Enuresis (Bedwetting)

For some time now, patient compliance with paper bladder diaries is being questioned. Paper bladder diaries are often incomplete, unreliable and/or of low quality. Multiple electronic bladder diaries have been developed to overcome some of the limitations associated with paper bladder diaries. However, based on several comparison studies between paper and electronic bladder diaries, it is not clear whether an electronic format alone is truly superior to the paper format. The investigators want to introduce and evaluate the feasibility of a new type of bladder diary: an automated bladder diary. In contrast to an electronic diary, an automated diary automatically registers voiding data using a connected measuring device. An electronic diary simply eliminates the use of paper, but the patient still needs to measure the voided volumes with a urinary container and manually enter them in the electronic diary. The investigators believe an automated diary may lead to improved patient compliance by reducing the required efforts from the patient and instead provide guidance and prompts.

Nocturnal Enuresis (NE) is defined as the involuntary passage of urine during sleep past the age of usual control, which is considered a developmental age of 5 to 7 years. NE is a common problem that causes distress to both children and their families. It has an adverse impact on behavior and social life, affects self-esteem, and can result in poor emotional well-being. In Egypt, the prevalence of NE in primary school children is about 15.4%. The family history was seen to have had a markedly significant impact on the occurrence of NE in the studied children. The mainstay of treatment is urotherapy with information and psychoeducation about normal lower urinary tract function, the underlying cause of MNE, disturbed bladder dysfunction in the child with NMNE, and instructions about therapeutic strategies. Alarm therapy and desmopressin are effective in randomized trials. Children with NMNE first need treatment of the underlying daytime functional bladder problem before treatment of nocturnal enuresis.

Urinary incontinence is defined by the International Children's Continence Society as involuntary urinary leakage that can be continuous or intermittent in children aged five and over. Urinary incontinence is divided into subgroups of daytime incontinence, nocturnal enuresis and combined daytime incontinence and nocturnal enuresis. Different pelvic floor rehabilitation programs appear to be effective in children with daytime incontinence and nocturnal enuresis but mostly focus on the pelvic floor muscle training component. However, pelvic floor rehabilitation includes many components such as education, lifestyle changes, manual techniques, pelvic floor muscle training, functional exercises, biofeedback therapy, electrical stimulation and home program. However, there is no study examining the effectiveness of a multimodal pelvic floor rehabilitation program in the treatment of children with urinary incontinence. It is also unclear for which urinary incontinence type the multimodal pelvic floor rehabilitation program will be more effective. Therefore, investigators aim to compare the effects of a multimodal pelvic floor rehabilitation program on lower urinary tract symptoms, pelvic floor muscles and other related muscle functions in children with different urinary incontinence types. Children between the ages of 5 and 18 who were diagnosed with urinary incontinence by applying to Ege University Faculty of Medicine, Department of Pediatric Urology will be included in the study. Participants will be divided into three groups: daytime incontinence, nocturnal enuresis, and combined daytime incontinence and nocturnal enuresis. A multimodal pelvic floor rehabilitation program will be performed on all children for 10 weeks, two days a week and approximately 45 minutes. A multimodal pelvic floor rehabilitation program will include education, bladder and bowel training, manual techniques, exercise training (diaphragmatic breathing exercise, pelvic floor muscle training, trunk stabilization exercises based on developmental kinesiology) and a home program. Children's lower urinary symptoms will be assessed with the Dysfunctional Voiding and Incontinence Scoring System, Bladder and Bowel Dysfunction Questionnaire, Childhood Bladder and Bowel Dysfunction Questionnaire, bladder and bowel diary, and the functions of the pelvic floor muscles and other related muscles will be assessed with superficial electromyography and ultrasonography.

