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National Clinical Guideline Centre (UK). Nocturnal Enuresis: The Management of Bedwetting in Children and Young People. London: Royal College of Physicians (UK); 2010. (NICE Clinical Guidelines, No. 111.)

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Nocturnal Enuresis: The Management of Bedwetting in Children and Young People.

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21Alternative treatments for the management of bedwetting

21.1. Introduction

Parents and carers are often reluctant to use pharmacological agents in children. Many children do not respond to alarms and desmopressin and parents and carers are interested in using alternative treatments for the management of bedwetting. The GDG considered it an important topic as parents and carers regularly ask for advice ask for advice and if useful it may be appropriate to offer these treatments.

The following interventions were included in the evidence review of the effectiveness of alternative treatments: acupuncture, chiropractic treatment, cranial osteopathy, homeopathy, homotoxicological remedies, hypnotherapy and reflexology. A short description of the intervention is included in the evidence review below.

21.2. What is the clinical and cost effectiveness of alternative treatments for children and young people under 19 years who have bedwetting

21.2.1. Evidence review

21.2.1.1. Hypnotherapy compared to imipramine for children with severe wetting

One randomised controlled trial, Banjerjee (1993) 165 compared hypnotherapy to imipramine. Banjerjee (1993) 165 considered children with severe wetting. Hypnotherapy was described as the child was first taught to relax and instructed to listen to the therapist and imagine what they were describing, they were then induced into hypnosis by and then given suggestions. Children were given two 30 minutes sessions in the first week, then one session in the second week, further sessions varied but were between once a week and once a fortnight; children receiving imipramine had 25 mg each night, the dose was increased each week if there was no response.

Table 21-1Hypnotherapy compared to imipramine - Clinical summary of findings

OutcomeHypnotherapyImipramineRelative risk (95% CI)Absolute effectQuality
Number of children who became completely dry or had a reduced number of wet nights18/25 (72%)19/25 (76%)RR 0.95 (0.68 to 1.32)38 fewer per 1000 (from 243 fewer to 243 more)VERY LOW
Number of children who relapsed at 6 months1/18 (5.6%)13/19 (68.4%)RR 0.08 (0.01 to 0.56)629 fewer per 1000 (from 301 fewer to 677 fewer)LOW

21.2.1.2. Acupuncture compared to sham acupuncture for children with night time only wetting

One randomised controlled trial, Mao (1998) 166 compared acupuncture to sham acupuncture. Mao (1998) 166 considered children with night time only wetting. Acupuncture was described as a needle being buried under the skin for 3 days and then a new needle buried at the same point for 3 days; children receiving sham acupuncture had a needle placed on the skin for 30 minutes daily for 6 days.

Table 21-2Acupuncture compared to sham acupuncture - Clinical summary of findings

OutcomeAcupunctureSham acupunctureRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights30/56 (53.6%)17/55 (30.9%)RR 1.73 (1.09 to 2.76)226 more per 1000 (from 28 more to 544 more)VERY LOW
Number of children who failed to achieve 14 consecutive dry nights or relapsed after treatment26/56 (46.4%)38/55 (69.1%)RR 0.67 (0.48 to 0.94)228 fewer per 1000 (from 41 fewer to 359 fewer)VERY LOW

21.2.1.3. Chiropractic treatment compared to no treatment for children with night time only wetting

One randomised controlled trial, LeBoeuf (1991) 167 compared chiropractic treatment to no treatment. LeBoeuf (1991) 167 considered children with night time only wetting. Chiropractic treatment was described as adjustments of the aberrant spinal movement through observation and palpation each visit.

Table 21-3Chiropractic treatment compared to no treatment - Clinical summary of findings

OutcomeChiropractic treatmentNo treatmentRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights per week at the end of 2 weeks of treatment10071-not pooledVERY LOW

21.2.1.4. Chiropractic treatment compared to sham chiropractic treatment for children with night time only wetting

One randomised controlled trial, Reed (1994) 168 compared chiropractic treatment to sham chiropractic treatment. Reed (1994) 168 considered children with night time only wetting. Chiropractic treatment was described as patients having spinal subluxation through high velocity, short lever thrust every 10 days, children were evaluated for segmental dysfunction using observation and palpation; children receiving sham chiropractic treatment followed the same procedure but received sham adjustment.

