Complex behavioural and educational interventions for nocturnal enuresis in children

Cathryn MA Glazener; Jonathan HC Evans; Rachel E Peto

doi:10.1002/14651858.CD004668

. 2004 Jan 26;2004(1):CD004668. doi: 10.1002/14651858.CD004668

Complex behavioural and educational interventions for nocturnal enuresis in children

Cathryn MA Glazener ^1,^✉, Jonathan HC Evans ², Rachel E Peto ³

Editor: Cochrane Incontinence Group

PMCID: PMC12575883 PMID: 14974076

Abstract

Background

Nocturnal 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 complex behavioural and educational interventions on nocturnal enuresis in children, and to compare them with other interventions.

Search methods

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 20 March 2008) and the reference lists of relevant articles.

Selection criteria

All randomised or quasi‐randomised trials of complex behavioural or educational interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and physical behavioural methods, alarms, desmopressin, tricyclic antidepressants, and miscellaneous other interventions.

Data collection and analysis

Two review authors independently assessed the quality of the eligible trials, and extracted data.

Main results

Eighteen trials involving 1174 children were identified which included a complex or educational intervention for nocturnal enuresis. The trials were mostly small and some had methodological problems including the use of a quasi‐randomised method of concealment of allocation in three trials and baseline differences between the groups in another three.

A complex intervention (such as dry bed training (DBT) or full spectrum home training (FSHT)) including an alarm was better than no‐treatment control groups (for example the relative risk (RR) for failure or relapse after stopping DBT was 0.25; 95% CI 0.16 to 0.39) but there was not enough evidence about the effects of complex interventions alone if an alarm was not used. A complex intervention on its own was not as good as an alarm on its own or the intervention supplemented by an alarm (e.g. RR for failure or relapse after DBT alone versus DBT plus alarm was 2.81; 95% CI 1.80 to 4.38). On the other hand, a complex intervention supplemented by a bed alarm might reduce the relapse rate compared with the alarm on its own (e.g. RR for failure or relapse after DBT plus alarm versus alarm alone was 0.5; 95% CI 0.31 to 0.80).

There was not enough evidence to judge whether providing educational information about enuresis was effective, irrespective of method of delivery. There was some evidence that direct contact between families and therapists enhanced the effect of a complex intervention, and that increased contact and support enhanced a package of simple behavioural interventions, but these were addressed only in single trials and the results would need to be confirmed by further randomised controlled trials, in particular the effect on use of resources.

Authors' conclusions

Keywords: Child, Humans, Patient Education as Topic, Behavior Therapy, Behavior Therapy/methods, Enuresis, Enuresis/therapy, Exercise Therapy, Exercise Therapy/methods

Plain language summary

Complex behavioural and educational interventions for bedwetting (nocturnal enuresis) in children

Night‐time bedwetting is common in childhood, and can cause stigma, stress and inconvenience. Bed alarms are the treatments which currently appear to work best in the long term. Complex interventions such as dry bed training can also be tried. This involves, as well as using an alarm to wake the child after he or she has wet the bed, getting them to go to the toilet repeatedly and changing their own sheets. The review found 18 trials in 1174 children who had received this sort of training or another treatment. Although an alarm on its own was better than the dry bed training on its own, there was some evidence that using them together might reduce the relapse rate after stopping alarm treatment, and without the adverse effects of drug treatment. However, both using an alarm and dry bed training needs time and effort from the child and family. There was not enough research comparing complex interventions with other techniques.

Background

This is one of seven reviews of interventions for bedwetting, or non‐organic nocturnal enuresis. The others focus on: desmopressin (Glazener 2002), tricyclic antidepressants and related drugs (Glazener 2003a), other drugs (Glazener 2003b), simple behavioural training (Glazener 2004), alarms (Glazener 2005b) and complementary and miscellaneous other therapies (Glazener 2005a). All seven were originally based on the work of Lister‐Sharp and her colleagues at the Centre for Reviews and Dissemination at the University of York, UK (Lister‐Sharp 1997). The current review concerns the use of complex behavioural interventions (for example dry bed training (DBT) or full spectrum home training (FSHT)) or educational initiatives to train the child. It is restricted to children with monosymptomatic nocturnal enuresis who are treated with complex behavioural or educational interventions, and includes other interventions if they are compared with such methods or used in combination with them.

Description of the condition

Nocturnal enuresis is the involuntary loss of urine at night, in the absence of organic disease and at an age when a child could reasonably be expected to be dry (by consensus, at a developmental age of five years) (APA 1980; WHO 1992). Although bedwetting in itself is pathologically benign and has a high rate of spontaneous remission, it may bring social and emotional stigma, and stress and inconvenience to both the person with enuresis and their families (Fitzwater 1992). Children who wet the bed may experience parental disapproval, sibling teasing and repeated treatment failure which may all lower self esteem (Warzak 1992). The children may also be at increased risk of emotional and physical abuse (Warzak 1992). Consequently, it is important that enuresis is properly managed on 'humane grounds' (Moffatt 1994).

Although daytime wetting is a significant problem and is often associated with bedwetting, it is usually considered separately. It has been suggested that there are different aetiologies underlying the two conditions (Jarvelin 1989). If daytime symptoms are present, investigations to identify physical causes such as urinary tract dysfunction, congenital malformation and neurogenic disorders are usually necessary (Djurhuus 1992). An organic cause is more often found in children with daytime wetting; more structural abnormalities and functional disorders of the urinary tract were found in daytime wetters than controls (Jarvelin 1990).

Prevalences and causes

Nocturnal enuresis is a complaint that affects many families. Estimating the prevalence of nocturnal enuresis is difficult, however, due to the variation in methods of diagnosis and definitions used (de Jonge 1973; Krantz 1994). In the United Kingdom, the generally quoted prevalence rates are that 15% to 20% of five year olds, 7% of seven year olds, 5% of ten year olds, 2% to 3% of 12 to 14 year olds and 1% to 2% of those aged 15 and over wet the bed on average twice a week (Blackwell 1989; Rutter 1973). Historically, the incidence of nocturnal enuresis was particularly high amongst children in residential care (Morgan 1970). About 1% of adults remain enuretic. Without treatment, about 15% of bedwetting children become dry each year (Forsythe 1974). However, it is not possible to predict which children will become dry spontaneously (Doleys 1977a).

The causes of nocturnal enuresis are unclear (Lister‐Sharp 1997). Genetic (APA 1980; Bakwin 1971; Bakwin 1973; Eiberg 1995), physiological (Djurhuus 1992; Norgaard 1993) and psychological (Devlin 1991; Moffatt 1989; Rutter 1973; Shaffer 1977) factors, as well as delay in maturation of the mechanism for bladder control (Jarvelin 1989; Koff 1995), have been suggested. Other factors which may contribute to bedwetting include: constipation, sleep apnoea and upper airway obstructive symptoms (Maizels 1993); and diet and mild caffeine drinks with diuretic effects (for example cola) (Blackwell 1989).

