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Neurostimulation Therapy for Pediatric Primary Enuresis: A Meta-analysis

Michael E.Chua, Nicolas Fernandez, Jessica M.Ming et al.

Urology, Volume 106, August 2017, Pages 183-187

Commentary by Guy Bogaert

In this literature review, a meta-analysis was performed from 7 nonheterogeneous randomized controlled trials that have addressed neurostimulation for nocturnal enuresis in children.  The authors conclude quite optimistic that “neurostimulation” is efficacious and safe for the treatment of nocturnal enuresis.  However, they also conclude that “further randomized clinical trials are necessary…”, already flawing their conclusion.

What exactly is neurostimulation?  Sometimes it is transcutaneous, sometimes percutaneous, some call it neuromodulation and every study has its own method, approach, currency or frequency of the stimulation.  A comparison with controls seems not sufficient, as the placebo effect may be very important.  Some studies have included placebo, but not all.  If looked upon in detail, I think that it is very difficult, if not even impossible to compare these studies.  I would therefore be very careful to draw any conclusions or accept any form of so-called “neurostimulation” as a standard treatment for children with nocturnal enuresis.  Neurostimulation for nocturnal enuresis will certainly remain experimental for a while.  

Abstract

Objective:

To assess the efficacy and safety of neurostimulation compared with control groups in the treatment of pediatric primary enuresis by performing meta-analysis of randomized controlled trials (RCTs).

Methods:

A systematic literature search with no language restriction was performed in August 2016. RCTs were identified and evaluated according to the Cochrane Collaboration risk of bias assessment recommendations. The number of patients with post-treatment responses such as partial response (PR) (50%-89%), complete response (CR) (≥90%), and full response (FR) (100%) were extracted for relative risk (RR) and 95% confidence interval (CI). Effect estimates were pooled using the Mantel-Haenszel method. The review protocol was registered in the PROSPERO registry (CRD42016043502).

Results:

A total of 292 subjects from 7 nonheterogeneous RCTs were included for meta-analysis. Pooled effect estimate of subjects with ≥50% post-treatment wet-night reduction (PR, CR, and FR) showed a significantly better outcome after neurostimulation compared with controls (RR = 2.20, 95% CI 1.66, 2.90), whereas patients with ≥90% post-treatment wet-night reduction (CR and FR) showed a significantly better outcome in the neurostimulation groups (RR = 2.79, 95% CI 1.54, 5.06). Furthermore, a significant mean difference in wet-night reduction per week was noted between treatment groups in favor of neurostimulation treatment (mean difference -1.95, 95% CI -2.84, -1.07). No serious adverse effects were noted related to neurostimulation therapy.

Conclusion:

Current evidence suggests that neurostimulation therapy is efficacious and safe for the treatment of PPE. Head-to-head randomized clinical trials are needed to further assess relative efficacy among variable treatment protocols.

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from Ferring

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Consensus Guidelines

Practical consensus guidelines for the management of enuresis. 
Evaluation and management of enuresis, a common condition, is not a priority in training programs for medical doctors (MDs), despite being a common condition. 

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Diagnosis and Treatment of Nocturnal Enuresis developed by the Working Group of Nocturnal Enuresis Belgium.