Table 21-4Chiropractic treatment compared to sham chiropractic treatment - Clinical summary of findings

OutcomeChiropractic treatmentSham chiropractic treatmentRelative risk (95% CI)Absolute effectQuality
Number of children who had greater than 50% improvement in the number of dry nights8/31 (25.8%)0/15 (0%)RR 8.5 (0.52 to 138.16)0 more per 1000 (from 0 fewer to 0 more)VERY LOW
Mean number of wet nights per 2 weeks at follow up3115-MD −3.6 (−5.93 to − 1.27)VERY LOW

21.2.1.5. Homotoxicological remedies compared to placebo for children with night time only wetting

One randomised controlled trial, Ferrara (2008) 124 compared homotoxicological remedies to placebo. Ferrara (2008) 124 considered children with night time only wetting. Homotoxicological remedies were described as 20 solidago drops three times a day and one biopax tablet in the evening; children receiving placebo had 20 placebo drops three times a day and one placebo tablet in the evening.

Table 21-5Homotoxicological remedies compared to placebo - Clinical summary of findings

OutcomeHomotoxicological remediesPlaceboRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights10/50 (20%)0/51 (0%)RR 21.41 (1.29 to 355.87)0 more per 1000 (from 0 more to 0 more)VERY LOW

21.2.1.6. Homotoxicological remedies compared to desmopressin for children with night time only wetting

One randomised controlled trial, Ferrara (2008) 124 compared homotoxicological remedies to desmopressin. Ferrara (2008) 124 considered children with night time only wetting. Homotoxicological remedies was described as above.

Table 21-6Homotoxicological remedies compared to desmopressin - Clinical summary of findings

OutcomeHomotoxicological remediesDesmopressinRelative risk (95% CI)Absolute effectQuality
Number of children who achieved 14 consecutive dry nights10/50 (20%)26/50 (52%)RR 0.38 (0.21 to 0.71)322 fewer per 1000 (from 151 fewer to 411 fewer)LOW

21.2.1.7. Hypnotherapy compared to no treatment for children with night time only wetting

One randomised controlled trial, Edwards (1985) 169 compared types of hypnotherapy to no treatment. Edwards (1985) 169 considered children with night time only wetting. The types of hypnotherapy were described as trance with suggestions (1), trance without suggestions (2) and suggestions without trance (3). Trance with suggestions was described as the child was induced into a trance in a special relaxing chair and listened to suggestions on a tape through headphones. Trance without suggestions was described as being induced into trance and then woken up, however the author stated due to moral reasons the children were given minimal suggestions before the trance. Suggestions without trance was described as the same procedure as trance with suggestions but without trance.

Table 21-7Trance with suggestions compared to no treatment - Clinical summary of findings

OutcomeTrance with suggestionsNo treatmentRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights per week at the end of treatment1212-not pooledVERY LOW
Mean number of wet nights per week at follow up1212-not pooledVERY LOW

Table 21-8Suggestions without trance compared to no treatment - Clinical summary of findings

OutcomeSuggestions without tranceNo treatmentRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights per week at the end of treatment1212-not pooledVERY LOW
Mean number of wet nights per week at follow up1212-not pooledVERY LOW

Table 21-9Trance without suggestions compared to no treatment - Clinical summary of findings

OutcomeTrance without suggestionsNo treatmentRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights per week at the end of treatment1212-not pooledVERY LOW
Mean number of wet nights per week at follow up1212-not pooledVERY LOW

21.2.1.8. Types of hypnotherapy for children with night time only wetting

One randomised controlled trial, Edwards (1985) 169 compared types of hypnotherapy. Edwards (1985) 169 considered children with night time only wetting. The types of hypnotherapy were as described above.