Interventions

Pharmacological, behavioural and a variety of other interventions are commonly used for people who wet the bed.

Pharmacological interventions include desmopressin, tricyclic drugs (amitriptyline, dothiepin, doxepin, trimipramine, clomipramine, desipramine, imipramine, lofepramine, nortriptyline and protriptyline), drugs related to the tricyclics (viloxazine, mianserin and maprotiline), and a variety of other drugs (for example amphetamine, diazepam and oxybutynin).

Behavioural interventions include simple interventions such as lifting, waking, reward systems, alarms, overlearning, retention control training and stop‐start training, and complex behavioural interventions such as dry‐bed training (DBT) and full spectrum home training (FSHT).

Educational interventions include different methods of providing information for children and their parents, or different methods of teaching or explanation for any other enuresis intervention.

Other and complementary interventions include counselling, psychotherapy, surgery and complementary therapies.

The current review was restricted to complex behavioural interventions, defined as those which use a number of different behavioural interventions in combination, and educational interventions. Other interventions were included if they were compared with such programmes.

Description of the intervention

Complex behavioural treatment programmes

Complex behavioural interventions include dry‐bed training and full spectrum home training.

Dry‐bed training (DBT)

Dry bed training was initially developed in the early 1970s for use with adults with learning disabilities (Azrin 1973). The original schedule involved an intensive training night, during which the patient was woken every hour and taken to the toilet. If an accident occurred, reprimands consisting of 45 minutes of 'cleanliness training' (changing the bed) and 'positive practice' (patient practices getting up and going to the toilet about nine times) were implemented. On subsequent nights, the individual was woken once and taken to the toilet, this nightly 'waking' occurring progressively earlier. Because of inherent difficulties in implementing this regimen, it has been modified. Variants such as Modified DBT forgo the reprimands and positive practice elements (Butler 1988). DBT may or may not include the use of an alarm to supplement the other elements of the programme.

Full spectrum home training (FSHT)

Full spectrum home training (Houts 1983; Howe 1992) combines a urine alarm triggered by wetting with cleanliness training, retention control training (teaching the children to retain progressively larger volumes of urine in their bladders during the day in order to try to increase bladder capacity) and over‐learning. For this, after successful alarm treatment, the children are given extra drinks at bed‐time to cause additional stress to the detrusor muscles in the bladder. Alarm treatment is then continued until 14 consecutive dry nights are once again achieved (Blackwell 1989).

Educational interventions

Educational interventions may range from those providing background information to parents or children about enuresis to specific materials prepared to advise users about how to implement various treatments (such as alarms or DBT). Some trials have compared different methods of delivery, such as oral, written, computer‐based (CD‐ROM) or using a video presentation, or different settings for teaching, such as home or clinic based.

Other interventions which were included in this review as comparisons were as follows:

Enuresis alarms

Enuresis alarms consist of some kind of alarm which is activated by inappropriate micturition. The first enuresis alarms were bed‐based, the child sleeping on a pad or mat containing an electrical circuit. When urine wets the pad, it completes the circuit causing a bell to ring. The alarm is intended to change the meaning of the sensation of having a full bladder from a signal to urinate to a signal to inhibit urination and waken (Forsythe 1989). There are now many variations: the alarm may be a bell, buzzer, visual signal such as a light or may vibrate. There are also many different tones and intensities. In 'mini‐alarm' systems, the sensor is placed in the pants, producing a discrete, portable system. Overlearning may be used to supplement successful alarm treatment.

Overlearning

An over‐learning procedure may be initiated after successful alarm treatment (for example achievement of 14 consecutive dry nights). Extra drinks are given at bed‐time to cause additional stress to the detrusor muscles in the bladder. Alarm treatment is then continued until 14 consecutive dry nights are again achieved (Blackwell 1989).

Simple behavioural interventions

Psychological interventions assume that the ability to remain dry at night is a learned response which can be achieved using conditioning techniques if it has not arisen spontaneously. These interventions include lifting, wakening, fluid restriction and reward systems.

Lifting

Carers 'lift' the child, while still asleep, out of bed to allow them to urinate in an appropriate place. It has been argued that this practice is counterproductive for a number of reasons. These include the child being denied the opportunity to learn the sensations that a full bladder produces and the child being encouraged to urinate without waking (Butler 1994). On the other hand, some suggest that lifting is effective, precluding the need for professional help (Shaffer 1977).

Scheduled wakening

This intervention involves waking the child to allow them to get up and urinate (Warzak 1994). A scheduled waking programme may be used with the child being woken progressively earlier after dry nights until the interval between going to bed and scheduled waking is one hour. Older individuals may use an alarm clock to wake themselves (Blackwell 1989).

Fluid restriction

This is a measure frequently implemented by parents (Shaffer 1977). Children are discouraged from drinking fluids in the evening before going to bed. However, fluid restriction may aggravate a low functional bladder capacity (Sorotzkin 1984). Even so, it might be useful to restrict drinks with diuretic properties (for example those containing caffeine such as cola), before retiring (Novello 1987).

Reward systems

Reward systems (for example star charts) are behavioural interventions which use positive reinforcement to encourage a desired behaviour. The child is rewarded for attaining an achievable goal, such as remaining dry all night ‐ or if this is too ambitious, an intermediate goal such as getting up to go to the toilet. These schemes should be negotiated with the child and family. The positive reinforcement of dry nights can help to reduce the negative emphasis on wet beds. These are often the first type of treatments proposed (Stewart 1975). However, unless used with care, a child may feel a failure if the reward is not attained (Blackwell 1989).

Retention control training and stop‐start training

Retention control training is an attempt to increase the functional bladder capacity using exercises such as delaying urination for extended periods of time or drinking increased fluids, analogous to bladder training in adults (Warzak 1994). The rationale is that if the bladder can hold larger volumes of urine, it will not empty so soon at night. In a review of simple behavioural interventions, retention control training was compared with no‐treatment controls, desmopressin and an alarm (Glazener 2004). There was not enough reliable evidence for any of the comparisons apart from with alarms, which were more effective than retention control training in one small trial (Bennett 1985). Stream interruption exercises may also be recommended, also called stop‐start training, and analogous to pelvic floor muscle training in adults (Novello 1987). The rationale is that strengthening the pelvic floor will help the child to control their wetting at night. However, no trials of stop‐start training alone were identified in the review (Glazener 2004).

Why it is important to do this review

The wide variety of treatments for nocturnal enuresis indicates the lack of consensus as to which is the best. Provided that a sufficient number of trials of adequate quality have been conducted, the most reliable evidence is likely to come from consideration of all well‐designed randomised controlled trials. Hence, there is a need for an easily accessible, periodically updated, comprehensive systematic review of such studies, which will not only help to identify optimal practice, but also highlight gaps in the evidence base.

Objectives

To determine the effects of complex behavioural or educational interventions for the treatment of children with nocturnal enuresis.

