Combined pharmacotherapy for nocturnal enuresis

Abstract

Nocturnal enuresis is a common childhood disorder. Tricyclic antidepressants and anticholinergic agents have been the well accepted pharmacological treatment for this disorder and are efficacious in 40-70% and 10-50% of cases, respectively. The present study was performed to evaluate the effect of a combined treatment of tricyclic antidepressant and an anticholinergic agent. Twenty-two children aged 6-12 years with primary monosymptomatic nocturnal enuresis who did not prefer to use a conditioning alarm were given a combined treatment of these drugs. After a control period of 1 month, each patient was treated for 6 months and then observed for 3 months. A 30-mg dose of amitriptyline or imipramine was given with either 2-4 mg oxybutinin or 10-20 mg propiverine. Efficacy was determined relative to the number of wet nights per week compared with the control period, with more than a 50% decrease in wet nights per week taken to indicate efficacy. The mean wet nights per week decreased from 6.1 to 1.7 (P<0.01), and efficacy was established in 20 patients (90.9%). Relapses occurred in 60.0% of patients during the follow-up period. No significant side effects were observed. The efficacy of the combined therapy in monosymptomatic nocturnal enuresis appears to be greater than that reported for either drug alone, and therefore can be a choice of treatment in order to motivate children with nocturnal enuresis.

Enuresis: How to Evaluate and Treat

“…Combination of different therapies may also be instituted, especially in treatment of resistant cases (Table 1). Prescribing tricyclic antidepressants in conjunction with anticholinergics, 38 alarm therapy plus desmopressin acetate, 39 and bladder training plus an anticholingergic 40 are 3 such examples of combination therapy. DeWachter et al 40 found that administering oxybutinin along with a program of retention control training (RCT) or daily water loading to the point of urgency may improve enuresis by increasing bladder capacity and stimulating self-awakening in a small subset of patients with refractory symptoms.…”

“…References: Physicians' Desk Reference,41 2003; The Harriet Lane Handbook,42 1996; Kaneko et al,38 2001.…”

Enuresis in Children: Diagnosis and Management

“…If no clear etiology is determined, there are several potential interventions that may abate the fre-quency of nighttime wetting. 12,13,15 Hormonal therapy with desmopressin has been shown to significantly reduce urine volume in some children with nighttime wetting, 14 despite the lack of consistent levels of nighttime antidi-uretic hormone levels in children with nighttime wetting. This may entail a reward system, and increasing the responsibility of the child by having him/her change the wet sheets.…”

“…Other options include imipramine, which often reduces nighttime wetting for unknown reasons. 12,13,15 Hormonal therapy with desmopressin has been shown to significantly reduce urine volume in some children with nighttime wetting, 14 despite the lack of consistent levels of nighttime antidi-uretic hormone levels in children with nighttime wetting. 11 Finally, although hypnotherapy has been shown to reduce nighttime enuresis in some children, psychotherapy has not been shown to have any significant effect.…”

Acupressure versus Oxybutinin in the Treatment of Enuresis

“…16 Another study showed that combined treatment with a tricyclic antidepressant and an anticholinergic reduced monosynaptic nocturnal enuresis by 90.9% after 6 months of drug administration; combination therapy was more effective than monotherapy with either drug. 17 De Grazia and Cimador administered a combination of desmopressin and oxybutinin to children with enuresis and voiding disturbance and found that 93.2% had recovered after 6 months. 18 A positive response to treatment was also observed in 65.25% of patients with urodynamically demonstrated detrusor hyper-reactivity treated with oxybutinin and imipramine.…”