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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Enuresis alarm treatment

RJ Butler and SL Gasson.

Review published: 2005.

CRD summary

This review aimed to determine the effectiveness of treatment for childhood nocturnal enuresis. Sixty-five percent of children using alarms in a subset of 20 studies were reported to have achieved 14 consecutive dry nights. However, the diversity, possible poor generalisability and the poor quality of many of the studies should be considered when interpreting the authors' findings.

Authors' objectives

To determine the effectiveness of enuresis alarms and the factors that influence their effectiveness in the treatment of childhood nocturnal enuresis.

Searching

The authors searched the NHS Dialog databases (which included MEDLINE, PsycINFO, British Nursing Index and EMBASE) from 1980 to 2002) using the terms 'nocturnal enuresis' and 'alarm'. Only articles published in the English language were retrieved.

Study selection

Study designs of evaluations included in the review

Any study of at least 10 participants, which investigated the intervention as the main focus or as a comparison group, was eligible for inclusion. The studies reported in the review included randomised controlled trials (RCTs), clinical controlled trials (CCT), quasi-RCTs, prospective uncontrolled studies, before-and-after studies and post hoc analyses.

Specific interventions included in the review

Studies that assessed any form of enuresis alarm as a 'stand-alone' intervention were eligible for inclusion. Various types of enuresis alarm were assessed in the review: traditional bed alarms, body alarms, delayed alarms, ultrasound alarms and vibrating alarms. The authors did not specify what, if anything, the intervention should be compared with. However, the studies included in the review compared alarms against no treatment, desmopressin, imipramine, retention-control training, arousal training, dry-bed training, modified dry-bed training, home spectrum training, or combination treatments such as alarm and rewards, and alarm and desmopressin.

Participants included in the review

Studies that included children suffering from nocturnal enuresis were eligible for inclusion; studies including adults were excluded. The studies reported in the review covered different age ranges of children, the youngest being 4 years and the oldest 18 years. Where stated, most of the studies included more males than females. The participants suffered from various forms of enuresis: primary, secondary, primary mono-symptomatic, non-organic nocturnal enuresis with no daytime wetting, urge syndrome, no daytime wetting, some daytime wetting, severe primary and intractable enuresis. The frequency of wetting at the start of the study also varied greatly from wet every night to wet at least once a week. The populations were from a number of different settings: specialist community clinics, enuresis clinics, hospital psychology clinics, hospital urology departments, paediatric clinics, university settings, home visits, and through no professional contact. A small number of studies failed to provide details of the setting used.

Outcomes assessed in the review

Studies assessing success and relapse rates were eligible for inclusion. Studies that assessed factors influencing success were also eligible for inclusion. The definition of success used in the included studies varied greatly, but the most common definition was 14 consecutive dry nights. Similarly, relapse was also variously defined in the studies, though a number of studies used a definition of more than one wet night a week.

How were decisions on the relevance of primary studies made?

The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.

Assessment of study quality

The authors did not state that they assessed validity; however, comments were made about the duration of the studies, the method of treatment allocation, study size, drop-out rate and blinding.

Data extraction

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

Success rates and relapse rates were presented as percentages with absolute numbers. The duration of the study, the drop-out rate, frequency of wetting at inclusion, and definitions of relapse and success were also reported for each study.

Methods of synthesis

How were the studies combined?

Given the heterogeneity observed in interventions, outcome definitions, populations and study designs, the studies were combined in a narrative and accompanied by data tables summarising the outcome data.

How were differences between studies investigated?

Differences between the studies were described in the text of the review and were also evident from the data tables. Data from a subset of 20 more homogeneous studies (n=721) were also summarised separately and the success rates combined to give an overall success rate.

Results of the review

Thirty-eight studies (n=1,984) were included in the review. Thirteen were randomised, three used consecutive assignment, three used alternate allocation, and a further eight were comparative studies but their method of allocation was not reported. Two studies were before-and-after studies and one was a post hoc analysis. One study allowed patients to choose their treatment allocation. The designs of the remaining studies were unclear.