The following interventions were tested:   1. a complex behavioural intervention versus no active (control) treatment;   2. one complex behavioural intervention alone versus another behavioural intervention;   3. a complex behavioural intervention in combination with another behavioural intervention versus a behavioural intervention alone;   4. one method of delivery of training for a complex behavioural intervention versus another one;   5. one component of a complex behavioural intervention or combination of components versus another;   6. a complex intervention versus drug therapy;   7. an educational intervention versus no treatment;   8. one educational intervention versus another.

Methods

Criteria for considering studies for this review

Types of studies

Randomised or quasi‐randomised trials of complex behavioural or educational interventions for the treatment of non‐organic nocturnal enuresis.

Types of participants

Children (as defined by the trialists, usually up to age 16) suffering from nocturnal enuresis. Trials which included children suffering from daytime enuresis or where some children may have had an organic cause contributing to their enuresis were only included if the primary problem was nocturnal enuresis.

Types of interventions

Complex behavioural interventions such as dry‐bed training (DBT) or full spectrum home training (FSHT), and educational interventions such as providing information or teaching about enuresis or its management (for example how to implement a complex intervention).   Comparisons included no active treatment, with and without alarms, stop‐start training (pelvic floor muscle training and bladder training), retention control training, reward systems and wakening.

Types of outcome measures

The outcomes considered in this review were:

change in the mean number of wet nights per week during treatment;
number of participants failing to attain 14 consecutive dry nights;
mean number of wet nights per week when participants were followed up after treatment had ceased;
number failing to attain 14 consecutive dry nights or subsequently relapsing; and
adverse events.

Timing of relapse and follow up were as defined by the trialists.

Search methods for identification of studies

This review has drawn on the search strategy developed for the Incontinence Review Group. Relevant trials were identified from the Cochrane Incontinence Group Specialised Register of controlled trials which is described under the Incontinence Group's details in The Cochrane Library (Please see the ‘Specialized Register’ section of the Group’s module in The Cochrane Library.). The register contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL and hand searching of journals and conference proceedings. The date of the most recent search of the register for this review: 20 March 2008.

The trials in the Cochrane Incontinence Group Specialised Register are also contained in CENTRAL.

The terms used to search the Cochrane Incontinence Group Trial Register are given below:   (TOPIC.URINE.ENURESIS*)   AND   ({DESIGN.CCT*} OR {DESIGN.RCT*})   (All searches were of the keyword field of Reference Manager 9.5 N, ISI ResearchSoft).

The reviewer authors also searched the reference lists of relevant articles. We did not impose any language or other restrictions on any of these searches.

Data collection and analysis

The studies for this review were assessed using the methods of The Cochrane Collaboration (Deeks 2005).

Selection of studies

The titles and, where possible, abstracts of all studies located by the searches were checked by two reviewer authors to identify those likely to be evaluations of the effects of interventions for nocturnal enuresis. Full papers were then obtained and assessed by two reviewer authors to identify those which met the inclusion criteria.

Data extraction and management

The data were extracted independently by two reviewer authors using a standard form. Differences were resolved by discussion.

Assessment of risk of bias in included studies

Each study was assessed using both general and specific quality criteria. The criteria applied were:

the level of concealment of random allocation in the trials (A = adequate method of concealment of allocation to groups, B = unclear, C = quasi‐randomised);
whether data to assess the comparability of groups at baseline were given, including baseline levels of wetting;
use of a 'wash‐out' period if a crossover design was employed;
intention‐to‐treat analysis;
whether outcomes were clearly defined;
blinding;
a follow up of at least three months or provision of follow‐up data;
whether useful data (for example means and standard deviations) were presented;
whether children with daytime wetting were specifically excluded;
whether children who had physical (organic) causes for their enuresis were specifically excluded.

However, none of these criteria were used to include or exclude trials.

Measures of treatment effect

Where appropriate, the results were converted to the mean and standard deviation of the number of wet nights per week; or the number of children failing to achieve cure during treatment, defined as 14 consecutive dry nights; or the number who were not cured during treatment plus those who relapsed after stopping active treatment (to allow for possible differences in initial 'success' rates). Where a mean value was reported with no standard deviation, we entered the data into 'Other data tables'.

Dealing with missing data

In general, dropouts were not taken into account and data were presented as given in the trial reports. However, if there was evidence of differential dropout from the groups which may have been caused by lack of response or adverse effects of the interventions, the data were recalculated as if the dropouts were failures.

Assessment of heterogeneity

Differences between trials were further investigated when statistically significant heterogeneity was found at the 10% probability level using the chi‐squared test or assessment of the I‐squared statistic (Higgins 2003), or appeared obvious from visual inspection of the results. If there was no obvious reason for the heterogeneity, or it persisted despite the removal of outlying trials, a random‐effects model could have been used. However, in the event this was not necessary.

Data synthesis

We intended, where possible, to calculate standardised effect sizes and 95% confidence intervals (CI); weighted mean differences (WMD) where outcomes were continuous variables and relative risks (RR) where they were binary. A fixed‐effect model was used to calculate the pooled estimates and the 95% CIs (Berlin 1989). The weighted mean differences were weighted by the inverse of the variance, and given as differences in number of wet nights per week. Negative values indicate fewer wet nights in the intervention group, at the left‐hand side of the tables.

Results

Description of studies

Results of the search

Of the studies identified for this review, 12 studies were excluded, and 18 trials were included. One study reference contained data from two trials (Houts 1987a; Houts 1987b).

Included studies

Size of trials

In the 18 included trials, a total of 1174 children were enrolled (an average of 65 per trial), of whom 746 received a complex behavioural or educational intervention. Total trial size ranged from 14 to 270 children. Further details are available in the Table Characteristics of included studies.

Interventions and comparisons

The complex or educational interventions identified comprised:

dry bed training (DBT) (Azrin 1974; Azrin 1978; Bennett 1985; Bollard 1981; Bollard 1982a; Bollard 1982b; Butler 1988; Butler 1990; Caceres 1982; Keating 1983; Nawaz 2002) including different components of DBT or different training regimens;
full spectrum home training (FSHT) (Houts 1986; Houts 1987a; Houts 1987b; van Kampen 2005) including different methods of teaching;
a 3‐step programme (reassurance to parents, bladder retention training and wakening using an alarm clock, and parental involvement) (Iester 1991);
a mixture of behavioural modifications (dietary and fluid adjustment, voiding schedules, double voiding, bedtime toileting, alarm clock once at night, pelvic floor training, environmental modifications, changes in parents' attitudes, improvement of self‐esteem, self care) (Fera 2004);
and two methods of delivery of educational information to families (enuresis information using written form versus multimedia on CD‐ROM, Redsell 2003); and live versus filmed delivery of FSHT (Houts 1987a; Houts 1987b).

The comparison interventions included no‐treatment or waiting list controls, alarms, stop‐start training (sphincter muscle exercises and bladder training), imipramine, desmopressin, pelvic floor muscle training and motivational therapy or counselling.

Ages of the children

The majority of the trials recruited children between the ages of 5 and 16 years, but none subdivided their results between younger children and teenagers. On average, the mean age was 8 to 10 years. Three trials included a few children younger than five years old (Azrin 1974; Azrin 1978; Keating 1983).

