Primary nocturnal enuresis (PNE) is currently defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, as involuntary voiding of urine during sleep at least twice per week in children over 5 years . This occurs in the absence of congenital or acquired defects of the central nervous system or by the effect of substances such as a diuretic .
Epidemiological comparison shows varying prevalence. Western countries have suggested a prevalence of PNE of 13–19% in boys of 5 years of age and 9–16% in girls of 5 years of age, whereas at the age of 16 years 1–2% of boys and girls continue to be affected by PNE .
Mild or moderate enuresis (less than 3 wet nights/week) in children is common and often spontaneously resolves, whereas severe enuresis (wetting every night) is uncommon and resolution rates are poor particularly after 10 years of age. PNE represents the least pathological end of the spectrum of ‘the wetting child’. However, it is often a source of considerable heartache to the child and parents and can be challenging and disheartening to the professionals approached for help .
Current medical treatment for the child with PNE centers on the three main pathological causes of the condition: lack of arginine–vasopression activity; bladder overactivity; and the inability to wake to void . The most commonly used medical treatments are pharmacological therapies including desmopressin, tricyclics, or oxybutynin and behavioral therapies . Alternative treatments such as biofeedback, acupuncture, and hypnotherapy also exist .
Although the use of acupuncture and Chinese herbal medicine for adults has grown widely in the USA, Oriental medicine is used less frequently in the treatment of children, and relatively few practitioners actually specialize in pediatrics .
Acupuncture is believed to normalize bladder function by invigorating the kidney, spleen, and brain, calming the mind, and adjusting Qi of the lungs, vital energy, and blood. The word itself is originally derived from Latin and refers to piercing with a sharp instrument. The practice uses the concept of 12 primary meridians or energy channels along which are distributed 360 acupuncture points. Each point is located in an area of low electrical resistance, and sites used to treat bladder dysfunction appear to coincide with innervation by spinal sacral segments S2 through S4. Stimulation of these acupoints by manual pressure, penetration of the skin, heating, the application of laser, electrotherapy, or moxibusion is thought to induce homeostatic changes . Most practitioners agree that optimal results will be obtained if a patient experiences the spread of treatment sensation (including numbness, heaviness, distension, and soreness) beyond the acupuncture site, a condition known as de Qi .
The aim of this study was to identify patients who had no success with behavioral and pharmacological therapy, to determine their response to acupuncture treatment, and to evaluate the treatment rate in children with primary persistent nocturnal enuresis.
Methods and results
The study consisted of 50 primary nocturnal enureic children and adolescents (31 boys, 19 girls) attending the Pediatrics and Urology Outpatient Clinic of Zagazig University Hospitals, during the year 2009. Their mean age was 10.8 years (range 9–17 years) and they had nocturnal enuresis of more than or equal to 2 nights per week during 2 weeks of observation, Table 1.
All patients had documented persistent PNE and no success with any other pharmacological treatments (desmopressin, imipramine, or oxybutynin), as well as behavioral therapy , Table 2.
Patients with a history of urinary tract infections, bladder dysfunction, psychiatric disorders, neurourological disorders, or other medical problems were referred to specialized clinics for further management and were excluded from the study.
Patients selected for acupuncture therapy underwent thorough counseling, involving a review of the therapy and its administration, a review of the calendar system, and a discussion of the treatment plan and its goals. Patients and their parents were also instructed to continue the follow-up at every 3 months after starting the therapy.
The principle of traditional Chinese acupuncture is based on dermal stimulation on local acupuncture points , which are shown in Fig. 1. Acupuncture treatment required needles to be inserted into acupoints; moxibustion applied to the points (UB67, UB28, UB23, Ren3, and Ren4) was also accepted. The treatment was applied with disposable acupuncture needles for 10 consecutive days in a month, and each therapy period lasted for 30 min . The progress of the therapy was monitored objectively using a calendar completed each morning by the parents and the child. The goal of the therapy was achieved completely dry nights over a period of 6 months. Patients had a follow-up visit every 3 months and were reevaluated. After 6 months of dry nights, the patients were asked about their waking patterns.
