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Alarm interventions for nocturnal enuresis in children
(Review)
Glazener CMA, Evans JHC, Peto RE
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2009, Issue 1
http://www.thecochranelibrary.com
Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
71DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 ALARM vs CONTROL, Outcome 1 Mean number of wet nights per week. . . . . 77
Analysis 1.3. Comparison 1 ALARM vs CONTROL, Outcome 3 Number not achieving 14 consecutive dry nights. 79
Analysis 1.4. Comparison 1 ALARM vs CONTROL, Outcome 4 Numbers not achieving 14 dry nights or relapsing. 81
Analysis 2.1. Comparison 2 COMPARING ALARMS, Outcome 1 Mean number of wet nights per week. . . . . 82
Analysis 2.3. Comparison 2 COMPARING ALARMS, Outcome 3 Numbers not achieving 14 dry nights. . . . . 83
Analysis 2.4. Comparison 2 COMPARING ALARMS, Outcome 4 Numbers not achieving 14 dry nights or relapsing. 85
Analysis 3.1. Comparison 3 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 1 Mean number of wet nights
per week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Analysis 3.3. Comparison 3 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 3 Numbers not achieving 14
dry nights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Analysis 3.4. Comparison 3 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 4 Mean number of wet nights
at follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Analysis 3.5. Comparison 3 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 5 Numbers not achieving 14
dry nights or relapsing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Analysis 4.1. Comparison 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 1 Mean number of
wet nights per week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Analysis 4.3. Comparison 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 3 Number not
achieving 14 consecutive dry nights. . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis 4.4. Comparison 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 4 Numbers not
achieving 14 dry nights or relapsing. . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Analysis 4.5. Comparison 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 5 Mean number of
wet nights at follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Analysis 5.1. Comparison 5 ALARM vs DRUGS, Outcome 1 Mean number of wet nights per week. . . . . . . 96
Analysis 5.3. Comparison 5 ALARM vs DRUGS, Outcome 3 Numbers not achieving 14 dry nights during treatment. 98
Analysis 5.5. Comparison 5 ALARM vs DRUGS, Outcome 5 Number not achieving 14 dry nights or relapsing. . . 100
Analysis 5.6. Comparison 5 ALARM vs DRUGS, Outcome 6 Mean number of wet nights at follow-up. . . . . . 101
Analysis 6.1. Comparison 6 ALARM vs OTHER / MISCELLANEOUS TREATMENTS, Outcome 1 Mean number of
wet nights per week. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Analysis 6.3. Comparison 6 ALARM vs OTHER / MISCELLANEOUS TREATMENTS, Outcome 3 Numbers not
achieving 14 dry nights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Analysis 6.4. Comparison 6 ALARM vs OTHER / MISCELLANEOUS TREATMENTS, Outcome 4 Number not
achieving 14 dry nights or relapsing. . . . . . . . . . . . . . . . . . . . . . . . . . . 103
103WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
103HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
104CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
104DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
104SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
105INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iAlarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Alarm interventions for nocturnal enuresis in children
Cathryn MA Glazener1, Jonathan HC Evans2, Rachel E Peto3
1Health Services Research Unit, University of Aberdeen, Aberdeen, UK. 2Department of Paediatric Nephrology, Nottingham University
Hospitals NHS Trust, Nottingham, UK. 3NHS Centre for Reviews & Dissemination, University of York, York, UK
Contact address: Cathryn MA Glazener, Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building,
Foresterhill, Aberdeen, Scotland, AB25 2ZD, UK. [email protected].
Editorial group: Cochrane Incontinence Group.
Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 27 February 2007.
Citation: Glazener CMA, Evans JHC, Peto RE. Alarm interventions for nocturnal enuresis in children. Cochrane Database of SystematicReviews 2005, Issue 2. Art. No.: CD002911. DOI: 10.1002/14651858.CD002911.pub2.
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2%
of young adults.
Objectives
To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions.
Search methods
We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 February 2007) and the reference lists of relevant
articles.
Selection criteria
All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused
solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin,
tricyclics, and miscellaneous other methods.
Data collection and analysis
Two reviewers independently assessed the quality of the eligible trials, and extracted data.
Main results
Fifty six trials met the inclusion criteria, involving 3257 children of whom 2412 used an alarm. The quality of many trials was poor,
and evidence for many comparisons was inadequate. Most alarms used audio methods.
Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45).
Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of
failure or relapse 45 of 81 (55%) versus 80 of 81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw
conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower
when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95%
1Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children
or their parents.
Although desmopressin may have a more immediate effect, alarms appeared to be as effective by the end of a course of treatment
(RR 0.85, 95% CI 0.53 to 1.37) but their relative effectiveness after stopping treatment was unclear from two small trials which
compared them directly. Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were
not significantly better than tricyclics during treatment (RR 0.59, 95% CI 0.32 to 1.09) but the relapse rate was less afterwards (7 of
12 (58%) versus 12 of 12 (100%), RR 0.58, 95% CI 0.36 to 0.94). However, other Cochrane reviews of desmopressin and tricyclics
suggest that drug treatment alone, while effective for some children during treatment, is unlikely to be followed by sustained cure as
almost all the children relapse.
Authors’ conclusions
Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin
or tricyclics because around half the children remain dry after alarm treatment stops. Overlearning (giving extra fluids at bedtime after
successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality
research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.