Table 21-10Trance with suggestions compared to suggestions without trance - Clinical summary of findings

OutcomeTrance with suggestionsSuggestions without tranceRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights per week at the end of treatment1212-not pooledVERY LOW
Mean number of wet nights per week at follow up1212-not pooledVERY LOW

Table 21-11Trance with suggestions compared to trance without suggestions - Clinical summary of findings

OutcomeTrance with suggestionsTrance without suggestionsRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights per week at the end of treatment1212-not pooledVERY LOW
Mean number of wet nights per week at follow up1212-not pooledVERY LOW

Table 21-12Suggestions without trance compared to trance without suggestions - Clinical summary of findings

OutcomeSuggestions without tranceTrance without suggestionsRelative risk (95% CI)Absolute effectQuality
Mean number of wet nights per week at the end of treatment1212-not pooledVERY LOW
Mean number of wet nights per week at follow up1212-not pooledVERY LOW

21.2.1.9. Laser acupuncture compared to desmopressin for children with monosymptomatic nocturnal enuresis

One randomised controlled trial, Radmayr (2001) 170 compared laser acupuncture to desmopressin. Radmayr (2001) 170 considered children with monosymptomatic nocturnal enuresis. Laser acupuncture was described as predefined acupuncture points being stimulated for 30 seconds each at each visit, children had 3 sessions a week and had between 10 and 15 sessions in total; children receiving desmopressin had 20 micrograms intranasal desmopressin, which was increased to 40 micrograms if needed.

Table 21-13Laser acupuncture compared to desmopressin - Clinical summary of findings

OutcomeLaser acupunctureDesmopressinRelative risk (95% CI)Absolute effectQuality
Number of children who achieved at greater than 90% improvement in the number of dry nights13/20 (65%)15/20 (75%)RR 0.87 (0.58 to 1.3)97 fewer per 1000 (from 315 fewer to 225 more)VERY LOW
Number of children who achieved 50% to 90% improvement in the number of dry nights2/20 (10%)2/20 (10%)RR 1 (0.16 to 6.42)0 fewer per 1000 (from 84 fewer to 542 more)VERY LOW

21.2.1.10. Electro-acupuncture for children with monosymptomatic nocturnal enuresis

One observational trial, Bjorkstrom (2000) 171 considered electro-acupuncture for children with monosymptomatic nocturnal enuresis. Children had twenty 30 minute sessions of electro-acupuncture over 8 weeks of treatment. Electro-acupuncture was described as the child was placed in a supine relaxed position, 7 disposable needles were placed at specific points. For the first 3 sessions these were manual stimulated, after this 2 pairs of needles were connected to an electro-stimulator.

21.2.2. Network Meta-Analysis

Homotoxicological remedies were amongst the interventions included in a network meta-analyses of interventions used for nocturnal enuresis. The summary of results of this analysis is presented in chapter 24 and a detailed description of the analysis is presented in appendix F. If studies did not meet the inclusion criteria of the network meta-analysis protocol as stated in appendix F they were not included in the network meta-analysis

21.2.3. Evidence statements

Studies including children with bedwetting and possible daytime symptoms

Hypnotherapy compared to imipramine (children with had severe bedwetting)
Banjerjee (1993) 165
  • One study showed there was no statistically significant difference in the number of children who became dry or had a reduced number of wet nights between children treated with hypnotherapy and children treated with imipramine. Relative risk 0.95, 95% CI 0.68, 1.32. Children had an age range of 5 to 16 years and had 3 months of treatment.
  • One study showed children treated with imipramine were more likely to relapse at 6 months compared to children treated with hypnotherapy. Relative risk 0.08, 95% CI 0.01, 0.56. Children had an age range of 5 to 16 years and had 3 months of treatment.