Settings and populations

Three trials recruited children from the community (Azrin 1974; Nawaz 2002; Redsell 2003); in three trials, children came from both community advertisements and referrals (Houts 1986; Houts 1987a; Houts 1987b); and the remaining trials did not give details but were mostly submitted from hospital clinics. None of the trials included children with special needs or from residential settings.

Previous treatment

In six trials, some of the children had failed with previous treatment (Bollard 1981; Bollard 1982a; Bollard 1982b; Butler 1988; Nawaz 2002; Redsell 2003); in two all had previously failed (Butler 1990; Caceres 1982); in another three, none had received previous treatment (Bennett 1985; Fera 2004; Iester 1991); and in the remainder this was not mentioned. However, if the children had been treated before, this was stopped during or before they entered the trial.

Duration of treatment

In six trials, treatment was continued for eight weeks or less (Azrin 1974; Azrin 1978; Bollard 1982b; Caceres 1982; Fera 2004; Keating 1983). In the remainder, children continued for 10 to 20 weeks, or until achieving 14 dry nights.

Excluded studies

Of the studies identified for this review, 12 were excluded, most often because they were not randomised controlled trials. In five cases, randomised controlled trials were excluded because they included mainly adults (Azrin 1973; Hanson 1988); all the children had daytime wetting (Smith 1979); because protocol violations resulted in children being moved from their assigned groups and, therefore, the data became unreliable (not intention‐to‐treat, Doleys 1977b); or because data from different RCTs were combined and control data not given (Whelan 1990). Details are given in the Table Characteristics of excluded studies.

Risk of bias in included studies

Allocation

Only one trial (Redsell 2003) used an adequate method of randomisation with secure concealment of allocation, but despite this there were some baseline differences between the groups. Three trials used an inadequate method of concealment of allocation (quasi‐randomisation) (Azrin 1974; Butler 1988; Butler 1990) and the remainder did not give enough detail for this to be assessed.

In three trials, the children were found to be not comparable at baseline on some or all factors (Bollard 1982b; Houts 1987a; Redsell 2003); and in another four they were found to be comparable (Fera 2004; Houts 1986; Keating 1983; Nawaz 2002). The remainder did not provide this information.

Incomplete outcome data

In three trials (Bollard 1981; Bollard 1982b; Keating 1983) continuous data were presented without measures of dispersion (SDs), and in the latter two, means had to be estimated from graphs. In one trial no data were useable in a meta‐analysis due to amalgamation of data from groups (Azrin 1974). In another (van Kampen 2005) no useable data were presented, nor were numbers of children per group given.

In seven of the trials, data were presented after treatment stopped (Bennett 1985; Bollard 1981; Houts 1986; Houts 1987a; Iester 1991; Keating 1983; Redsell 2003).

In six trials, a few children dropped out from each group (Bennett 1985; Bollard 1981; Butler 1990; Houts 1986; Keating 1983; van Kampen 2005). The remainder either reported that there were no dropouts or presented data for all included children. However, in one trial, 12 out of 20 children dropped out from one group only, DBT without an alarm (Bollard 1981). These were counted as failed in meta‐analyses as the trialists stated that these children dropped out because they had a poor response. In another trial, children were much less likely to comply with treatment if they were randomised to imipramine or three‐step therapy (compared with three‐step therapy supplemented by counselling and education), although follow up data were provided for all children (Iester 1991).

Other potential sources of bias

Daytime wetting, organic causes and baseline recording of wetting

Children with organic causes were specifically excluded in 12 trials. Organic causes were either not mentioned or not excluded in seven trials (Bennett 1985; Bollard 1981; Caceres 1982; Fera 2004; Houts 1986; Houts 1987a; Houts 1987b). In seven trials, children with daytime wetting were definitely excluded (Azrin 1978; Butler 1990; Fera 2004; Houts 1987a; Houts 1987b; Keating 1983; Nawaz 2002). In one, some children with daytime wetting were included, although if they had an organic cause identified they were excluded (Bollard 1981); and in another they were only included if the daytime wetting was not significant (Bennett 1985). In one trial, some of the children did have daytime wetting, organic causes or behaviour problems (Caceres 1982). The remainder did not mention daytime wetting. Only one of the trials failed to give systematic details about baseline wetting before starting the trial (Iester 1991).

Effects of interventions

1. Complex or educational interventions versus no‐treatment controls (Analysis 1, Other data tables 1.2)

No‐treatment controls were compared with a variety of complex interventions:

DBT with alarm (Bollard 1981; Bollard 1982b; Bennett 1985; Nawaz 2002);
DBT without alarm (Bollard 1981; Bollard 1982b; Keating 1983); and
FSHT with alarm (Houts 1986).

If children were allocated to DBT or FSHT including an alarm triggered by wetting as part of the package, they had fewer wet nights (Analysis 1.1; Analysis 1.2) (Bennett 1985; Bollard 1982b; Nawaz 2002) and were more likely to become dry during treatment (e.g. RR for failure 0.17; 95% CI 0.11 to 0.28, Analysis 1.3.4) (Bollard 1981, Bollard 1982b; Bennett 1985; Nawaz 2002) and afterwards (e.g. RR for failure or relapse after stopping treatment 0.25; 95% CI 0.16 to 0.39, Analysis 1.4.4) (data from Groups A, B and C combined) (Bollard 1981) than those allocated to no‐treatment control groups. Although there appeared to be significant statistical heterogeneity between the trials (Analysis 1.3.4), this is likely to be a statistical artefact as it disappeared when the data were expressed as cure rather than failure rates.

1.1 — Comparison 1 Complex interventions versus no‐treatment controls, Outcome 1 Mean number of wet nights per week on treatment.

1.2. Analysis.

Comparison 1 Complex interventions versus no‐treatment controls, Outcome 2 Mean number of wet nights per week on treatment (no SDs).

Mean number of wet nights per week on treatment (no SDs)
Study	Complex	Control
DBT (office training of parent and child, no alarm) vs control
Keating 1983	Mean 2.7 wet nights (n=7)	Mean 2 wet nights (n=7)
DBT (home training of parent and child, no alarm) vs control
Keating 1983	Mean 2.5 wet nights (n=9)	Mean 2 wet nights (n=7)
DBT (office training of parent only, no alarm) vs control
Keating 1983	Mean 1.9 wet nights (n=7)	Mean 2 wet nights (n=7)
DBT with alarm vs control
Bollard 1981	Mean 0 wet nights (n=60)   (groups A, B and C)	Mean 4.4 wet nights (n=20)   (group F)
Bollard 1982b	Mean 0.2 wet nights (n=10)	Mean 5.3 wet nights (n=10)
DBT without alarm vs control
Bollard 1981	Mean 3.8 wet nights (n=20)   (group D including dropouts)	Mean 4.4 wet nights (n=20)   (group F)
Bollard 1982b	Mean 3.25 wet nights (n=10)	Mean 5.3 wet nights (n=10)