Nocturnal enuresis (NE) is defined as nighttime urinary incontinence (bedwetting) during sleep in a healthy child older than five years, occurring at least twice a week for at least three consecutive months, sufficient to wet most or all of the sleeping area. NE is categorized into two types based on the presence or absence of daytime lower urinary tract symptoms (LUTS): monosymptomatic nocturnal enuresis (MNE) and non-monosymptomatic nocturnal enuresis (NMNE). MNE refers to involuntary nighttime urinary incontinence during sleep in children older than five years without any congenital or acquired urological or central nervous system (CNS) disorders and without daytime LUTS. Approximately 80% of children diagnosed with NE are classified as having MNE. NE is further subdivided into primary and secondary subgroups based on the onset period. Primary NE refers to children who have had less than six months of dryness since toilet training, whereas secondary NE is diagnosed in children who have experienced six months or more of dryness since toilet training . In summary, primary MNE is used to diagnose children who have had less than six months of nighttime dryness since toilet training and lack daytime LUTS. NE, previously viewed as a psychiatric disorder, is now understood to involve a variety of mechanisms and multifactorial causes. Studies suggest that children with NE exhibit a range of symptoms across different systems. The current understanding of NE's etiology includes three main factors:reduced noctural bladder capacity, nocturnal polyuria and decreased arousability during sleep. Treatment options for MNE include urotherapy (healthy bladder and bowel training), enuresis alarms (bedwetting alarms), and pharmacological agents such as desmopressin acetate (DDAVP), anticholinergics, and tricyclic antidepressants. These methods can be used alone or in combination for the treatment of MNE. Among first-line treatments, enuresis alarms (evidence level 1A) and DDAVP (evidence level 1A) are widely accepted approaches in pediatric urology. It is estimated that approximately one-third of enuretic children may require additional treatment following first-line interventions. DDAVP is a pharmacological agent developed as an analog of vasopressin or antidiuretic hormone. Its antienuretic effect reduces the volume of urine produced overnight, allowing the bladder to store the produced urine. Literature reports that about one-third of children undergoing DDAVP therapy achieve reliable dryness while on the medication, another third experience moderate benefits, and the remaining third see no benefit Although high relapse rates of NE have been reported following the cessation of DDAVP treatment, a recent meta-analysis showed that structured dose-dependent discontinuation of DDAVP provides better relapse-free rates. Although DDAVP and alarm therapy, both with evidence level 1A, are established first-line treatments for MNE, research continues into additional therapies and complementary approaches that may enhance treatment success. These include chiropractic therapy, homeopathy, pelvic floor exercises, electrotherapy, breathing exercises, hypnosis, Ayurveda, reflexology, traditional Chinese and Iranian medicine, massage, yoga, and herbal treatments. Considering the potential pharmacological side effects and the lack of adherence among families, DDAVP alone may be insufficient for treating PMNE. Additionally, given the deviations in pelvic floor muscle (PFM) activation values reported in enuretic children, it is necessary to investigate a combined approach incorporating PFM rehabilitation into medical treatment for children diagnosed with PMNE. The study's hypothesize is Structured Pelvic Floor Muscle Rehabilitation (SPFMR), applied to children with PMNE who are already receiving DDAVP therapy (as prescribed by a pediatric urology physician), will reduce the frequency and severity of enuresis episodes and decrease relapse rates in both short- and long-term follow-ups. The study protocol will adhere to applicable regulations, the current Declaration of Helsinki, and the principles of Good Clinical Practice. Since participants are under the age of 18, written and verbal consent will be obtained from their parents. The study will commence after receiving ethics committee approval and completing the clinical trial registration. Physiotherapy Modalities to Be Used in Structured Pelvic Floor Muscle Rehabilitation (SPFMR): \- Diaphragmatic Breathing Training: The diaphragm is not only a respiratory muscle but also a part of the core system. It works synergistically with PFM to ensure the proper function of the pelvic floor. \]. The diaphragm plays a vital role in generating proper intra-abdominal pressure and transmitting it from the cranial to the caudal regions. Additionally, the pushing pressure generated by the diaphragm is crucial for voiding (urination, defecation, and childbirth) and the functional activity of PFM. In PFMRG, diaphragmatic breathing exercises will involve inhaling through the nose for 4 seconds and exhaling through the mouth for 8 seconds in a series of 30 repetitions lasting approximately 6 minutes. Breaks will be given in case of dizziness or discomfort, after which the exercises will resume. \- Biofeedback-Assisted PFM Training Biofeedback therapy is a non-invasive, easily accessible technique for treating pediatric pelvic floor dysfunction. As a physical therapy modality, biofeedback aims to train appropriate PFM activity essential for normal, healthy bowel and bladder function. Electromyographic biofeedback is the most commonly used type