Background:
Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults.
Objectives:
To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions.
Search methods:
We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 February 2007) and the reference lists of relevant articles.Selection criteria: All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods.
Data collection and analysis:
Two reviewers independently assessed the quality of the eligible trials, and extracted data.
Main results:
Fifty six trials met the inclusion criteria, involving 3257 children of whom 2412 used an alarm. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods.Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45 of 81 (55%) versus 80 of 81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95% CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents.Although desmopressin may have a more immediate effect, alarms appeared to be as effective by the end of a course of treatment (RR 0.85, 95% CI 0.53 to 1.37) but their relative effectiveness after stopping treatment was unclear from two small trials which compared them directly. Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were not significantly better than tricyclics during treatment (RR 0.59, 95% CI 0.32 to 1.09) but the relapse rate was less afterwards (7 of 12 (58%) versus 12 of 12 (100%), RR 0.58, 95% CI 0.36 to 0.94). However, other Cochrane reviews of desmopressin and tricyclics suggest that drug treatment alone, while effective for some children during treatment, is unlikely to be followed by sustained cure as almost all the children relapse.
Authors' conclusions:
Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics because around half the children remain dry after alarm treatment stops. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.
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