients with Overactive Bladder: Efficacy
and Safety Results from a Randomised, Double-blind, Dose-ranging, Phase 2 Study (Symphony)
Fig. 3 Change from baseline to end of treatment in mean volume voided per
micturition (in millilitres)
compared with (A) solifenacin 5 mg and (B) placebo. EOT = end of treatment; MIRA
= mirabegron;
MVV = mean volume voided per micturition; SOLI = solifena...
Paul Abrams , Con Kelleher , David Staskin , Tomasz Rechberger , Richard Kay , Reynaldo Martina , Donald Newgreen...
European Urology, 2014
http://dx.doi.org/10.1016/j.eururo.2014.02.012
Cochrane rev. 2012
“Botulinum-A toxin injection in children with non-neurogenic
overactive detrusor is an excellent treatment adjunct, leading to
long-term results in 70% after 1 injection.”
Hoebeke et al, J Urol. 2006
Management of dysfunctional voiding
CIC
STAGE 4
Urodynamic investigation
and
assessment of kidney status
Biofeedback (+/- anticholinergic)
General measures
Positioning
Constipation management
Management of UTI
STAGE 1