for treating these dysfunctions. Biofeedback therapy is an instrument-based learning process that uses operant conditioning. It provides visual, auditory, and verbal feedback to promote self-control over physiological processes that are otherwise outside awareness or under limited voluntary control, such as autonomic and neuromuscular activity. Before starting each session, the microvolt value produced by submaximal muscle contraction will be measured three times and recorded using the Libert Phenix device. The CE certificate and registration of the device with the Ministry of Health are provided. Subsequently, PFM will be trained with 15-second phasic contractions at 30%, 60%, and 90% of submaximal strength, followed by 10 seconds of relaxation to achieve basal relaxation. Each phasic contraction training period will be completed in 25 seconds. The phasic training period will include 24 repetitions completed in 600 seconds (10 minutes). Following phasic contraction training, tonic contraction exercises will be performed at 30% muscle contraction based on recorded submaximal activation. Each tonic contraction will last for 10 seconds, followed by a 10-second relaxation period to achieve basal relaxation, with one tonic contraction cycle completed in 20 seconds. The tonic contraction training period will consist of 30 repetitions, completed in 600 seconds (10 minutes). The endurance training, starting at 30%, will gradually progress to 40%, 50%, 60%, and 80%. SPFMRG participants will be taught to perform proper PFM contractions without engaging their adductor or gluteal muscles. Training will begin in the supine position and progress to seated and then standing positions to introduce gravitational effects over the weeks. \- Core Stabilization and Combined Squat Exercises: In addition to ensuring continence and supporting various pelvic organs, PFMs are a component of the local stabilization system, playing a critical role in the lumbopelvic region in association with the transversus abdominis and multifidus muscles. These muscles work synergistically with other muscles surrounding the abdominal cavity, such as the anterolateral abdominal muscles and thoracic diaphragm, to regulate intra-abdominal pressure and ensure abdominal stability. Core stabilization exercises will follow the Dynamic Neuromuscular Stabilization (DNS) method, based on developmental kinesiology. DNS focuses on the integrated spinal stabilization system, targeting deep cervical flexors, the diaphragm, transversus abdominis, multifidus, and PFMs, by mimicking stabilization patterns observed in healthy infants. DNS exercises aim to activate the spinal stabilization system effectively through repetition and help individuals regain control during various tasks. While DNS methods have been studied for urinary incontinence in adults, studies are needed on pediatric incontinence. DNS methods have been applied in pediatric populations with cerebral palsy. DNS Exercises: * Crawling Bug: Supine position with a 55 cm Pilates ball positioned between the feet and hands, rotating the ball 5 times x 3 sets. * Rocking Bear: Quadruped position, lifting and lowering the knees 5 cm above the mat, 10 repetitions x 3 sets. * Reaching Cat: Cross-extension exercise with a resistance band looped around the foot, one end held by the participant in a quadruped position, 10 repetitions x 3 sets. * Showering Elephant: Holding a 55 cm Pilates ball between the hands, synchronizing squats with lifting the ball to shoulder height, 10 repetitions x 3 sets. * External Rotator and Adductor Strengthening: Strengthening the external rotator muscles, including the obturator internus (OI), has been shown to play a synergistic role in enhancing PFM function and strength. It has also been reported as an easily applicable and comprehensible auxiliary exercise for women with reduced PFM contraction ability. While studies on the role of OI in PFM rehabilitation are abundant in adult women, pediatric studies are limited and primarily case studies . Participants will perform abduction and external rotation of the lower extremities with a resistance band placed between the knees, 10 repetitions x 3 set. While studies on the role of OI in PFM rehabilitation are abundant in adult women, pediatric studies are limited and primarily case studies. Participants will perform abduction and external rotation of the lower extremities with a resistance band placed between the knees, 10 repetitions x 3 set. \- Balance Training: Participants will perform balance exercises on a Bosu ball in both double-leg and single-leg stances, with eyes open and closed, for 30 seconds x 3 sets. \- Home Exercises: Participants will be asked to perform the following home exercises three times per week. * Diaphragmatic breathing exercises: Inhaling for 4 seconds, exhaling for 8 seconds, 30 repetitions (approximately 6 minutes). * PFM contractions: 10 seconds of contraction, followed by 10 seconds of relaxation, for 6 cycles. * 10 squat exercises. * Crawling Bug and Rocking Bear exercises: 30 seconds x 3 sets. Participants will be provided with a home exercise tracking chart, monitored weekly by the research physiotherapist. After the treatment, participants' dry nights and symptoms will be converted into percentages following the ICCS treatment outcome recommendations. According to this recommendation, a reduction of less than 50% in symptoms will be considered no response to treatment; a reduction of 50% to 99% in symptoms will be considered a partial response, and the complete resolution of symptoms (100% reduction) will be considered full success.