Studies including children with bedwetting only

Acupuncture compared to sham acupuncture
Mao (1998) 166
  • One study showed children treated with acupuncture were more likely to achieve 14 consecutive dry nights compared to children treated with sham acupuncture. Relative risk 1.73, 95% CI 1.09, 2.76. Children had an age range of 5 to 15 years, the length of treatment varied depending upon response.
  • One study showed children treated with acupuncture were less likely to fail to achieve 14 consecutive dry nights or relapse after treatment compared to children treated with sham acupuncture. Relative risk 0.67, 95% CI 0.48, 0.94. Children had an age range of 5 to 15 years, the length of treatment varied depending upon response.
Chiropractic treatment compared to no treatment
Leboeuf (1991) 167
  • One study showed children who had no treatment had 0.5 fewer wet nights per week at the end of treatment compared to children who had chiropractic treatment. No information on variability was given in the study, therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 8.3 years and had 2 weeks of treatment.
Chiropractic treatment compared to sham chiropractic treatment
Reed (1994) 168
  • One study showed there was no statistically significant difference in the number of children who achieved a greater than 50% improvement in the number of dry nights between children treated with chiropractic treatment and children treated with sham chiropractic treatment. Relative risk 8.5, 95% CI 0.52, 138.16. Children had an age range of 5 to 13 years and had 10 weeks of treatment.
  • One study showed children treated with chiropractic treatment had fewer wet nights per 2 weeks at follow up compared to children treated with sham chiropractic treatment. Mean difference −3.6, 95% CI −5.93, −1.27. Children had an age range of 5 to 13 years and had 10 weeks of treatment.
Homotoxicological remedies compared to placebo
Ferrara (2008) 124
  • One study showed children treated with homotoxicological remedies were more likely to achieve 14 consecutive dry nights compared to children treated with placebo. Relative risk 21.41, 95% CI 1.29, 355.87. Children had a mean age of 8.5 years and had 3 months of treatment.
Homotoxicological remedies compared to desmopressin
Ferrara (2008) 124
  • One study showed children treated with desmopressin were more likely to achieve 14 consecutive dry nights compared to children treated with homotoxicological remedies. Relative risk 0.38, 95% CI 0.21, 0.71. Children had a mean age of 8.5 years and had 3 months of treatment.
Hypnotherapy compared to no treatment
Edwards (1985) 169
  • One study showed children treated with trance with suggestions had 2.4 fewer wet nights per week at the end of treatment compared to children who had no treatment. No information on variability was given in the study, therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.
  • One study showed children treated with trance with suggestions had 1.5 fewer wet nights per week at follow up compared to children who had no treatment. No information on variability was given in the study. Therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.
  • One study showed children treated with trance without suggestions had 2.7 fewer wet nights per week at the end of treatment compared to children who had no treatment. No information on variability was given in the study. Therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.
  • One study showed children treated with trance without suggestions had 2.3 fewer wet nights per week at follow up compared to children who had no treatment. No information on variability was given in the study. Therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.
  • One study showed children treated with suggestions without trance had 2.4 fewer wet nights per week at the end of treatment compared to children who had no treatment. No information on variability was given in the study. Therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.
  • One study showed children treated with suggestions without trance had 1.8 fewer wet nights per week at follow up compared to children who had no treatment. No information on variability was given in the study. Therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.
Types of hypnotherapy
Edwards (1985) 169
  • One study showed the was no difference in the mean number of wet nights per week at the end of treatment between children treated with trance with suggestions compared to children treated with suggestions without trance. No information on variability was given in the study. Therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.
  • One study showed children treated with suggestions without trance had 0.3 fewer wet nights per week at follow up compared to children treated with trance with suggestions. No information on variability was given in the study. Therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.
  • One study showed children treated with trance without suggestions had 0.3 fewer wet nights per week at the end of treatment compared to children treated with suggestions without trance. No information on variability was given in the study. Therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.
  • One study showed children treated with trance without suggestions had 0.5 fewer wet nights per week at follow up compared to children treated with suggestions without trance. No information on variability was given in the study. T therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.
  • One study showed children treated with trance without suggestions had 0.3 fewer wet nights per week at the end of treatment compared to children treated with trance with suggestions. No information on variability was given in the study. Therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.
  • One study showed children treated with trance without suggestions had 0.8 fewer wet nights per week at follow up compared to children treated with trance with suggestions. No information on variability was given in the study. Therefore calculation of standard deviation was not possible and the mean difference and CI were not estimable. Children had a mean age of 10.5 years and had 6 weeks of treatment.