P L A I N L A N G U A G E S U M M A R Y
Alarm interventions for nocturnal enuresis (bedwetting) in children
Night-time bedwetting is common in childhood, and can cause stigma, stress and inconvenience. The review of trials found 56 studies
involving 3257 children. Alarm interventions reduce night-time bed wetting in about two thirds of children during treatment, and
about half the children remained dry after stopping using the alarm. Alarms take longer to reduce bedwetting than desmopressin, but
their effects continue after treatment in half the children who use alarms. So alarms are better in the long term than treatment with
desmopressin or tricyclic drugs. Overlearning (giving children extra fluids at bedtime after successfully becoming dry using an alarm)
and dry bed training (getting children to go to the toilet repeatedly and changing their own sheets when they wet) may reduce the
relapse rate. There are no serious side-effects, which can occur with drug treatment. However, children need more supervision and time
from other family members at first. There was not enough evidence with which to compare alarms with other non-drug treatments.
Because some of the studies were of poor quality, better research comparing alarms with other treatments is needed, including follow-
up to measure relapse rates.
B A C K G R O U N D
This is one of seven reviews of interventions for bedwetting,
or non-organic nocturnal enuresis. The others focus on: desmo-
pressin (Glazener 2002), tricyclics and related drugs (Glazener
2003a), other drugs (Glazener 2003b), simple behavioural train-
ing (Glazener 2004b), complex behavioural training (Glazener
2004b) and complementary and miscellaneous other interventions
(Glazener 2005b). All seven are based on the work of Lister-Sharp
and her colleagues at the Centre for Reviews and Dissemination at
the University of York, UK (Lister-Sharp 1997). The current re-
view is a further update of previously published Cochrane reviews
(Glazener 2001; Glazener 2003c; Glazener 2005a). It concerns
the use of alarms triggered by wetting (e.g. pad-and-bell alarms)
to waken the child. It is restricted to children with monosymp-
tomatic nocturnal enuresis who are treated with an alarm triggered
by wetting, and includes other interventions if they are compared
with such alarms or used in combination with them.
Nocturnal enuresis is the involuntary loss of urine at night, in the
absence of organic (physical) disease such as urinary tract infection
or detrusor overactivity, at an age when a child could reasonably
be expected to be dry (by consensus, at a developmental age of
five years) (APA 1980; WHO 1992). Although bedwetting in it-
self is pathologically benign and has a high rate of spontaneous
remission, it may bring social and emotional stigma, stress and
inconvenience to both the person with enuresis and their fami-
lies (Fitzwater 1992). Children who wet the bed may experience
parental disapproval, sibling teasing and repeated treatment failure
2Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
which may lower self esteem (Warzak 1992). The children may
also be at increased risk of emotional and physical abuse (Warzak
1992). Consequently, it is important that enuresis is properly man-
aged (Moffatt 1994).
Although daytime wetting is a significant problem and is often
associated with bedwetting, it is usually considered separately. It
has been suggested that there are different aetiologies underly-
ing monosymptomatic nocturnal enuresis and daytime wetting
(Jarvelin 1989). If daytime symptoms are present, investigations
to identify physical causes such as urinary tract dysfunction, con-
genital malformation and neurogenic disorders are usually neces-
sary (Djurhuus 1992). An organic cause is more often found in
children with daytime wetting; for example more structural ab-
normalities and functional disorders of the urinary tract are found
in daytime wetters than controls (Jarvelin 1990).
Prevalences and causes
Nocturnal enuresis is a complaint that affects many families. Es-
timating the prevalence of monosymptomatic nocturnal enuresis
is difficult, however, because there is variation in methods of di-
agnosis and definitions (de Jonge 1973; Krantz 1994). About 13
to 19% of boys and 9 to 16% of girls at age five wet the bed at
least once per month (Devlin 1991; Feehan 1990; Rutter 1973;
Verhulst 1985). Although enuresis shows a steady decline with
age, 2 to 3% still wet regularly during the late teens and early
adulthood (Forsythe 1974). The incidence of nocturnal enuresis
is particularly high amongst children in residential care (Morgan
1970). Without treatment, about 15% of bedwetting children be-
come dry each year (Forsythe 1974). However, it is not possible
to predict which children will become dry spontaneously (Doleys
1977).
The causes of monosymptomatic nocturnal enuresis are unclear
(Lister-Sharp 1997). Genetic (APA 1980; Bakwin 1971; Bakwin
1973; Eiberg 1995), physiological (Djurhuus 1992; Norgaard
1993) and psychological (Devlin 1991; Rutter 1973; Shaffer 1977;
Moffatt 1989) factors, as well as delay in maturation of the mech-
anism for bladder control (Jarvelin 1989; Koff 1995), have been
suggested. Other factors which may contribute to bedwetting in-
clude: constipation, sleep apnoea and upper airway obstructive
symptoms (Maizels 1993); and diet and mild caffeine drinks with
diuretic effects (e.g. cola) (Blackwell 1989).
Interventions
Pharmacological, psychological/behavioural and a variety of ’un-
conventional’ interventions are commonly used for people who
wet the bed.
• Pharmacological interventions include desmopressin
(Glazener 2002), tricyclic drugs (amitriptyline, dothiepin,
doxepin, trimipramine, clomipramine, desipramine, imipramine,
lofepramine, nortriptyline and protriptyline, Glazener 2003a),
drugs related to the tricyclics (viloxazine, desipramine, mianserin
and maprotiline, Glazener 2003a), and a variety of other drugs
(e.g. amphetamine, diazepam and oxybutynin, Glazener 2003b).
These are discussed in separate reviews as indicated.
• Behavioural interventions include simple methods (e.g. star
charts, reward systems, overlearning, retention control training,
urine stream interruption exercises, lifting and scheduled
wakening, Glazener 2004b), and complex (multidimensional)
behavioural methods (e.g. dry bed training, full spectrum home
training, Glazener 2004a).
