Therapiealgorithmus bei Enuresis nocturna

Abstract

Monotherapeutic strategies often have only partial success in primary nocturnal enuresis (PNE). This analysis evaluated whether adjuvant treatment strategies improve outcomes. PNE children were submitted to a distinct therapeutic strategy including urotherapy (behavioral modifications), a first-line and, if necessary, a second-line treatment period. Outcome was the relief of bedwetting, the follow-up was 3-79 months. Urotherapy was applied. Nonresponders were assigned to desmopressin as first-line treatment. For complete responders a structured withdrawal program was applied. Partial responders were assigned to adjuvant second-line treatment according to their individual symptomatology, masked at basic investigations, incorporating either anticholinergics (propiverine hydrochloride), biofeedback, alpha-blocker (alfuzosin), alarm or psychotherapy, in addition to desmopressin. Nonresponders were referred to specialized management. The study included 259 children suffering from PNE (92 girls, 167 boys, aged 5-18 years): 42 children were relieved from bedwetting after urotherapy and 136 children had a complete response to desmopressin. Three nonresponders were assigned to specialized management, 61 partial responders had adjuvant treatments, and 17 partial responders had no further treatment. The suggested treatment algorithm resulted in 227 complete responders, 29 partial responders, and 3 nonresponders. The need for preliminary urotherapy is evident. The proposed desmopressin monotherapeutic strategy, incorporating a structured withdrawal program, is more effective than the standard desmopressin treatment module. Applying adjuvant treatment modules improves the complete response rate up to 88%. In partial responders overall efficacy rates are improved further. Nonresponders (1.2%) will be referred to specialized management, but many partial responders will gain improvement sufficient to refrain from invasive procedures.

Failure of monotherapy in primary monosymptomatic enuresis: a combined desmopressin and propiverine treatment regimen improves efficacy outcomes

“…Marschall‐Kehrel et al. [6] reduced propiverine by 5 mg every 2 weeks, a SWP also applied in our study.…”

“…Marschall‐Kehrel et al. [6] allocated partial responders after desmopressin monotherapy to a combined desmopressin and propiverine regimen, thus significantly improving the success rates. However, it might be advocated that as a first‐line approach monotherapy is preferable, minimizing of drug exposure, with fewer adverse events, and thus improving the compliance of the patients.…”

“…To the best of our knowledge the present is the first study evaluating the combination of propiverine and desmopressin in children with PME unresponsive to previous treatments. Previous studies used different criteria of success, varying from subjective improvement [5,7,17] to achieving dryness during defined periods of nights [4,6,9,[18][19][20][21]. These studies were initiated before the terminology recommendations of the International Children's Continence Society [13], defining a response as a '90% or greater decrease' and full response as a '100% decrease or less than one symptom occurrence monthly' .…”

“…Whether a combined treatment regimen of desmopressin and propiverine should be administered as a first-line treatment, not only in children unresponsive to monotherapy but also in primary cases, for minimizing therapeutic failures, is a matter for discussion. Marschall-Kehrel et al [6] allocated partial responders after desmopressin monotherapy to a combined desmopressin and propiverine regimen, thus significantly improving the success rates. However, it might be advocated that as a first-line approach monotherapy is preferable, minimizing of drug exposure, with fewer adverse events, and thus improving the compliance of the patients.…”

“…Nevertheless, a relapse rate of > 20% after completing the SWP needs explanation. It underlines the undoubtedly highly negative selected patients in the study, contrary to treatmentnaive patients in many studies [4][5][6][7][8][9][10]17,18].…”