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Dear editor, we read with interest the randomised controlled trial by Borgström et al.1 showing the lack of effectiveness of daytime urotherapy as first-line treatment of nocturnal enuresis. While the study has the remarkable point of strength of a prospective trial with a control, we take exception with some of the authors’ statements, and believe that some limits should be acknowledged.
Reduction of enuresis frequency was evaluated after 7 and 8 weeks since the beginning of the study while previous studies showed effectiveness for longer treatments, lasting four months, with a 60% success rate2. While the authors acknowledge this difference they simply state that a longer duration would disqualify the therapy as a first-line choice anyway, increasing the risks of drop out. We believe that this is, as the author state in the discussion, simply their view, which is not based on any evidence. The length of a treatment should not necessarily rule out it as a first line option, especially when weighted against the costs of other options, specifically unpleasantness of the alarm and possible adverse effects of desmopressin. As a matter of fact, it could be speculated that 8 weeks are a too short period in a physiological perspective to develop different voiding patterns after years of an enuretic bladder function.
Moreover, patients’ follow-up consisted only in contact by phone after 2 and 6 weeks, without clinical examination, and this could have contributed t...
Moreover, patients’ follow-up consisted only in contact by phone after 2 and 6 weeks, without clinical examination, and this could have contributed to poor effectiveness of urotherapy too.
Lastly and above all, the authors considered daytime incontinence and voiding dysfunction among the exclusion criteria of the study, but it is well known that many enuretic children present daytime symptoms too in up to 90% of cases2 or bladder dysfunction even with enuresis as the only detectable symptom.3 These disorders, once identified, must be treated because they can lead to urological dysfunctions in adulthood4 and behavioural therapy still represents a cornerstone of treatment. We believe that this is a further reason why urotherapy should not be disqualified as a first-line treatment only without the evidence of long term treatment data.
In conclusion, we suggest that daytime urotherapy studies need to be carried out for longer periods to confirm or rule out its effectiveness. Until then urotherapy should not be considered an alternative choice to alarm therapy and pharmacological treatment but a complementary one, in order to obtain a global approach to nocturnal enuresis in children.
1. Borgström M, Bergsten A, Tunebjer M, et al. Daytime urotherapy in nocturnal enuresis: a randomised, controlled trial. Archives of Disease in Childhood Published Online First: 24 January 2022. doi: 10.1136/archdischild-2021-323488
2. Pennesi M, Pitter M, Bordugo A, Minisini S, Peratoner L. Behavioral therapy for primary nocturnal enuresis. J Urol. 2004; 171(January):408-410. doi:10.1097/01.ju.0000097497.75022.e8
3. Yeung CK, Chiu HN, Sit FKY. Bladder dysfunction in children with refractory monosymptomatic primary nocturnal enuresis. J Urol. 1999; 162:1049-1055.
4. Bower WF, Sit FKY, Yeung CK. Nocturnal Enuresis in Adolescents and Adults is Associated With Childhood Elimination Symptoms. J Urol. 2006; 176(October):1771-1775. doi:10.1016/j.juro.2006.04.087