Mean number of wet nights per week on treatment (no SDs)
Study	Component X	Component Y
alarm + waking VS alarm + retention control training
Bollard 1982a	Mean 1.35 wet nights (n=12)	Mean 1.2 wet nights (n=12)
alarm + waking VS alarm + positive practice+ cleanliness training
Bollard 1982a	Mean 1.35 wet nights (n=12)	Mean 1.15 wet nights (n=12)
alarm + waking VS alarm + waking + retention control training
Bollard 1982a	Mean 1.35 wet nights (n=12)	Mean 0.7 wet nights (n=12)
alarm + waking VS alarm + waking + positive practice + cleanliness training
Bollard 1982a	Mean 1.35 wet nights (n=12)	Mean 0.5 wet nights (n=12)
alarm + waking VS alarm + retention control training + positive practice + cleanliness training
Bollard 1982a	Mean 1.35 wet nights (n=12)	Mean 1.05 wet nights (n=12)
alarm + retention control training VS alarm + positive practice+ cleanliness training
Bollard 1982a	Mean 1.2 wet nights (n=12)	Mean 1.15 wet nights (n=12)
alarm + retention control training VS alarm + waking + retention control training
Bollard 1982a	Mean 1.2 wet nights (n=12)	Mean 0.7 wet nights (n=12)
alarm + retention control training VS alarm + waking + positive practice + cleanliness training
Bollard 1982a	Mean 1.2 wet nights (n=12)	Mean 0.5 wet nights (n=12)
alarm + retention control training VS alarm + retention control training + positive practice + CT
Bollard 1982a	Mean 1.2 wet nights (n=12)	Mean 1.05 wet nights (n=12)
alarm + positive practice + cleanliness VS alarm + waking + retention control training
Bollard 1982a	Mean 1.15 wet nights (n=12)	Mean 0.7 wet nights (n=12)
alarm + positive practice + cleanliness VS alarm + waking + positive practice + cleanliness training
Bollard 1982a	Mean 1.15 wet nights (n=12)	Mean 0.5 wet nights (n=12)
alarm + positive practice + cleanliness training VS alarm + retention control training + PP + CT
Bollard 1982a	Mean 1.15 wet nights (n=12)	Mean 1.05 wet nights (n=12)
alarm + waking + retention control training VS alarm + waking + positive practice + cleanliness training
Bollard 1982a	Mean 0.7 wet nights (n=12)	Mean 0.5 wet nights (n=12)
alarm + waking + retention control training VS alarm + retention control training + positive practice + CT
Bollard 1982a	Mean 0.7 wet nights (n=12)	Mean 1.05 wet nights (n=12)
alarm + waking + positive practice + cleanliness training VS alarm + retention control training + PP + CT
Bollard 1982a	Mean 0.5 wet nights (n=12)	Mean 1.05 wet nights (n=12)

Date	Event	Description
13 September 2005	New search has been performed	Minor update for Issue 1 2006: two new trials added (Fera 2004 and van Kampen 2005), but the conclusions of the review were unchanged.
26 November 2003	New citation required and conclusions have changed	Review first published: Issue 1 2004

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mean number of wet nights per week on treatment	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
1.1 DBT + alarm vs control	2	43	Mean Difference (IV, Fixed, 95% CI)	‐4.09 [‐5.44, ‐2.74]
2 Mean number of wet nights per week on treatment (no SDs)			Other data	No numeric data
2.1 DBT (office training of parent and child, no alarm) vs control			Other data	No numeric data
2.2 DBT (home training of parent and child, no alarm) vs control			Other data	No numeric data
2.3 DBT (office training of parent only, no alarm) vs control			Other data	No numeric data
2.4 DBT with alarm vs control			Other data	No numeric data
2.5 DBT without alarm vs control			Other data	No numeric data
3 Number not achieving 14 consecutive dry nights	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
3.1 DBT (alarm + therapist at home) vs control	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	0.03 [0.00, 0.42]
3.2 DBT (alarm + therapist in hosp) vs control	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	0.03 [0.00, 0.42]
3.3 DBT (alarm + parents as therapists at home) vs control	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	0.03 [0.00, 0.42]
3.4 DBT + alarm vs control	4	143	Risk Ratio (M‐H, Fixed, 95% CI)	0.19 [0.12, 0.30]
3.5 FSHT + alarm vs control	1	24	Risk Ratio (M‐H, Fixed, 95% CI)	0.34 [0.16, 0.72]
3.6 DBT without alarm vs control	2	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.66, 1.03]
4 Number failing or relapsing	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
4.1 DBT (alarm + therapist at home) vs control	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 DBT (alarm + therapist in hospital) vs control	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.3 DBT (alarm + parents as therapists at home) vs control	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.4 DBT with alarm vs control	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.5 FSHT with alarm vs control	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.6 DBT without alarm vs control	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Mean number of wet nights per week on treatment (no SDs)
Study	Complex	Other
DBT vs alarm
Bollard 1981	Mean 3.8 wet nights (n=20)   (Group D including dropouts)	Mean 0.6 wet nights (n=20)   (Group E)
DBT vs DBT + alarm
Bollard 1981	Mean 3.8 wet nights (n=20)   (Group D including dropouts)	Mean 0 wet nights (n=60)   (Groups A+B+C)
Bollard 1982b	Mean 3.25 wet nights (n=10)	Mean 0.2 wet nights (n=10)

Mean number of wet nights per week on treatment (no SDs)
Study	Complex + other	Other
DBT + alarm vs alarm
Bollard 1981	Mean 0 wet nights (n=60)   (Groups A+B+C)	Mean 0.6 wet nights (n=20)   (Group E)
Butler 1988	Mean 1.05 wet nights (n=35)	Mean 1.81 wet nights (n=28)
Butler 1990	Mean 1.79 wet nights (n=24)	Mean 1.56 wet nights (n=24)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Number not achieving 14 consecutive dry nights	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
1.1 DBT + alarm vs alarm	4	186	Risk Ratio (M‐H, Fixed, 95% CI)	0.60 [0.38, 0.94]
2 Number failing or relapsing	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
2.1 DBT + alarm vs alarm	2	104	Risk Ratio (M‐H, Fixed, 95% CI)	0.5 [0.31, 0.80]

Mean number of wet nights per week on treatment (no SDs)
Study	Complex 1	Complex 2
therapist at home vs therapist in hospital
Bollard 1981	Mean 0 wet nights (n=20)	Mean 0 wet nights (n=20)
therapist at home vs parent as therapist at home
Bollard 1981	Mean 0 wet nights (n=20)	Mean 0 wet nights (n=20)
therapist in hospital vs parent as therapist at home
Bollard 1981	Mean 0 wet nights (n=20)	Mean 0 wet nights (n=20)
teaching for parent and child in hospital vs teaching for parent only in hospital
Keating 1983	Mean 2.7 wet nights (n=7)	Mean 1.9 wet nights (n=7)
teaching for parent and child in hospital vs teaching for parent and child at home
Keating 1983	Mean 2.7 wet nights (n=7)	Mean 2.5 wet nights (n=7)
teaching for parent and child at home vs teaching for parent only in hospital
Keating 1983	Mean 2.5 wet nights (n=7)	Mean 1.9 wet nights (n=7)

