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Clonidine May Have a Beneficial Effect in Refractory Nocturnal Enuresis

Ohtomo Y.

Pediatr Int. 2017 Feb 24. doi: 10.1111/ped.13269. [Epub ahead of print]

Commentary by Konstantinos Kamperis

Clonidine, revisited. New treatment modality for refractory enuresis?

The treatment of children with nocturnal enuresis can be an easy task, as the majority of these children would respond to either desmopressin or the conditioning alarm. There is however at least one third of children suffering from bedwetting that will not respond to first line treatment and the management of these refractory cases of bedwetting can be particularly challenging.

This study by Ohtomo concerns these refractory cases. The author recruited 148 patients with nocturnal enuresis both monosymptomatic and non-monosymptomatic that have previously been resistant to alarm, desmopressin and anticholinergics. Children were treated with clonidine an alpha2 adrenergic agonist at bedtime for 4 weeks in combination with desmopressin, alarm and solifenacin. The occurrence of enuresis as well as nocturnal urine production was monitored. Up to 56% of the children experienced partial or full response. No changes in regards to nocturnal urine production were seen following the addition of clonidine. Two children experienced side effects (orthostatic hypotension).  The author hypothesizes that clonidine exerts its actions by direct stimulation of the central nervous system in the same fashion as other stimulants or by influencing sleep architecture through its sedative properties.

Based on these interesting findings clonidine may represent a possible treatment for therapy resistant cases. However, as clonidine was used as add-on therapy in the present study and the design was uncontrolled it is necessary to wait for randomized controlled trials before clonidine can become part of the treatment of nocturnal enuresis. In the meantime, the use of clonidine for bedwetting is still off-label but may be justified in selected cases.

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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.