• Other interventions include psychotherapy, surgery, fluid
deprivation and complementary therapies (review in
preparation).
Enuresis alarms
Enuresis alarms consist of some kind of alarm which is activated
by micturition. The first enuresis alarms were bed-based, the child
sleeping on a pad or mat containing an electrical circuit (Mowrer
1938). Urine, coming into contact with this would complete the
circuit causing a bell to ring. Historically, some alarms worked
by giving an electric stimulus or shock to the children’s skin. The
alarm is intended to change the meaning of the sensation of having
a full bladder from a signal to urinate to a signal to inhibit urination
and waken (Forsythe 1989). There are now many variations: the
alarm may be a bell, buzzer, a visual signal such as a light or it
may vibrate. There are also many different tones and intensities,
and the alarm may be set to operate only intermittently or after
an interval. In ’mini-alarm’ systems, the sensor is placed in pants,
producing a discrete, portable system (’body-worn’ alarm).
Overlearning
An over-learning procedure may be initiated after successful alarm
treatment (e.g. achievement of 14 consecutive dry nights). Extra
drinks are given at bed-time to cause additional stress to the de-
trusor muscles in the bladder. Alarm treatment is then continued
until 14 consecutive dry nights are once again achieved (Blackwell
1989).
Other behavioural interventions
These include:
Lifting
Lifting involves taking the child to the toilet during the night to
empty their bladder, usually before the time that bedwetting is
expected, without necessarily waking the child.
3Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Waking
This intervention involves waking the child to allow them to get
up and urinate (Warzak 1994). A scheduled waking programme
may be used with the child being woken progressively earlier after
dry nights until the interval between going to bed and scheduled
waking is one hour. Older individuals may use an alarm clock to
wake themselves (Blackwell 1989). However, the use of an alarm
clock in this circumstance is not included as an alarm triggered by
bedwetting as defined in this review.
Reward systems (e.g. star chart)
Systems to reward the child for dry nights are often used as first
line treatment. For example, the child might receive a star for every
dry night, and a reward after a preset number of stars have been
earned.
Retention control training
This is an attempt to increase the functional bladder capacity using
exercises such as delaying urination for extended periods of time
or drinking increased fluids (Warzak 1994).
Stop-start training
Stream interruption exercises (pelvic floor muscle training) have
also been used (Novello 1987).
Dry bed training
Dry bed training was initially developed in the early 1970s for use
with people with learning disabilities (Azrin 1973). The original
schedule involved an intensive training night, during which the
patient was woken every hour and taken to the toilet. If an accident
occurred, 45 minutes of ’cleanliness training’ (changing the bed)
and ’positive practice’ (child practices getting up and going to the
toilet about nine times) was implemented. On subsequent nights,
the individual was woken once and taken to the toilet, this nightly
wakening occurring progressively earlier. The wakening might or
might not be triggered by an alarm.
Other (miscellaneous) interventions in the current review include:
cognitive therapy, psychotherapy, counselling, education/informa-
tion systems, restricted diet and shaming. These are described in
the Table of Included Studies.
The wide variety of treatments for nocturnal enuresis indicates the
lack of consensus as to which is the best. Provided that a sufficient
number of adequate quality have been conducted, the most reli-
able evidence is likely to come from consideration of all well-de-
signed randomised controlled trials. Hence, there is a need for an
easily accessible, periodically updated, comprehensive systematic
review of such studies which will not only help to identify optimal
practice, but also highlight gaps in the evidence base.
O B J E C T I V E S
To determine the effects of alarms for the treatment of children
with nocturnal enuresis.
The following hypotheses were tested:
1. alarms are better than no active treatment/non-functioning
alarms;
2. one type of alarm is better than another one;
3. alarm treatment alone is better than a behavioural intervention
alone;
4. alarm treatment alone is better than alarm treatment supple-
mented by a behavioural method;
5. alarm treatment alone is better than a drug treatment alone or
better than alarm treatment supplemented by a drug;
6. alarm treatment alone is better than treatments other than be-
havioural or drugs.
M E T H O D S
Criteria for considering studies for this review
Types of studies
Randomised or quasi-randomised trials of alarm interventions for
the treatment of non-organic nocturnal enuresis.
Types of participants
Children (as defined by the trialists, usually up to age 16) suffering
from nocturnal enuresis. Trials which included children suffering
from daytime enuresis or where some children may have had an
organic cause contributing to their enuresis were only included if
the primary problem was nocturnal enuresis.
Types of interventions
Any trial which used an alarm in at least one arm of the study.
Comparisons were made with no active treatment, behavioural in-
terventions and drugs (either alone or in combination with alarms)
and any other treatments not already specified.
4Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Types of outcome measures
The outcomes considered in this review were:
• change in the mean number of wet nights per week during
treatment;
• number of participants failing to attain 14 consecutive dry
nights;
• mean number of wet nights per week when participants
were followed up after treatment had ceased;
• number failing to attain 14 consecutive dry nights or
subsequently relapsing; and
• adverse events.
Timing of relapse and follow up was as defined by the trialists.
Search methods for identification of studies
This review has drawn on the search strategy developed for the In-
continence Review Group. Relevant trials were identified from the
Group’s Specialised Register of controlled trials which is described
under the Incontinence Group’s details in The Cochrane Library (For more details please see the ‘Specialized Register’ section of
the Group’s module in The Cochrane Library). The register con-
tains trials identified from MEDLINE, CINAHL, the Cochrane
Central Register of Controlled Trials (CENTRAL) and hand
searching of journals and conference proceedings. Date of the most
recent search of the register for this review: 28 February 2007.