Methods	RCT ‐ coin flip used to randomise each of pairs of children   Systematic baseline measure of wetting: Yes   Organic causes excluded: Yes   Daytime wetting: Not mentioned Setting: children who responded to a newspaper advertisement for enuretics
Participants	No. of children (boys): 26 (19)   Exclusion: medical causes   Ages: 3+, mean 8 years   Baseline frequency 7 days/week.
Interventions	Expt 1   A (7): DBT (parent‐and‐child alarm; PP; W; increasing fluid intake; rewards; CT; training in inhibiting urination (? retention control training)   B (7): Child‐only alarm for first 2 weeks only (then DBT)   Expt 2   C (6): DBT, parent‐only alarm   D (6): Child‐only alarm Duration of treatment: 2 weeks (then all groups received DBT + Alarm) Follow up: 6 months
Outcomes	Fewer wet nights in first 2 weeks with A+C (median 1 vs B+D 5 in second week, P<0.005).   More children achieving 6 dry nights in A
Notes	Pairs matched for age, sex and frequency of wetting   No useable data.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	High risk	C ‐ Inadequate

Methods	RCT (details not given)   Systematic baseline measure of wetting: Yes   Organic causes excluded: Yes   Daytime wetting excluded: Yes
Participants	No. of children (boys): 55 (41)   Inclusion: Age at least 3 years; no daytime wetting; wetting at least 4 times per week; able to understand instructions; medical examination and treatment Age: mean 7 years (range 3‐14) (20 less than 6 years)   Baseline wetting: 91% of nights
Interventions	A (28): Intensive DBT (PP, CT) plus rehearsing during the day with increased fluid intake, stream interruption exercises, Retention Control Training, repeated awakening, rewards for dry nights or compliance but NO ALARM   B (27): Alarm (pad‐and‐buzzer)   Duration of trial: 2 weeks, after which parents could swap to other arm
Outcomes	Per cent wet nights during 2 weeks: A, 15%; B, 76%   No. of children swapping to other group after 2 weeks: A, 0/27; B, 23/27
Notes	Comparability of groups at baseline not reported   No FU possible after 2 weeks   No SDs   Very young children (20 under age 6 years) included
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Methods	RCT   Systematic baseline measure of wetting: Yes   Organic causes excluded: Not mentioned   Daytime wetting: excluded if significant
Participants	No. of children (boys): 40 (25)   Dropouts: 32 (A,9; B,11; C,10; D,3)   Inclusion: primary nocturnal enuresis, referred to enuresis service by GP, negligible daytime wetting   Exclusion: encopresis, previous behavioural intervention, gross psychopathology   Age mean 8.5 years (SD 3.2) range 5‐12   Baseline wetting: dry nights, boys 3/14; girls 2.4/14
Interventions	A: (9) Alarm (pad and buzzer)   B: (12) Stop‐start training (sphinchter muscle exercises, bladder training)   C: (10) Dry Bed Training including alarm   D: (9) Waiting list control (used star chart after first dry night)   Duration of treatment: 10 weeks
Outcomes	Mean dry nights in last 2 weeks of 12 weeks treatment: A, 12 (SD 3.9); B, 7.5 (5.2); C, 11.2 (3.6); D, 3.7 (3.0)   No. achieving 14 dry nights:   A, 4/9; B, 2/12; C, 5/10; D, 0/9   Mean dry nights at followup:   A, 12.3 (3.1); B, 7.1 (5.8); C, 9.3 (5.3). (D treated after 12 weeks)   Adverse events: not mentioned
Notes	All children got star charts after their first dry night   High dropout rate
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Methods	Experiment 2   RCT   Systematic baseline measure of wetting: Yes   Organic causes excluded: Yes   Daytime wetting excluded: No   Analysed on intention to treat basis and with dropouts excluded
Participants	Experiment 2   Number of children: 100   No. of boys: A:14 B:13 C:16 D:14 E:14 F:11   No. of dropouts: 12 from D Inclusion: thorough medical examination; regularly wetting at least one night per week; no other treatment during trial   Previous treatment: no details   Mean age (years): A:9.3 B:8.11 C:9.7 D:8.6 E:8.8 F:8.10 Baseline wetting: mean number of wet nights: A:5.8 B:5.2 C:6.0 D:5.7 E:6.0 F:4.7
Interventions	Experiment 2   A (20): DBT (A + W + CT + PP) with therapist at home   B (20): DBT (A + W + CT + PP) with therapist at hospital   C (20): DBT (A + W + CT + PP) with parents as therapists at home   D (20): DBT (W + CT + PP) with parents as therapists at home WITHOUT enuresis alarm.   E (20): alarm   F (20): waiting list control Duration of treatment: until 14 consecutive dry nights or 20 weeks FU at 3, 6 and 12 months
Outcomes	Experiment 2   Comparing DBT with alarm only ‐ DBT significantly more effective in terms of number of wet nights and days to dryness Mean number of wet nights per week at end of week 20   (incl dropouts) A:0, B:0, C:0, D: (n=20) 3.8, E: 0.6, F: 4.4   (excl dropouts) A:0, B:0, C:0, D:(n=8) 1.3, E:0.6, F:4.4 No. achieving 14 consecutive dry nights: A:20, B:20, C:20, D:5, E:16, F:2   (p < 0.05) No. relapsing: A:5, B:6, C:4, D:2, E:6, F:2 NS ie no. failing or relapsing: A: 5/20, B: 6/20, C: 4/20, D: 17/20, E: 10/20, F: 20/20
Notes	Experiment 2   No details of blinding   DBT no alarm group (D) younger than others and   more girls in waiting list control group (F)   No SDs
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Methods	Mainly RCT but also comparison with previous study [A] and [H] from another study   Systematic baseline measure of wetting: Yes   Organic causes excluded: Yes   Daytime wetting excluded: Not mentioned
Participants	No. of children (2 groups combined) (boys): 127 (88)   Inclusion: no underlying organic pathology Previous treatment: many had previously sought help but none undergoing any form of enuresis related drug or psychotherapy at the time of the study.   Mean age: 9 years 10 months   Baseline wetting: Overall mean number of wet nights per week = 5.5
Interventions	[A (35): alarm only (A)]   B (12): alarm (A) + waking schedule (W)   C (12): A+retention control training   D (12): A+ positive practice (PP)+ cleanliness training (CT)   E (12): A+W+retention control training F (12): A+W+PP +CT   G (12): A+retention control training+PP +CT   [H (20): Full DBT]   Duration of treatment: 20 weeks   Follow up: none
Outcomes	Mean no. of wet nights during 20 week treatment period:   A: 27 B: 13 C: 24 D: 23 E: 14 F: 10 G: 21 H: 11 Number of cases becoming dry: A: 31 B: 12 C: 11 D: 10 E: 12 F: 12 G: 11 H: 20 Significant difference in response rate of group with waking schedule vs those without (Chi squared = 13.04, df = 3, p < 0.01)
Notes	Groups A and H from another trial, data not used   No analysis of comparability of groups   No blinding   No SDs   No follow up
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Methods	CCT (alternate allocation)   Systematic baseline measure of wetting: Yes   Organic causes excluded: Yes   Daytime wetting excluded: Not mentioned
Participants	No. of children: originally 74 but 11 excluded after baseline assessments (A: 18 B: 29) Inclusion: age at least 6 years;wetting at least five nights a week for a month; normal clinical exam; normal urine on microscopy; normal intelligence (assessed by reference to educational background and parental‐child interview); not having any form of enuresis related drug or psychotherapeutic treatment Previous treatment: 36 (48.6%) enuresis alarm Mean age: A: 8.99 B: 9.86 Baseline wetting: mean number of dry nights during 4 weeks   A: 1.07 B: 1.02
Interventions	A (28): Standard enuresis alarm treatment (A)   B (35): Modified DBT + alarm (A + W + PP + retention control training) WITHOUT reprimands during CT   Duration of treatment: 16 weeks   No Follow up
Outcomes	Mean number of dry nights in last 4 weeks   A:20.76 B:23.79 F(1,46) = 1.77   Number of children achieving 14 dry night criterion   A:20/28 (71%) B: 25/35 (71%) no significant difference Mothers in dropout group significantly more angry with bedwetting than other groups
Notes	No significant difference between groups for demographic factors but Group B more likely to have previously used alarm   Analysis of covariance adjusted for the effects of previous experience with enuresis alarm   No blinding   Not intention to treat
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	High risk	C ‐ Inadequate