Studies including children with monosymptomatic nocturnal enuresis

Laser acupuncture compared to desmopressin
Radmayr (2001) 170
  • One study showed there was no statistically significant difference in the number of children who achieved greater than 90% improvement in the number of wet nights between children treated with laser acupuncture and children treated with desmopressin. Relative risk 0.87, 95% CI 0.58, 1.3. Children had a mean age of 8.6 years in the desmopressin group and 8 years in the acupuncture group and had 3 months of treatment.
  • One study showed there was no difference in the number of children who achieved 50% to 90% improvement in the number of wet nights between children treated with laser acupuncture and children treated with desmopressin. Relative risk 1, 95% CI 0.16, 6.42. Children had a mean age of 8.6 years in the desmopressin group and 8 years in the acupuncture group and had 3 months of treatment.
Electro-acupuncture
Bjorkstom (2000) 171
  • One observational study showed children treated with electro-acupuncture had an increase in the mean number of dry nights during 8 weeks of treatment. Children had a mean age of 10.3 years and had 8 weeks of treatment.
  • One observational study showed children treated with electro-acupuncture had an increase in the mean number of dry nights at 3 and 6 months follow up. Children had a mean age of 10.3 years and had 8 weeks of treatment.
  • One observational study showed 8% of children treated with electro-acupuncture achieved 90% reduction in the number of wet nights at the end of treatment. Children had a mean age of 10.3 years and had 8 weeks of treatment.
  • One observational study showed 22% of children treated with electro-acupuncture achieved 90% reduction in the number of wet nights at 3 months follow up. Children had a mean age of 10.3 years and had 8 weeks of treatment.
  • One observational study showed 22% of children treated with electro-acupuncture achieved 90% reduction in the number of wet nights at 6 months follow up. Children had a mean age of 10.3 years and had 8 weeks of treatment.
  • One observational study showed 26% of children treated with electro-acupuncture achieved 50% to 90% reduction in the number of wet nights at 6 months follow up. Children had a mean age of 10.3 years and had 8 weeks of treatment.

NCGC network meta-analysis (see appendix F)

  • The NCGC NMA showed there was no statistically significant difference in the number of children who achieved a full response between children treated with homotoxicological remedy and no treatment/placebo. Relative risk 4.969, 95% CI 0.820, 9.032. Children had an age range of 5 to 17 years and treatment for a minimum of 8 weeks.

For estimates of treatment effect relative to other active comparators, please see section 24.4 in chapter 24.

21.2.4. Evidence to recommendations

Relative values of different outcomes

The GDG considered the children, young people and parents or carers starting treatment for bedwetting were seeking an outcome of sustained dryness. A number of different outcomes were used to capture this: the outcome of 14 consecutive dry nights, reduction in wet nights and the mean number of wet nights allow evaluation of the effectiveness of treatment. Follow up rates where available can indicate sustained dryness.

Trade off between clinical benefit and harms

No evidence of harm was found.

Economic considerations

No health economic evidence was available and the clinical evidence was insufficient to make a recommendation for acupuncture, hypnotherapy and chiropractic. It is highly uncertain as to whether these interventions would represent good value for money.

Quality of evidence (this includes clinical and economic)

The available clinical evidence was poor.

Other considerations

Accupuncture: Three studies each considering different types of acupuncture, with a range of results. All studies appeared to show some improvement with the result from laser acupuncture the clearest. In this study there appeared some equivalence between the effect of laser acupuncture and desmopressin which is a recognized treatment with a larger evidence base for its use.

The GDG considered that the evidence suggested that acupuncture might be of some benefit. There was insufficient evidence to recommend acupuncture but the GDG considered it an important research recommendation for acupuncture to be evaluated further.

Hypnotherapy: One small study compared hypnotherapy to imipramine and children treated with hypnotherapy were less likely to relapse. The GDG considered that hypnotherapy may work in similar ways to CBT treatment in that the child or young person learns more about their problem and may be likely to engage more fully with the behavioral components of management.

The GDG made a research recommendation for further research on hypnotherapy as a treatment for bedwetting.

Chiropractic treatment: The evidence review found no evidence for effectiveness of chiropractic treatment in bedwetting. One relatively large study comparing chiropractic treatment to no treatment reported that children or young people who had no treatment had 0.5 fewer wet nights per week but did report any statistical information. Study reported adverse effects (2%)

Homotoxicological remedies: A single well conducted study showed homotoxicological remedies are significantly more effective than placebo but significantly less effective than desmopressin. Confidence interval was quite wide and the GDG considered that the outcomes in the placebo arm were poorer than expected. It is unclear what the intervention is, why the ingredients were used and the GDG did not consider the evidence adequate to recommend use or to recommend research in this area.

21.2.5. Recommendations

No recommendations were made

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