The trials in the Incontinence Group Specialised Register are also
contained in CENTRAL. The terms used to search the Inconti-
nence Group Specialised Trials Register are given below:
(TOPIC.URINE.ENURESIS*)
AND
({DESIGN.CCT*} OR {DESIGN.RCT*})
(All searches were of the keyword field of Reference Manager 9.5
N, ISI ResearchSoft).
The review authors also searched the reference lists of relevant
articles. We did not impose any language or other restrictions on
any of these searches.
Data collection and analysis
The studies for this review were assessed using the methods of the
Cochrane Collaboration (Deeks 2006).
Identification of primary studies
The titles and where possible abstracts of all studies located by the
searches were checked to identify those likely to be evaluations
of the effects of interventions for nocturnal enuresis. Full papers
were then obtained and assessed to identify those which met the
inclusion criteria.
Quality assessment
A range of both general and more specific quality issues were noted,
including:
• the level of concealment of random allocation in the trials
(A=adequate method of concealment of allocation to groups, B=
unclear, C=quasi-randomised, Deeks 2006);
• whether data to assess the comparability of groups at
baseline were given, including baseline levels of wetting;
• use of a ’wash-out’ period if a crossover design was
employed;
• intention-to-treat analysis;
• whether outcomes were clearly defined;
• blinding;
• a follow-up of at least three months or provision of follow-
up data;
• whether useful data (e.g. means and standard deviations)
were presented;
• whether children with daytime wetting were specifically
excluded;
• whether children who had physical (organic) causes for
their enuresis were specifically excluded.
However, none of these criteria were used to include or exclude
trials.
Data extraction
The data were extracted using a standard form, independently by
two review authors.
Data analysis
Where appropriate, the results were converted to the mean and
standard deviation of the number of WET nights per WEEK, or
the number of children failing to achieve cure during treatment,
defined as 14 consecutive dry nights, or the number who were
not cured during treatment plus those who relapsed after stopping
active treatment (to allow for possible differences in initial ’suc-
cess’ rates). Where a mean value was reported with no standard
deviation, we entered the data into ’Other Data Tables’.
We intended, where possible, to calculate standardised effect sizes
and 95% confidence intervals (CI): weighted mean differences
(WMD) where outcomes were continuous variables and relative
risks (RR) where they were binary. A fixed effect model was used
to calculate the pooled estimates and the 95% CIs (Berlin 1989).
The weighted mean differences were weighted by the inverse of
the variance, and given as differences in number of wet nights per
week. Negative values indicate fewer wet nights in the group on
the left of the MetaView.
Differences between trials were further investigated when statis-
tically significant heterogeneity was apparent either at the 10%
probability level, using the chi squared test or assessment of the I-
squared statistic (Higgins 2003), or from visual inspection of the
5Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
results. If there was no obvious reason for the heterogeneity, or it
persisted despite the removal of outlying trials, a random effects
model was used.
Crossover trials were marked with the suffix ’#’. Data from the
one trial identified were entered into ’Other Data Tables’.
In general, dropouts were not taken into account and data were
presented as given in the trial reports. However, if there were ev-
idence of differential dropouts from the groups which may have
been caused by adverse effects of the interventions, the data were
recalculated as if the dropouts were failures.
R E S U L T S
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies; Characteristics of ongoing studies.
Eighty four studies were identified as including an alarm interven-
tion. Thirty were excluded, the majority because they were not
randomised controlled trials. Three of these 30 were RCTs which
included an adult population (Azrin 1973; Crisp 1984; Hanson
1988) and one other was excluded because children were switched
between groups (McConaghy 1969). One of these trials was an ’in-
cluded study’ in a previous version of this review (Hanson 1988).
Details are given in the Table of Excluded Studies.
Fifty six randomised controlled trials were included in the review
(see Table of Included Studies). They were described in 52 reports
(three reports each described two trials (Bollard 1981a; Bollard
1981b; Butler 1990a; Butler 1990b; Geffken 1986a; Geffken
1986b), and one described three trials (Lovibond 1964a; Lovibond
1964b; Lovibond 1964c)). One study (reported here as two sepa-
rate trials) divided children into two groups according to their base-
line maximal functional bladder capacity, large or small (Geffken
1986a; Geffken 1986b).
Trials with methodological flaws
Two included trials failed to provide reliable data, one because
groups were combined and results reported only as medians for
the combined groups (Azrin 1974) and the other because children
who dropped out from the alarm groups (due to inability to use
the alarm or family disruption) were replaced by other children
resulting in non-randomised groups and unreliable data (Turner
1970). No data from these trials have been used in the review.
Types of interventions
The trials all included an alarm which activated a bell or buzzer
when triggered by wetting. In the majority, this was the stan-
dard bed-pad-and-bell but variations included body-worn alarms
(Butler 1990a) and electric shock alarms (Elinder 1985; Hojsgaard
1979; Lovibond 1964a; McKendry 1975; Netley 1984).
Numbers of children
In total, 3257 children were studied, of whom 2412 received an
alarm intervention either alone or in combination with another
treatment. In general, sample sizes were small, ranging from 14 to
222 with an average of about 57 participants per trial.
Duration of treatment
Duration of treatment varied amongst the trials: alarms were used
for between two and eight weeks in 16 trials, eight to 12 weeks in 18
trials, and for more than 12 weeks in 22 trials. However, children
usually stopped earlier than the maximum allowed duration of
treatment if they became dry.
Baseline wetting, organic causes and daytime wetting
In 14 trials, there was no period of baseline recording of wetting
before beginning the trial. In seven trials, authors failed to report
that children with a possible organic cause for their bedwetting
were excluded. In one of these seven, neither of these measures
of quality (baseline wetting or exclusion of organic causes) were
recorded (Forrester 1964). Of the seven trials where organic causes
were not specifically excluded, two included some children with
daytime wetting (Caceres 1982; Moffatt 1987), three failed to
record information about daytime wetting (Forrester 1964; Houts
1986; van Londen 1993) and only two explicitly excluded chil-
dren whose primary problem was daytime wetting (Bennett 1985;
Lynch 1984). However, no trials included children with known
organic causes.
In 19 trials, children with diurnal (daytime as well as night-
time) wetting were specifically excluded. Six trials included at least
some children with daytime wetting (Bradbury 1995; Caceres
1982; Gibb 2004; McKendry 1975; Moffatt 1987; Taylor 1975)
although in three, organic causes were specifically excluded
(Bradbury 1995; McKendry 1975; Taylor 1975). Another in-
cluded diurnal wetting ’only if negligible’ (Bennett 1985). One
trial included some children who also had encopresis (Taylor
1975). The remaining trials did not mention daytime wetting.
Follow up
Of the 56 included studies, only 29 trials provided follow-up data
about wet nights or relapse rates after the end of trial treatment.
In some trials follow up was not possible because children were
given alternative (non-randomised) treatments.
6Alarm interventions for nocturnal enuresis in children (Review)
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Settings
The children were recruited in different settings. In six trials, they
were identified from the community by advertising in the media;
in 18 they were recruited in hospital or community outpatient
clinics; in four both methods were used; three trials were in resi-
dential institutions (Jehu 1977) or amongst children with special
needs (Kennedy 1968; Sloop 1973); and in 22 the setting was not
specified.
Ages of children
Most trials required children to be at least five years old at entry,
but in six trials a few younger children were included (Azrin 1974;
Azrin 1978; Jehu 1977; Taylor 1975; Wright 1974; Young 1972).
Previous treatment
In four trials, children were only included if they had not previously
had treatment for their enuresis (Butler 1990a; Faraj 1999; Ng
2005; Sloop 1973); in another four, all the children had failed
with previous treatment (Butler 1990b; Caceres 1982; Gibb 2004;
Scholander 1968); in a further 16 trials some children had received
previous treatment (Bollard 1982a; Bradbury 1995; Butler 1988;
Elinder 1985; Fielding 1980; Jehu 1977; Leebeek 2001; Longstaffe
2000; Motavalli 1994; Nawaz 2002; Rodriguez 2001; Sukhai 1989
#; Tobias 2001; Wagner 1982; Wille 1986; Young 1972); the
remainder did not provide this information.
Risk of bias in included studies
Of the 56 included trials, nine reported concealment of alloca-
tion to groups which was probably adequate (e.g. by use of sealed
opaque envelopes or remote computer allocation, rated as A: Azrin
1974; Bradbury 1995; Leebeek 2001; Longstaffe 2000; Moffatt
1987; Motavalli 1994; Ng 2005; Scholander 1968; Sukhai 1989
#); 39 trials did not provide adequate detail for this to be assessed
(rated as B); and seven used methods where allocation definitely
was not adequately concealed (i.e. quasi-randomised such as alter-
nate numbers, rated as C: Butler 1990a; Butler 1990b; Kennedy
1968; Ronen 1992; Taylor 1975; Wagner 1985; Werry 1965). In
one further trial, although the initial randomisation was classed as
A and stratified by age and sex, there were differential dropouts
from the groups and they were non-systematically replaced result-
ing in unreliable groups (Turner 1970).
Crossover trials
There was one double-blind cross-over trial (Sukhai 1989 #). An
alarm in both arms of the trial was supplemented by desmopressin
or placebo for two weeks, crossing over to the alternative arm after a
two-week washout period. Follow-up information could therefore
not be given separately for each regimen.
Dropouts
Only three trials reported that there were no dropouts (Scholander
1968; Sukhai 1989 #; Wagner 1985). Where the drop-out rates
in treatment and comparison groups were similar and no reasons
were given, or where children randomised were found ineligible
or did not attend for initial monitoring, analyses were conducted
according to actual results reported, excluding drop-outs. There
were 28 such trials, in which dropouts did not seem to be affected
by group of allocation (Bennett 1985; Bollard 1981a; Butler 1988;
Butler 1990a; Butler 1990b; Elinder 1985; Faraj 1999; Fielding
1980; Forrester 1964; Fournier 1987; Geffken 1986a; Geffken
1986b; Houts 1986; Jehu 1977; Kolvin 1972; Lovibond 1964a;
Lynch 1984; Moffatt 1987; Netley 1984; Ng 2005; Rodriguez
2001; Ronen 1992; Wagner 1982; Werry 1965; Wright 1974). In
one other trial, the number of dropouts was unclear because each
was replaced with a subsequent child seen in the clinic (Taylor
1975) but as this did not seem to be affected by the intervention
allocated, the data have been used as reported.
However, where reasons for drop-out were reported as clearly re-
lated to the treatment group (e.g. unacceptability of the particular
treatment, adverse effects) they were included as failures. There
were three trials which reported such differential dropouts from
the groups, probably caused by adverse effects of the interven-
tions. In the first two, data were reported as if the dropouts were
failures (Bollard 1981b; McKendry 1975). In the other, children
were differentially withdrawn from treatment, making the groups
unreliable: data were not used from this study (Turner 1970).
Dropouts were usually due to: children not being sufficiently
enuretic at baseline assessment or found not to be eligible in other
ways for the trial; failure to attend for monitoring or follow up;
receiving the wrong intervention; non-compliance or difficulty
with using the equipment; family disruption; failure of the treat-
ment; and in the case of the alarms which delivered electric shocks,
the parents or the child being unwilling to experience the shocks
(Elinder 1985; Lovibond 1964a; McKendry 1975; Netley 1984).
Statistical reporting
Eighteen trials reported continuous data but failed to provide
measures of dispersion such as SDs (Azrin 1978; Baker 1969;
Bollard 1981a; Bollard 1981b; Bollard 1982a; Butler 1988; Butler
1990a; Butler 1990b; Danquah 1975; Fielding 1980; Finley 1973;
Fournier 1987; Jehu 1977; Kolvin 1972; Leebeek 2001; Wagner
1982; Wagner 1985; Wright 1974). These data were entered into
Other Data Tables.
Effects of interventions
1. Alarms compared with placebo / no treatment
control (Comparison 01, Other Data Tables 01)
7Alarm interventions for nocturnal enuresis in children (Review)
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Seventeen trials compared an alarm with a no-treatment control
group. The controls were:
• a no-treatment or waiting list control in 16 trials (Baker
1969; Bennett 1985; Bollard 1981a; Bollard 1981b; Hojsgaard
1979; Houts 1986; Jehu 1977; Lynch 1984; Moffatt 1987;
Nawaz 2002; Ronen 1992; Sacks 1974; Sloop 1973; Wagner
1982; Wagner 1985; Werry 1965); and
• one trial used a non-functioning device as a control
(Elinder 1985).
The types of alarms were:
• two trials used a delayed-alarm (Lynch 1984; Wagner
1985);
• one included an unsupervised alarm group (Bollard 1981a);
• two used an electric shock to the children’s skin, the Uristop
device (Elinder 1985; Hojsgaard 1979); and
• all remaining trials used a pad-and buzzer type of alarm to
wake the children when wetting occurred.
During treatment
Nine trials provided data about wet nights during treatment. On
average, there were over three fewer wet nights per week using the
standard alarm, compared to no-treatment controls (e.g. WMD -
3.34, 95% CI -4.14 to -2.55 in the four trials which reported SDs,
Comparison 01.01.01) (Bennett 1985; Lynch 1984; Nawaz 2002;
Ronen 1992); and in 6 of 6 trials where SDs were not reported
(Other Data Tables 01.02.01) (Baker 1969; Bollard 1981a; Bollard
1981b; Jehu 1977; Wagner 1982; Wagner 1985). In 13 trials,
the relative risk of failure was less in the alarm groups of all the
trials (107 of 316, 34% did not achieve 14 dry nights versus 250
of 260, 96% in no-treatment controls, RR 0.38, 95% CI 0.33
to 0.45, Comparison 01.03.01) (Bennett 1985; Bollard 1981a;
Bollard 1981b; Houts 1986; Jehu 1977; Lynch 1984; Moffatt
1987; Nawaz 2002; Ronen 1992; Sacks 1974; Sloop 1973; Wagner
1982; Wagner 1985; Werry 1965).
There was significant heterogeneity (P less than 0.00001). After
exclusion of two trials which involved children in residential homes
(Jehu 1977) or with learning disabilities (Sloop 1973) and a fur-
ther three trials which used quasi-randomised methods of alloca-
tion to groups (Ronen 1992; Wagner 1985; Werry 1965) the het-
erogeneity was reduced but still significant (P equals 0.013) while
the RR for failure remained similar in favour of alarm treatment
(RR 0.36, 95% CI 0.29 to 0.44). The remaining heterogeneity
may have been due to differences in types or effectiveness of the
alarms used (as the children in all the control groups had a similar
failure rate of over 90%) or differences between types of children
for example in baseline severity of wetting. It is more likely, how-
ever, that the heterogeneity is a statistical artefact caused by the
high proportion of children who failed, because the heterogeneity
disappears if the data are entered as cure rates instead of failure
rates.
Only three trials involved delayed or unsupervised alarms, but the
net effect was still generally in favour of the alarm group during
treatment (Comparisons 01.03.02, 01.03.03, Other Data Tables
01.02.02, 01.02.03) (Bollard 1981a; Lynch 1984; Wagner 1985).
After treatment stops
About half the children failed or relapsed after stopping standard
alarm treatment compared to nearly all after control interventions
(45 of 81 (55%) versus 80 of 81 (99%), RR 0.56, 95% CI 0.46
to 0.68, Comparison 01.04.01) (Bollard 1981a; Bollard 1981b;
Sloop 1973; Wagner 1982; Wagner 1985). There was no evidence
of heterogeneity amongst these five trials for this outcome. There
were no data for the number of wet nights after treatment stops.
Electric shock alarms
There was not enough evidence from two small trials to assess the
electric shock (Uristop) alarms (Comparison 01.03.04, Hojsgaard
1979; 01.03.05, Elinder 1985). It was reported that some children
were frightened of them, or their parents refused to let them be
used.
2. Comparisons between alarms (Comparison 02,
Other Data Tables 02)
Eleven trials compared different alarms or their use in different
circumstances. A large number of variations on standard alarm
treatment were tested, including:
• a body-worn alarm (Butler 1990a);
• intermittent alarm (Taylor 1975);
• time-delay before bell rings (Lynch 1984; Wagner 1985);
• alarm used without supervision (Bollard 1981a);
• loud versus quiet bells, with or without light (Finley 1973;
Finley 1977);
• an alarm which only wakes the parents (Finley 1973);
• a double (twin) alarm using both a bell and a buzzer
(Lovibond 1964a; Lovibond 1964c);
• an electric stimulation (shock) alarm (Crosby Dri-nite,
Lovibond 1964a); and
• a body-worn audio alarm versus a body-worn vibrating
alarm (Tobias 2001).
Immediate versus time delay alarm
In two small trials there were fewer wet nights when using an
alarm which woke the child immediately rather than after a time-
delay of 3 minutes (WMD -2.5, 95% CI -3.99 to -1.01, Compar-
ison 02.01.01, Lynch 1984; Other Data Tables 02.02.02, Wagner
1985) and differences in failure or relapse rates were consis-
tent with this but were not statistically significant (Comparisons
02.03.03, 02.04.03) (Lynch 1984; Wagner 1985).
8Alarm interventions for nocturnal enuresis in children (Review)
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Waking child versus waking parents
In one small trial, an alarm which woke the child directly was
more successful than one which only woke the parents (Compar-
isons 02.03.06, 02.03.07, 02.04.06, 02.04.07; Other Data Tables
02.02.05, 02.02.06) (Finley 1973).
Body-worn versus bed alarm
In another small trial, body-worn alarms appeared to be as effec-
tive as standard bed pad alarms (albeit with wide confidence inter-
vals) but children preferred the body-worn alarm (Comparisons
02.03.01, 02.04.01; Other Data Tables 02.02.01) (Butler 1990a).
Electric shock alarm
In one small trial, three children received corrosive skin burns and
two others discontinued treatment due to fear when using an alarm
which delivered an electric shock (Crosby Dri-nite, Lovibond
1964a). The alarm was therefore not used in subsequent trials.
Other alarms
There were no other clear differences between different types of
alarms or different ways of using them. However, some children
reported that the body-worn vibrating alarm was more uncom-
fortable than the audio alarm (Tobias 2001).
3. Alarms compared with behavioural interventions
(Comparison 03, Other Data Tables 03)
Eight trials compared alarms with a variety of simple or complex
behavioural interventions:
• star charts or rewards (Ronen 1992);
• star chart plus wakening (Baker 1969);
• wakening or lifting (Fournier 1987; Lovibond 1964b);
• retention control training and stop-start training (pelvic
floor muscle training) (Bennett 1985); and
• Dry Bed Training (complex intervention without an alarm)
(Azrin 1978; Bollard 1981b; Caceres 1982).
Simple behavioural interventions
Alarms were better than stop-start training in terms of wet nights
per week both during (WMD -2.25, 95% CI -4.2 to -0.3) and after
(WMD -2.6, 95% CI -4.53 to -0.67) treatment in one small trial
(Comparisons 03.01.02, 03.04.01) (Bennett 1985). However, the
chance of cure was not significantly higher (Comparison 03.03.02)
although in the same direction.
There were no significant differences between alarms and other
simple behavioural methods such as lifting, wakening or rewards
in four other trials (Baker 1969; Fournier 1987; Lovibond 1964b;
Ronen 1992), although all trials tended to favour alarms in respect
of mean wet nights (Comparison 03.01.01, Other Data Tables
03.02.01, 03.02.02, 03.02.03).
Complex behavioural interventions
During treatment, there was no clear difference in wet nights
between alarm and dry bed training in three trials (without
an alarm) (Comparison 03.03.03; Other Data Tables 03.02.03)
(Azrin 1978; Bollard 1981b; Caceres 1982), but there was sig-
nificant heterogeneity. In the Azrin trial, children only received
treatment for two weeks before being switched to the other arm,
which may not have been long enough for the alarm to work
(Azrin 1978). Excluding this trial, the heterogeneity was no longer
significant and the RR for failing to achieve 14 dry nights was
0.22, 95% CI 0.09 to 0.53 (Bollard 1981b; Caceres 1982). In the
one small trial which provided data after the trial stopped, there
was less chance of failure or relapse after alarm treatment alone
than after dry bed training alone (RR 0.59, 95% CI 0.37 to 0.95,
Comparison 03.05.03) (Bollard 1981b).
4. Alarms compared with alarm programmes
augmented by behavioural interventions
(Comparison 04, Other Data Tables 04)
Sixteen trials compared alarms alone with alarm programmes aug-
mented by behavioural interventions:
• supplementation of the alarm by supervision (Bollard
1981a);
• alarm plus retention control training (Bollard 1982a;
Fielding 1980; Geffken 1986a; Geffken 1986b; Houts 1986);
• alarm plus dry bed training (Azrin 1974; Bennett 1985;
Bollard 1981b; Bollard 1982a; Butler 1988; Butler 1990b;
Nawaz 2002);
• alarm plus waking (Bollard 1982a);
• alarm plus rewards with and without penalties (van Londen
1993);
• alarm plus overlearning (Houts 1986; Taylor 1975; Young
1972); and
• alarm plus positive practice with cleanliness training
(Bollard 1982a).
Supplementing alarms with retention control training
Although alarms alone were better than alarms plus retention con-
trol training in five trials in terms of failure rates during treat-
ment (RR 0.37, 95% CI 0.18 to 0.76, Comparison 04.03.02)
(Bollard 1982a; Fielding 1980; Geffken 1986a; Geffken 1986b;
Houts 1986), this was not reflected in terms of wet nights dur-
ing treatment (Comparison 04.01.01) (Geffken 1986a; Geffken
1986b) or in failure or relapse rates after the end of treatment
(RR 1.12, 95% CI 0.77 to 1.64, Comparison 04.04.02) (Fielding
1980; Geffken 1986a; Geffken 1986b; Houts 1986). However,
the trials were all small.
