PEDIATRIC UROLOGY

Desmopressin for the treatment of nocturnal bedwetting in patients with neural tube closure defects
Del Gado R, Aceto G, Del Gaizo D, Del Gado G, Polidori G, Chiozza ML
Paediatrics Department, University of Bari, Bari, Italy
J Urol. 2004; 171: 1656-8

• Purpose: We evaluated desmopressin (DDAVP) treatment in patients with neuropathic bladder secondary to neural tube closure defects (NTDs) and nocturnal incontinence.
• Materials and Methods: We selected 25 patients, that is 10 males (40%) and 15 females (60%), between ages 7 and 16 years (mean 9.8) with neuropathic bladder secondary to NTDs without a ventricular-peritoneal shunt. All had a low pressure bladder and presented with daytime continence between catheterizations but had persistent nocturnal urine loss 7 nights weekly. They underwent treatment with oral DDAVP according to a certain design, namely an initial dose of 0.2 mg for 3 weeks, which was increased to 0.3 or 0.4 mg for another 3 weeks in non responders. The average dose was 0.2 mg. At the effective minimal dose (bedwetting decrease greater than 50%) patients continued for 6 months and then decreased by intervals of 0.05 mg every 2 weeks. In the event of recurrence treatment continued for 1 year.
• Results: All patients responded to treatment during the nighttime hours except 1 who suspended treatment after 4 weeks. There were no adverse effects from DDAVP.
• Conclusions: Treating nocturnal bedwetting with DDAVP in patients with NTDs was effective and safe. Nevertheless, to our knowledge treatment duration has not yet been determined.
  
  
• Editorial Comment
  The authors study nocturnal enuresis in a select group of children with neurogenic bladder dysfunction. They note that although bladder management in these patients often makes these patients dry during the day, many are wet at night. In this small study, 24 of 25 patients responded to DDAVP by becoming dry at night. There were no complications.
  Although this is a creative approach and likely to lead to quality of life improvement in these patients, there are some concerns. First, the authors acknowledge that this is a selected group of patients. However, they do not give the criteria for selection, except for the exclusion of those with a ventriculoperitoneal shunt. Why were these excluded, since they make up the majority of the population of children with neurogenic bladder dysfunction? Moreover, the authors monitored daily weights and electrolytes in the beginning of the study, but provide no data on the results. How did they counsel the patients regarding drinking? Were they placed on evening fluid restriction? If so, might this negatively affect quality of life? Overall, this is a creative and interesting preliminary study of an interesting problem that warrants further examination.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA