Review question
Is desmopressin an effective treatment for bedwetting in children?
Key messages:
Desmopressin may improve bedwetting.
Only one study assessed quality of life.
Further studies with good patient numbers are required.
What is enuresis? What does desmopressin do ?
Enuresis or bedwetting is involuntary wetting during sleep at an age when a child should be dry, usually at age five. The generally quoted prevalence rates (that is the proportion of a population with bedwetting in a given time period) are 15% to 20% of five-year-olds, 7% of seven-year-olds, 5% of 10-year-old children, and 2% to 3% of teenagers.
Various treatments have been used to treat bedwetting. Desmopressin is a man-made form of vasopressin, a chemical released from the brain that helps control the amount of urine made by the kidneys. Desmopressin is used to control bedwetting at night and reduces the number of bedwetting episodes.
Why was it important to do this review?
Although bedwetting is not a harmful condition and, with time, stops spontaneously, it is stigmatising and can impact the child’s quality of life, emotional and psychological wellbeing. It is a condition that unsettles the whole family and the affected children may suffer parental discontentment, teasing and may be at risk of physical or emotional abuse. Successful therapies that reduce bedwetting improve the child's self-esteem and, therefore, it is important to see if desmopressin is as effective as other known treatments.
How is the condition treated ?
• Desmopressin therapy
• Alarm therapy
• Anticholinergic medications
• Combination therapy – such as desmopressin and alarm therapy compared to desmopressin therapy
There are several other therapies, such as behavioural therapies and laser therapy, though we have concentrated on the main therapies utilised.
What did we want to find out?
We wanted to see if desmopressin:
• was effective in reducing the episodes of wet nights children may have;
• was as effective as other treatments such as alarm therapy in treating bedwetting;
• worked in combination with other treatments;
• was associated with any unwanted effects.
What did we do?
We searched for studies where people were randomly placed into different treatment groups.
We searched for and included studies that compared:
• desmopressin with no treatment or placebo;
• desmopressin and alarm therapy;
• combination treatments of desmopressin and alarm.
We compared and analysed our results, then rated our confidence in the evidence based on factors such as study methods and size of the studies.
What did we find?
We found 98 studies with 8699 participants, of whom 5616 received desmopressin.
Main results
• We found the use of desmopressin compared with placebo may improve wetting by giving children one more dry night a week while receiving treatment. This suggests that more children may stop wetting while using desmopressin (28% versus 1% who are given placebo or no treatment).
• More children who received desmopressin therapy compared with placebo probably achieved 14 consecutive dry nights at the end of treatment.
• We found that, when desmopressin was compared with alarm therapy, there was little to no difference in the number of children achieving 14 dry nights in a row. The evidence is also uncertain if desmopressin versus alarm therapy reduces the number of dry nights per week.
• We found that combining desmopressin with alarm therapy may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin alone.
• We found that side effects were commonly reported for desmopressin. These included dizziness, headache, mood changes, abdominal discomfort, nasal discomfort, hyponatraemia (low sodium level) and one report of a seizure. Thirty-two studies reported no adverse effects occurring, and 25 studies omitted to report or mention adverse effects.
What are the limitations of the evidence?
We, however, have little confidence in the evidence as, in several studies, participants were aware of the therapy they were receiving, and several studies were very small.
How up-to-date is this review?
The evidence is current up to January 2023.
阅读完整摘要
Enuresis (bedwetting) affects up to 20% of five-year-old children and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Desmopressin has been used to treat bedwetting since the 1970s.
This is an update of a Cochrane review first published in 2000 and last updated in 2006.
研究目的
To assess the effects of desmopressin on treating nocturnal enuresis in children.
检索策略
We searched Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched January 2023) and reference lists of relevant articles.
纳入排除标准
We included randomised or quasi-randomised trials of desmopressin or desmopressin combined with another intervention for treating nocturnal enuresis in children between five and 16 years old.
资料收集与分析
Three review authors independently extracted data and assessed the risk of bias in the eligible trials. We used standard methodological procedures expected by Cochrane.
主要结果
We identified 50 new studies for this review, which now includes 95 studies (8473) participants, of whom 5434 received desmopressin. In this review we continued the assessment of the effect of combination therapy involving desmopressin. The majority of the trials were in children between the ages of five to 16 years in an outpatient setting. The quality of the evidence was assessed as low or very low.