Methods	Experiment 2   CCT (alternate allocation)   Systematic baseline measure of wetting: Yes   Organic causes excluded: Yes   Daytime wetting excluded: Yes
Participants	Experiment 2   No. of children (boys): 48 (39)   Number of dropouts: A: 2 B 1   Inclusion: wetting at least 4 nights a week for a month; nomal physical examination; normal urine microscopy; normal intelligence (assessed by reference to educational background and parent\child interview); no associated diurnal enuresis Previous treatment: failed with pad and bell alarm Mean age (years): A: 10.2 B: 11.2   Severity at baseline: mean number of DRY nights per week: A: 1.2 B: 1.3
Interventions	Experiment 2   A (24): Modified DBT + alarm (A + W + retention control training)   B (24): body‐worn alarm (A) Duration of treatment: 16 weeks   Follow up after 6 months
Outcomes	Experiment 2   Mean number of wet nights in 16 weeks   A: 28.7 B: 25.0 Number (%) attaining 14 consecutive dry nights   A: 14 (58) B: 20 (83) Mean number of wet nights to achievement of 14 consecutive dry nights   A: 53.7 B: 40.7 Number (%) children relapsing: A: 7 (50) B: 9 (45) (ie fail or relapse: A: 17/24, B: 13/24)
Notes	Experiment 2   Groups did not differ significantly on any variable   Unclear if intention to treat analysis   No SDs
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	High risk	C ‐ Inadequate

Methods	RCT (randomized in 2 groups)   Systematic baseline measure of wetting: Yes   Organic causes excluded: No   Daytime wetting excluded: Yes   Setting: Federal University of Sao Paulo
Participants	No. of children (boys): 30 (21)   Dropouts: None   Inclusion: monosymptomatic nocturnal enuresis, age over 5 years, no daytime wetting   Exclusion: none mentioned   Previous treatment: none   Age, mean years (SD): 9.23 (1.85)   Baseline wetting, mean (SD) wet nights in 2 weeks: 9.40 (3.40)
Interventions	A (15): DDAVP (desmopressin), titrated to maximum 0.4 mg at bedtime   B (15): behavioural modification (dietary and fluid adjustment, voiding schedules, double voiding, bedtime toileting, alarm clock once at night, pelvic floor training, environmental modifications, changes in parents' attitudes, improvement of self‐esteem, self care)   Duration of treatment: 30 days   Follow up: none
Outcomes	Wet nights during last 2 weeks of treatment N, mean (SD): A: 15, 7.27 (4), B: 15, 3.93 (3.32)   50% improvement: A: 7/15, B: 8/15   Complete failure: A: 5/15, B: 1/15   Adverse effects: not mentioned
Notes	Groups comparable at baseline on age, gender and baseline wetting   No data for children 'cured' (14 consecutive dry nights)
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Methods	RCT (randomly divided with computer)   Systematic baseline measure of wetting: No   Organic causes excluded: Yes   Daytime wetting excluded: Not mentioned
Participants	No. of children: 168   Inclusion: functional enuresis   Exclusion: organic causes, emotional disturbance   Previous Rx: none   Ages: 6‐11 years
Interventions	A (36): 6 weeks with imipramine 0.9‐1.5 mg/kg, max 50mg   B (36): 3 step programme: a) reassurance to parents; b) bladder retention training and wakening with alarm clock before micturition; c) parental involvement   C (96): Motivational therapy (counselling) + education (computer programme) + 3 step therapy   Duration Rx: 6months   Follow up: 12 months
Outcomes	Failure rates:   A: 22/36, B: 12/36, C: 15/96   Relapse A: 2, B: 2, C: 3   Failure + relapse rates: A: 24/36, B: 14/36, C: 18/96   Compliance with Rx: A: 14/36, B: 24/36, C: 81/96
Notes	Pad‐and‐bell wetting alarm not used
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Methods	RCT (random allocation to groups following matching on age and sex)   Systematic baseline measure of wetting: Yes   Organic causes excluded: Yes   Daytime wetting excluded: Yes Setting: community health centres in Glasgow, Scotland
Participants	No. of children (boys): 36 (18)   Dropouts: 0 Inclusion: Age 7‐12 years, baseline wetting at least twice per months, attending mainstream school and willing to be randomised Exclusion: medical, physiological or psychiatric pathology, diurnal enuresis, encopresis Previous treatment: some, but stopped during trial Age: Mean 9.9 years (SD 1.83)   Baseline wetting: mean 5.67 per week (SD 1.26) for 4 weeks
Interventions	A (12): DBT + alarm   B (12): alarm only   C (12): untreated controls continued recording wet nights for 16 weeks, then offered treatment they preferred   A + B also received standardised instrucitons (manual and videotape) and had 2 weekly telephone calls Duration of treatment: 16 weeks or until 14 dry nights if earlier Follow up: 6 months
Outcomes	Wet nights per week during trial (final week): A: mean 0.83 (SD 1.40), B: 3.25 (2.67), C: 5 (2.26)   No. not achieving 14 dry nights: A: 4/12, B: 9/12, C: 11/12   No. relapsing after end of trial: A: 1, B: 1   Fail or relapse rate: A: 5/12, B: 10/12
Notes	Groups comparable on age, sex, baseline wetting and DepCat (deprivation) scores   DBT described as: intensive first night, arousing child and taking him to toilet, accident contingencies and normal routine
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	B ‐ Unclear