Background: According to International Children's Continence Society, first-line treatment of children with daytime urinary incontinence is standard urotherapy, eventually followed by pharmacotherapy of anticholinergics. The effect of medical treatment is sparsely investigated and primarily in non-randomized trials. Objectives: The primary objective is to evaluate if (1) combination therapy of solifenacin and mirabegron in low doses is superior to monotherapy of solifenacin in high dose and if (2) combination therapy of mirabegron and solifenacin in low doses is superior to monotherapy of mirabegron in high dose in treatment of daytime urinary incontinence among children aged 5 to 14 years who are none complete responders to respectively monotherapy of solifenacin in low dose or monotherapy of mirabegron in low dose. The secondary objective is to evaluate the treatment response of combination therapy of solifenacin and mirabegron in low doses, monotherapy in high dose and monotherapy in low doses as supplementary comparisons. Additionally, the secondary objective is to evaluate side effects, safety, and tolerability of the medical treatment as well as the effect of treatment on well-being and quality of life. Study design: The BeDry study is designed as a multicenter, randomized, single-blinded, controlled clinical trial. Included children will be randomized 1:1:1:1 to one of four treatment groups. Children aged 5-14 years diagnosed with daytime urinary incontinence refractory to standard urotherapy will be randomized. Initially two groups will receive solifenacin 5 mg and two groups will receive mirabegron 25 mg. After 6 weeks, non-complete respondsers will receive add-on treatment according to their primary randomization group; group 1A will reviece solifenacin 5 mg and add-on solifenacin 5 mg, group 1B will receive solifenacin 5 mg and add-on mirabegron 25 mg, group 2A will receive mirabegron 25 mg and add-on mirabegron 25 mg, group 2B will receive mirabegron 25 mg and add-on solifenacin 5 mg. Total treatment period will be 18 weeks. The primary endpoint measure is treatment response assessed by change from visit 2 to end of study, according to number of wet days pr. 7 days by DryPie. Perspectives: The trial has the potential to optimize medical treatment of children with daytime urinary incontinence, to shorten the treatment period, diminish side effects and minimized unnecessary medical expenses. Ethics: All pharmacological side effects will be handled in accordance with the Danish legislation. No risk or unknown side effects are expected to urotherapy, medical treatment or withdrawal. No risks are expected by the clinical examination and paraclinical measurements. The therapeutic potential for future patients justifies the project to be carried out. Participation in this study will not lead to any disadvantages for the patient in their treatment. The study will be conducted in accordance with the protocol, applicable regulatory requirements according to Good Clinical Practice and the ethical principles of the Declaration of Helsinki. The study is approved by the authorities. Significant additions or changes to the protocol may be conducted after the application for amendment is approved by the Regulatory Authority and the Ethics Committee. Information regarding the participants is protected according to the General Data Protection Regulation and the actual law. The study is registered at the research inventory of the Regions of Denmark (1-16-02-210-24) and at Aarhus University (ARG-2024-731-23829). The study is registered and authorized at CTIS (EU CT 2023-510187-13-00).