Success and relapse rates.

Overall, the 38 included studies were very heterogeneous making analysis difficult. A subset of 20 more homogeneous studies (n=721) had the following characteristics: success defined as 14 consecutive dry nights, study duration of at least 6 weeks, enuresis alarms used as monotherapy (except where additional procedures were coupled with the alarm), and the exclusion of children with both daytime and night-time wetting. The overall success rate from this subset of studies was 65% (range: 4 to 55); 2 studies suggested that effectiveness was unaffected by age or gender. Relapse rates, where reported, ranged from 1 to 29%. No significant differences in effectiveness were found between traditional and either vibrating (1 study) or delayed triggering alarms (1 study), between bed and body-worn alarms (2 studies), and between alarms and imipramine (1 study). The intervention was found to be more effective than no treatment or waiting-list controls (3 studies), imipramine (3 studies), retention-control training (1 study), random waking (1 study), psychological treatments without an alarm (1 study) and placebo (1 study). Adjunct treatments to alarm use did not increase effectiveness in the case of offering rewards for dry nights (1 study), but did in the case of arousal training (1 study). Dry-bed training was found to both enhance (1 study) and to have no effect (2 studies) on the effectiveness of alarms. A component analysis suggested that apart from the waking schedule, none of the additional procedures studied significantly altered the effectiveness of alarms. Modified dry-bed training alone was found to be similar to alarms (1 study).

Factors affecting success.

The studies found a number of factors affecting the success rate of alarms, including: unsatisfactory living conditions and other environmental factors (2 studies); previous failures with alarm treatment (1 study); severe wetting at baseline (2 studies, although one other study failed to support this finding); multiple wetting at night (1 study); daytime wetting (3 studies); small daytime bladder capacity (1 study) and signs of bladder urgency and frequency (1 study) (although one study contradicted this); lack of concern or motivation (2 studies); stress and family difficulties (2 studies); punitive parental attitudes to wetting (1 study); perception of behavioural problems (1 study); and higher socioeconomic status (1 study). Treatment withdrawal was found to be associated with parental intolerance (5 studies), low self-esteem (1 study) and behavioural problems (2 studies).

Authors' conclusions

The intervention appeared effective for the treatment of childhood nocturnal enuresis, with 65% of children achieving 14 consecutive dry nights. However, this finding was based on research studies often carried out in specialist clinics and so might not be generalisable to the general population. A number of factors, both pre- and during treatment, might have affected the successfulness of the intervention in any one child and these might assist clinical decision-making.

CRD commentary

This review was based on a clear but broad research question, owing to wide inclusion criteria for the types of intervention and study design. The authors conducted a reasonable search of electronic databases, although it was unclear whether relevant literature might have been missed by limiting the searches to articles published in English between 1980 and 2002. Publication bias may also be a problem as the authors made no apparent attempts to locate unpublished studies. Although many study details were presented in the paper, it was unclear whether the authors tried to ensure that the data were reported without bias or error, as the methods for the study selection and data extraction processes were not given. Similarly, a formal assessment of study validity does not appear to have been performed, although the authors referred to some aspects of study quality in their report. Given the heterogeneity between the studies, the use of a narrative synthesis was appropriate and the analysis of a more homogeneous subgroup of studies helped summarise the overall findings. The heterogeneity, possible poor generalisability and the poor quality of many of the studies should be considered when interpreting the authors' findings and conclusions.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that further research is required to confirm that offering contingent rewards for dry nights does not increase the effectiveness of alarms.

Funding

East Leeds Primary Care Trust.

Bibliographic details

Butler R J, Gasson S L. Enuresis alarm treatment. Scandinavian Journal of Urology and Nephrology 2005; 39(5): 349-357. [PubMed: 16257835]

Indexing Status

Subject indexing assigned by NLM

MeSH

Behavior Therapy /methods; Circadian Rhythm; Enuresis /physiopathology /therapy; Humans; Treatment Outcome

AccessionNumber

12006000089

Database entry date

31/08/2007

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 16257835