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
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| Outcome | Hypnotherapy | Imipramine | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who became completely dry or had a reduced number of wet nights | 18/25 (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 months | 1/18 (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
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| Outcome | Acupuncture | Sham acupuncture | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved 14 consecutive dry nights | 30/56 (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 treatment | 26/56 (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
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| Outcome | Chiropractic treatment | No treatment | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Mean number of wet nights per week at the end of 2 weeks of treatment | 100 | 71 | - | not pooled | VERY 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
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| Outcome | Chiropractic treatment | Sham chiropractic treatment | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who had greater than 50% improvement in the number of dry nights | 8/31 (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 up | 31 | 15 | - | 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
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| Outcome | Homotoxicological remedies | Placebo | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved 14 consecutive dry nights | 10/50 (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
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| Outcome | Homotoxicological remedies | Desmopressin | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved 14 consecutive dry nights | 10/50 (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
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| Outcome | Trance with suggestions | No treatment | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Mean number of wet nights per week at the end of treatment | 12 | 12 | - | not pooled | VERY LOW |
| Mean number of wet nights per week at follow up | 12 | 12 | - | not pooled | VERY LOW |
Table 21-8Suggestions without trance compared to no treatment - Clinical summary of findings
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| Outcome | Suggestions without trance | No treatment | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Mean number of wet nights per week at the end of treatment | 12 | 12 | - | not pooled | VERY LOW |
| Mean number of wet nights per week at follow up | 12 | 12 | - | not pooled | VERY LOW |
Table 21-9Trance without suggestions compared to no treatment - Clinical summary of findings
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| Outcome | Trance without suggestions | No treatment | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Mean number of wet nights per week at the end of treatment | 12 | 12 | - | not pooled | VERY LOW |
| Mean number of wet nights per week at follow up | 12 | 12 | - | not pooled | VERY 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
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| Outcome | Trance with suggestions | Suggestions without trance | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Mean number of wet nights per week at the end of treatment | 12 | 12 | - | not pooled | VERY LOW |
| Mean number of wet nights per week at follow up | 12 | 12 | - | not pooled | VERY LOW |
Table 21-11Trance with suggestions compared to trance without suggestions - Clinical summary of findings
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| Outcome | Trance with suggestions | Trance without suggestions | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Mean number of wet nights per week at the end of treatment | 12 | 12 | - | not pooled | VERY LOW |
| Mean number of wet nights per week at follow up | 12 | 12 | - | not pooled | VERY LOW |
Table 21-12Suggestions without trance compared to trance without suggestions - Clinical summary of findings
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| Outcome | Suggestions without trance | Trance without suggestions | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Mean number of wet nights per week at the end of treatment | 12 | 12 | - | not pooled | VERY LOW |
| Mean number of wet nights per week at follow up | 12 | 12 | - | not pooled | VERY 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
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| Outcome | Laser acupuncture | Desmopressin | Relative risk (95% CI) | Absolute effect | Quality |
|---|
| Number of children who achieved at greater than 90% improvement in the number of dry nights | 13/20 (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 nights | 2/20 (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.
21.2.4. 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.