The first comparison was desmopressin versus placebo. Desmopressin may reduce the mean number of wet nights per week compared with placebo (MD -1.81, 95% CI -2.24 to -1.39; participants = 1267; studies = 16; low-certainty evidence). Desmopressin probably leads to more children achieving 14 consecutive dry nights by the end of treatment compared with placebo (RR 3.18, 95% CI 1.75 to 5.80; participants = 922 : studies = 11; moderate-certainty evidence). There may be little to no difference in children experiencing adverse effects with desmopressin compared to placebo (RR 1.11, 95% CI 0.81 to 1.52; participants = 269; studies = 3; low-certainty evidence).
Desmopressin was compared with alarm therapy. It is uncertain if there is any difference between desmopressin compared with alarm training in reducing the number of wet nights per week (MD 0.63, 95% CI -0.49 to 1.75; participants = 285; studies = 4; I2 = 82%; very low-certainty evidence). There may be little or no difference between desmopressin and alarm therapy in the number of children achieving 14 consecutive dry nights (RR 0.98, 95% CI 0.88 to 1.09; participants = 1530; studies = 15; low-certainty evidence). There may be little to no difference in children experiencing side effects with desmopressin therapy compared with alarm therapy (RR 1.50, 95% CI 0.33 to 6.78; participants = 461, studies = 4; low-certainty evidence).
We compared desmopressin with other medications, including tricyclics and anticholinergics. It is uncertain if there is any difference between desmopressin compared to tricyclics in reducing the mean number of wet nights per week (MD 0.23, 95% CI - 0.88 to 1.33; participants = 331; studies = 4; I2 = 79%; very low-certainty evidence) or in the number of children achieving 14 consecutive dry nights at the end of treatment (RR 0.94, 95% CI 0.63 to 1.38; participants = 371; studies = 7; I2 = 71%; very low-certainty evidence). It is uncertain whether children experience more side effects with desmopressin compared with tricyclics (RR 0.29, 95%CI 0.06 to 1.39; participants = 351; studies = 4, very low-certainty evidence).
This review included studies with combination therapies. It is uncertain if desmopressin combined with alarm therapy reduces the mean number of wet nights at the end of treatment compared with alarm monotherapy (MD -0.80, 95% CI -1.34 to -0.25; participants = 528; studies = 6; I2 = 84%; very low-certainty evidence); or if it increases the number of children achieving 14 consecutive dry nights (RR 1.25, 95% CI 0.96 to 1.63; participants = 822; studies = 10; very low-certainty evidence). Desmopressin plus alarm therapy may make little to no difference in children experiencing side effects compared with alarm therapy alone (RR 1.05 95% CI 0.07 to 16.56; participants = 207; studies = 1; low-certainty evidence).
Combining desmopressin with alarm therapy probably reduces the number of wet nights at the end of treatment (MD -0.88; 95%CI -1.38 to -0.38; participants = 156; studies = 2; moderate-certainty evidence), and may increase the number of children achieving 14 consecutive dry nights at the end of treatment compared with desmopressin monotherapy (RR 1.26, 95% CI 1.06 to 1.51; participants = 370; studies = 5; low-certainty evidence). It is uncertain if combined desmopressin and anticholinergic therapy versus desmopressin monotherapy reduces the mean number of wet nights at the end of therapy (MD -0.50; 95% CI -1.05 to 0.06; participants = 188; studies = 3; I2 = 66%; very low-certainty evidence); or if it may increase the number of children achieving 14 consecutive dry nights at the end of treatment (RR 1.53, 95% CI 1.10 to 2.11; participants = 611; studies = 8; low-certainty evidence). There may be little to no difference in adverse events between desmopressin plus anticholinergics and desmopressin monotherapy (RR 1.51 95% CI 0.73 to 3.09, participants = 187; studies =2; low-certainty evidence).
Minor adverse effects were common for desmopressin, including dizziness, headache, mood changes, gastrointestinal discomfort, nasal discomfort, hyponatraemia and one report of a convulsion.
作者结论
Desmopressin compared with placebo may increase the number of dry nights per week at the end of treatment in children. Desmopressin therapy may be as effective as alarm therapy at the end of treatment. However, the quality of evidence was assessed as low or very low. Alarm therapy compared to desmopressin may improve the number of children who are dry at follow-up (moderate-certainty evidence).