Criteria of therapeutic effects  after two courses of the treatment were as follows:
Cure: enuresis disappeared, or the sick child could wake up voluntarily at night to micturate, with no relapse within half a year.
Improvement (remarkable effect): the sick child could wake up voluntarily at night to micturate, and enuresis occurred occasionally within half a year, but disease condition was improved compared with before.
Failure: the condition had no change
Within 6 months, 38 (76%) patients were completely dry and/or could wake up voluntarily at night to void with no relapse (cure), whereas nine (18%) patients could wake up at night to micturate (i.e. developed nocturia) and enuresis occurred occasionally (<20% of nights), but disease condition improved compared with earlier condition (improvement). In three (6%) patients, the condition had no change (failure), Table 3.
Twelve patients who had partial cure or failure of therapy received another course of acupuncture, with follow-up for another 6 months. Eight (66.7%) patients achieved complete cure, and four (33.3%) patients did not respond (failure), Table 4.
After 1 year of follow-up, final response to acupuncture therapy of persistent PNE accounted for complete cure without relapse in 46 (92%) patients and failure of treatment in four (8%) patients. No side effects were reported during the treatment.
PNE can be caused by nocturnal polyuria, inability to wake up, and a constitutionally small bladder . PNE persisting into adult life can be a very distressing symptom with significant implications for self-esteem and for developing relationships. In addition, adults presenting with lower urinary tract symptoms and who had a history of enuresis beyond the age of 6–7 years, appear to have a higher incidence of overactive bladder, particularly in men. In addition, PNE must be treated as it is a disease that can result in low self-esteem, some secondary psychological problems, and in low school performance of affected children [2,14].
In this study, traditional Chinese acupuncture was applied to treat persistent PNE in older children and adolescents (≥9 years). Realizing the spontaneous remission rate of 15% per year and the relatively low incidence (2–3%) of nocturnal enuresis in older children, it was felt that these children need help to deal with the psychosocial issues relating to bedwetting. The treatment was directed toward alleviating the symptoms of NE rather than curing the condition because the exact pathophysiological mechanism involved are unclear.
In this study, all patients had documented persistent PNE and no success with any other pharmacological treatments (desmopressin, imipramine, or oxybutynin) or behavioral therapy.
Research from as early as 1958 identified spinal and peripheral nerves and their terminals dispersed within 5 mm of known acupuncture meridians. Nerves from such acupuncture points feed into the same area of the spine as certain viscera that have long been linked with such points . More recently, high concentrations of neuroendocrine transmitters and hormones have been identified at acupuncture points. Furthermore, needling or mechanical stimulation of these points induces release and spread of neurotransmitter substances . Furthermore, an autonomic response occurs during acupuncture, as evidenced by significant reduction in average heart rate during treatment . Such a theoretical framework provides some evidence in support of the efficacy of acupuncture for NE .
In this study, initial response after two courses of acupuncture therapy for patients suffering from persistent PNE accounted for complete cure without relapse in 38 (76%) patients, partial cure (improvement) in nine (18%) patients, and failure of treatment in three (6%) patients. Nonrespondents and those who showed partial cure received another course of acupuncture therapy, with complete cure in 66.7% (eight of 12 patients) and further failure in 33.3% (four of 12 patients).
After 12 months of follow-up, final response to acupuncture therapy, for persistent PNE, accounted for complete cure in 46 (92%) patients, and failure of treatment in four (8%) patients. No side effects were reported during the study. Similar results were obtained by other studies [12,13,17].
Given the good overall success rate in the treatment of enuresis with traditional Chinese acupuncture, this treatment is attractive for treating patients with PNE, especially in the preadolescent and adolescent periods. These results are better than the spontaneous resolution rate or outcomes with other treatments.
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