Lymphoedema is caused by malfunction of the lymphatic system whether or not in combination with extra load on this system. Some patients develop lymphoedema after treatment for cancer: secondary lymphoedema or acquired lymphoedema. In 2018, 11 645 patients in Belgium were diagnosed with urogenital cancer cancer, including prostate and bladder cancer. A possible treatment consists of prostatectomy or cystectomy in combination with transperitoneal pelvic lymph node dissection. Patients who undergo treatment for cancer may develop lower limb lymphoedema or lymphoedema at midline. To the researchers knowledge, investigation of incidence of lower limb lymphoedema (LLL) is limited. Also, the prognostic variables for the development of LLL are unknown. Furthermore, no scientific evidence consists regarding which (combination of) clinical measurement methods are most sensitive to detect early LLL after transperitoneal pelvic lymph node dissection. Thresholds to identify subclinical lymphoedema in one or both legs are lacking. Besides lymphoedema in the lower limbs, treatment for cancer also often results in urinary problems. Especially urinary stress incontinence has been described in literature. However, in clinical practice, it is clear that prostatectomy is often associated with other urinary complications, as nocturia and nocturnal polyuria. To the researchers knowledge, there are no trials investigating the prognostic variables for the development of nocturia/ nocturnal polyuria after transperitoneal pelvic lymph node dissection for urogenital cancer. Therefore, the researchers will execute a trial investigating the epidemiology (i. e incidence, prevalence and prognostic variables), detection methods and the feasibility of a trial about the early treatment of LLL after transperitoneal pelvic lymph node dissection for urogenital cancer. The epidemiology of LLL, nocturia and nocturnal polyuria will be investigated. Participants: 150 patients undergoing a transperitoneal pelvic lymph node dissection for urogenital cancer will be included. These participants will be followed-up from baseline (pre-surgery) until 1 year post-surgery. All participants are evaluated at the University Hospitals Leuven, campus Gasthuisberg. Procedure: The potential participant will be screened first to see if the patients meets the inclusion criteria. After signing the informed consent form, the participant will be followed in the prospective observational trial. The duration of the prospective observational trial is 2 years. Participants can be included until 1 year after the start of the trial. Evaluation: There will be clinical evaluation of lymphoedema as well as treatment for lymphoedema. Participants in the prospective observational trial will be evaluated 4 times: baseline (pre-surgery), 6 weeks, 6 and 12 months post-surgery. Treatment: All participants in the prospective observational trial receive standard of care. This consists out of information, skincare and exercises. The information about lymphoedema and its prevention is given by the physical therapist of the department of urology during the hospital stay. Skincare consists of daily moisturizer of legs and feet and prevention and care of wounds. The exercises are supervised by the home physical therapist. The frequency of the session at the physical therapist are gradually decreased.

The present study will use a within-person, randomized cross-over experimental design to test the effects of exogenous melatonin supplementation on the sleep and daytime functioning of typically developing adolescents with short or disrupted sleep of behavioral origins (i.e., difficulty falling asleep, staying asleep, or premature waking resulting in short or disrupted sleep not attributed to an organic sleep condition).

This randomized controlled trial aims to evaluate the clinical efficacy of the Micturition Desire-Relaxation Training Device in managing LUTD in children over a six-month period. A stratified block randomization method will be used, matching participants based on sex, age, and enuresis frequency. Eligible participants will be stratified by sex and age, and then randomly assigned (1:1) to either the intervention group or the sham intervention group using a computer-generated sequence. This method ensures group balance regarding baseline characteristics and enuresis severity. In the intervention group, baseline voiding diaries will be completed prior to initiating training. The first session will be supervised by trained medical personnel, during which participants and caregivers will receive standardized instruction in device usage and bladder relaxation techniques. Each session will last approximately 10 minutes and will be conducted 3-4 times during the initial instructional phase. The device will then be provided for home use at no cost. Caregivers will receive remote support from study physicians during the intervention period. Home-based training will include 5-10 sessions per day, each lasting 10 minutes. Daily records-including images of urine output, session duration, and any adverse events-will be uploaded to a secure cloud platform for physician review. The intervention will continue for 8 weeks. Monthly records of fluid intake and voiding behavior will be maintained throughout the study. Follow-up assessments, including voiding diaries and enuresis questionnaires, will be performed at 3 and 6 months post-intervention to assess recurrence and long-term outcomes. The sham group will follow identical baseline and training schedules; however, the device will remain inactive during each session. After 4 weeks, participants in this group will submit fluid intake and voiding records. Primary outcome measures include the enuresis improvement rate, frequency of daytime urinary incontinence, and total number of voiding episodes within 24 hours. Secondary outcomes will include: scores for the micturition desire-awakening function, timing of enuresis events, bedtime and wake time, standardized bladder capacity, bladder variability rate, behavioral responses during incontinence, psychological/behavioral characteristics, and enuresis recurrence.

The aim of the study is to evaluate the role of sulbutiamine in treatment of monosymptomatic nocturnal enuresis in children by using it alone or as a combination therapy with tricyclic antidepressants (imipramine+sulbutiamine).

Nocturnal enuresis (NE) is defined as intermittent incontinence during sleep in a child aged 5 years or more in the absence of congenital anomalies of the urinary tract or congenital or acquired defects of the central nervous system. It affects 15-20% of children aged 5 years and 1-2% of adolescents with spontaneous recovery occurs at a rate of 10-15% per year. About 75% of affected children have primary nocturnal enuresis, who never attained continence for longer than 6 months during sleep. Patients with mono-symptomatic nocturnal enuresis (MNE) do not have any other symptoms of lower urinary tract dysfunction. The standard view of NE pathogenesis as being the result of either nocturnal polyuria or nocturnal detrusal overactivity with high arousal thresholds has become well-established, but further research now complicates the picture. First, Psychological/psychiatric problems are overrepresented in enuresis and might in a minority of cases have a causal or aggravating role. Second, Nocturnal polyuria is not always linked to vasopressin deficiency. Third, nocturnal detrusal overactivity is in itself pathogenetically heterogeneous, and could be linked to constipation. Fourth, Sleep of enuretic children might be "deep," but possibly also disturbed (by obstructed airways or a distended or contracting bladder). Standard first line treatments for MNE are alarm therapy or desmopressin. Alarm therapy conditions the child to inhibit urination during sleep or to wake to void when the bladder is full. Desmopressin decreases the amount of overnight urine produced, thereby reducing the need to wake to void. Tricyclic antidepressants are also sometimes used for treating enuresis. Combination therapy of desmopressin plus alarm is often taken into consideration when the patients are refractory to single treatment, have behavioral problems or frequent night-time enuresis. Anticholinergic agents (AA), such as tolterodine, oxybutynin and propiverine, can prevent involuntary detrusal contractions. They can significantly decrease urge incontinence in children. Desmopressin plus AA therapy is often used in non-responders to desmopressin monotherapy or in those with a restricted bladder capacity and thickened bladder wall. Desmopressin is more effective and has lower rate of side effects in comparison to Oxybutynin for treatment of NE. However, it has been proved that desmopressin plus AA combination (Oxybutynin or Solifenacin) therapy has higher response rates and lower relapse rates compared with desmopressin monotherapy as first-line treatment for children with primary mono-symptomatic nocturnal enuresis (PMNE) with an acceptable tolerability profile. This can be explained by bladder reservoir dysfunction during sleep which is relatively common in MNE. This phenomenon may explain treatment failure with desmopressin, despite adequate antidiuretic response. In combination therapy, desmopressin reduces urine production and the AA allows the bladder to store more urine due to increased functional bladder capacity. Adrenoceptors have two main groups, α and β, and several subtypes. β1-, 2- and 3-adrenoceptors have been identified in human urothelium and detrusor muscle, with β3 being highly expressed in the urinary bladder. β3-adrenoceptors have been demonstrated as the predominant subtype, with 95% of all β-adrenoceptor mRNA in the human bladder relating to this subtype; this receptor is thought to be important for mediating human detrusal relaxation. This is supported by animal studies in which β3-adrenoceptor agonists have been demonstrated to cause dose-dependent detrusal relaxation during the storage phase of the micturition cycle and to inhibit neurogenic detrusal overactivity during in vitro studies. Mirabegron, a β3-adrenoceptor agonist, improves storage function and subjective symptoms without affecting voiding function in women with OAB. To the best of our knowledge, no study used AA plus Mirabegron for treatment of PMNE In this study, we hypothesize that the combined detrusal relaxing effect of AA and β3- adrenoceptor agonist will produce better outcome regarding number of wet nights than desmopressin monotherapy in children with PMNE.