Methods	RCT (cluster randomised controlled trial, stratified on Jarman index, ethnicity and electoral ward)   Systematic baseline measure of wetting: Yes   Organic causes excluded: No   Daytime wetting excluded: Not mentioned Setting: school nurse‐led enuresis clinics in Leicestershire, UK
Participants	No. of children (boys):270 (of 287 eligible) (176)   Inclusion: Primary (79%) and secondary (19%) enuresis, re‐referrals 23%   Previous treatment: not in last 6 months Age: mean 7.98 years (SD 2.23) (range 5‐16)
Interventions	A (108): multimedia interactive CD‐rom with enuresis information   B (87): Leaflets with same information   C (75): control, no extra information   All children also had 4 weeks baseline assessment with star chart reward system, and received other enuresis treatment as deemed appropriate by their therapists (including alarms in some cases) Duration of treatment: 6 months   Follow up: 6 months
Outcomes	No. not achieving 14 dry nights during first 6 months: A: 51/108, B: 46/87, C: 39/75   Failure or relapse: A: 87/108, B: 61/87, C: 57/75 Also maternal tolerance scale, impact of bedwetting score
Notes	Groups comparable at baseline on age, and clinics comparable on Jarman indices and ethnicity, but postcode analysis showed group A were from a more advantaged population, fewer ethnic minority children   Power calculation done a priori   Re‐referred children older (mean 9.96 vs 7.38 years)
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Low risk	A ‐ Adequate

Methods	RCT (stratified on age)   Systematic baseline measure of wetting: No   Organic causes excluded: Yes   Daytime wetting excluded: Not mentioned   Setting: Catholic University, Leuven
Participants	No. of children: 63   Dropouts: 4   Inclusion criteria: nocturnal enuresis   Exclusion criteria: not stated   Previous treatment: not stated
Interventions	A (n not given): FSHT + pelvic floor muscle training (PFMT)   B (n not given): FSHT without pelvic floor muscle training   Duration of treatment: 6 months
Outcomes	Number in groups not given, 88.9% cure rate in whole group at 6 months   Authors state: no difference in efficacy or duration of treatment between the groups, and age and baseline motivation predicted success
Notes	FSHT = enuresis alarm, overlearning after 14 dry nights, motivation + rewards, diary with fixed drinking and voiding times   PFMT = pelvic floor muscle training, 10 fast and 10 slow contractions daily at home   No useable data
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Study	Reason for exclusion
Azrin 1973	Excluded because participants were adults, and no useable data provided.   RCT: Yes   Comparison group: Yes   Organic causes excluded: Yes   Systematic baseline measurement of wetting: Yes   Systematic outcome measure: Yes   Intervention: Alarms, dry bed training in adults with severe learning difficulties in a state hospital
Bollard 1977	RCT: no   Comparison group: yes   Systematic baseline: no   Organic causes excluded: yes   Systematic outcome measure: yes   Intervention: DBT with parents as trainers with and without alarm
Doleys 1977b	Excluded because children moved from B to A, therefore data unreliable   RCT: CCT (stratified by baseline wetting frequency and sex, method of allocation not specified)   Comparison group: yes   Systematic baseline: yes   Organic causes excluded: yes   Intervention: Dry bed training (alarm, training night, PP, CT, rewards for dry nights) versus Retention control training (stop‐start training, progressive increase in bladder capapcity)
Griffiths 1982	RCT: no   Comparison group: no   Systematic baseline: yes   Organic causes excluded: no   Systematic outcome measure: no   Intervention: DBT in children
Hanson 1988	Excluded because population was young adults (age 13‐29) with learning difficulties in residential centre   RCT: Yes   Comparison group: Yes   Organic causes excluded: No   Systematic baseline measurement of wetting: Yes   Systematic outcome measures: Yes   Interventions: Alarms, DBT, yoked awakening, rewards
Hunt 1989	RCT: no   Comparison group: no   Systematic baseline: yes   Organic causes excluded: yes   Systematic outcome measure: yes   Intervention: DBT
Kaplan 1988	RCT: no   Comparison group: yes   Organic causes excluded: yes   Systematic baseline measurement of wetting: no   Systematic outcome measures: yes   Interventions: Alarms, dry bed training, motivation
Nettelbeck 1979	RCT: no   Comparison group: yes   Systematic baseline: yes   Organic causes excluded: yes   Systematic outcome measure: yes   Intervention: DBT
Schulz 1978	RCT: no   Comparison group: yes   Systematic baseline: no   Organic causes excluded: yes   Systematic outcome measure: yes   Intervention: DBT, alarms
Smith 1979	Excluded because population had daytime wetting   RCT: yes (CCT)   Intervention: alarms, behaviour training (individual versus group)
van Son 1990	RCT: no   Comparison group: no   Intervention: DBT in 9 adults
Whelan 1990	Excluded because two separate RCTs were combined (effectively results presented for groups at different times, and no results from control groups)   RCT: yes   Comparison group: yes but no data provided   Systematic baseline: yes   Organic causes excluded: no   Systematic outcome measure: not by group allocation   Interventions: FSHT + alarm + (in second RCT) waking schedule

PERMALINK

Complex behavioural and educational interventions for nocturnal enuresis in children

Cathryn MA Glazener

Jonathan HC Evans

Rachel E Peto

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Background

Description of the condition

Prevalences and causes

Interventions

Description of the intervention

Complex behavioural treatment programmes

Dry‐bed training (DBT)

Full spectrum home training (FSHT)

Educational interventions

Enuresis alarms

Overlearning

Simple behavioural interventions

Lifting

Scheduled wakening

Fluid restriction

Reward systems

Retention control training and stop‐start training

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Search methods for identification of studies

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Dealing with missing data

Assessment of heterogeneity

Data synthesis

Results

Description of studies

Results of the search

Included studies

Size of trials

Interventions and comparisons

Ages of the children

Settings and populations

Previous treatment

Duration of treatment

Excluded studies

Risk of bias in included studies

Allocation

Incomplete outcome data

Other potential sources of bias

Daytime wetting, organic causes and baseline recording of wetting

Effects of interventions

1. Complex or educational interventions versus no‐treatment controls (Analysis 1, Other data tables 1.2)

1.1. Analysis.

1.2. Analysis.

1.3. Analysis.

1.4. Analysis.

2. Complex interventions alone versus other behavioural interventions (Analysis 2, Other data tables 2.2)

2.3. Analysis.

3. Supplemented complex interventions versus other behavioural interventions (Analyses 3 and 4, Other data tables 3.2)

3.3. Analysis.

4.1. Analysis.

4.2. Analysis.

5. Complex interventions ‐ different training regimens (Analysis 5, Other data tables 5.1)

5.2. Analysis.

6. Comparing components of complex interventions (Analysis 6, Other data tables 6.1)

6.1. Analysis.