9Alarm interventions for nocturnal enuresis in children (Review)
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Supplementing alarms with overlearning
Although the results during treatment were similar for alarms
compared with alarms plus overlearning (Comparisons 04.03.04,
04.03.05) there may be less relapse after treatment stops if over-
learning is used after successful alarm treatment (33 of 67 (49%)
failed or relapsed after alarms alone versus 19 of 77 (25%)
with overlearning, RR 1.92, 95% CI 1.27 to 2.92, Comparison
04.04.04) (Taylor 1975; Young 1972).
Supplementing alarms with dry bed training
In the five trials which compared an alarm alone with an alarm
supplemented by dry bed training (Bennett 1985; Bollard 1981b;
Butler 1988; Butler 1990b; Nawaz 2002) the trend in favour
of supplementation did not reach statistical significance (Com-
parisons 04.01.02, 04.03.06, 04.04.04; and Other Data Tables
04.02.03) and there was significant heterogeneity in the three
Comparisons. This heterogeneity could have been due to the in-
clusion of one trial (Butler 1990b) which used different types of
alarms in the two arms (bed alarm plus DBT in one versus body-
worn (pants) alarm in the other). All the children included in this
trial had already failed using a standard bed alarm. Removal of this
trial reduced or removed the heterogeneity: the failure or relapse
rate was reduced in the group supplemented with dry bed training
(20/32, 63% relapsing with alarm alone versus only 20 of 72, 27%
when supplemented with dry bed training: RR 2.0, 95% CI 1.25
to 3.20, Comparison 04.04.07) (Bollard 1981b; Nawaz 2002).
Supplementing alarms with rewards and penalties
In one trial, adding rewards for dry beds or correct behaviour
to alarm treatment was associated with lower failure rates during
treatment (Comparison 04.03.08) but using penalties for wet beds
was less effective or counterproductive after treatment had finished
(e.g. failure or relapse rate 10 of 36 (28%) after alarms alone versus
21of 39 (54%) when supplemented by penalties, RR 0.52, 95%
CI 0.28 to 0.94, Comparison 04.04.09 and RR 0.54, 95% CI
0.30 to 0.96, Comparison 04.04.10) (van Londen 1993).
Other methods of augmentation
In general, participants using alarms alone were as likely to attain
14 consecutive dry nights as those whose alarms were augmented
with other strategies, but the confidence intervals were all wide.
The pattern of results remained essentially the same when subse-
quent relapse rates were also taken into account.
5. Alarms compared with drugs (Comparison 05,
Other Data Tables 05)
Twenty trials included a comparison of alarms with drugs either
alone or in combination. These included:
• placebo (Fournier 1987; Kolvin 1972; Longstaffe 2000;
Wright 1974);
• desmopressin (Faraj 1999; Longstaffe 2000; Ng 2005;
Wille 1986);
• alarm supplemented by desmopressin (Bradbury 1995;
Gibb 2004; Leebeek 2001; Ng 2005; Sukhai 1989 #; Rodriguez
2001);
• imipramine and other tricyclics (Danquah 1975; Fournier
1987; Kolvin 1972; McKendry 1975; Motavalli 1994; Netley
1984; Wagner 1982);
• alarm supplemented by a tricyclic (Fournier 1987;
Scholander 1968); and
• other drugs (Forrester 1964; Kennedy 1968; Wright 1974).
Alarm versus placebo alone
Alarms were better than placebo drug treatment in terms of
fewer wet nights during and after treatment (Other Data Tables
05.02.01, 05.04.01) (Fournier 1987; Kolvin 1972; Wright 1974),
and a lower failure rate during treatment (RR 0.68, 95% CI 0.48
to 0.97, Comparison 05.03.01) (Longstaffe 2000). Follow-up data
after stopping treatment were not available.
Alarm versus desmopressin alone
In the first week of treatment, children had fewer wet nights dur-
ing desmopressin treatment (WMD 2.1, 95% CI 0.99 to 3.21,
Comparison 05.01.03) (Wille 1986). Towards the end of treat-
ment, they had fewer wet nights on alarms in three trials but
this did not reach statistical significance and there was hetero-
geneity (WMD -0.41 wet nights fewer with alarms, 95% CI -
1.20 to 0.38, random effects used, Comparison 05.01.04) (Ng
2005; Wille 1986); Other Data Tables 05.02.02, (Faraj 1999)).
Although there was a lower failure rate during alarm treatment in
four trials (RR 0.85, 95% CI 0.53 to 1.37, Comparison 05.03.02)
(Faraj 1999; Longstaffe 2000; Ng 2005; Wille 1986), this did
not reach statistical significance and there was significant hetero-
geneity (therefore random effects used). Two small trials provided
follow-up data: although fewer children failed or relapsed after
alarm treatment stopped (29 of 57 (51%) versus 46 of 62 (74%)
after desmopressin, this did not reach statistical significance and
random effects were used due to heterogeneity (RR 0.53, 95%
CI 0.14 to 2.06, Comparison 05.05.01) (Ng 2005; Wille 1986):
some of the heterogeneity might be explained because the defini-
tion of cure was less strict than 14 consecutive dry nights in one
of the trials (Wille 1986). There were, however, fewer wet nights
after alarm treatment stopped in both trials (WMD -1.59, 95%
CI -2.86 to -0.32 using random effects, Comparison 05.06.01)
(Ng 2005; Wille 1986).
Alarm versus alarm combined with desmopressin treatment
10Alarm interventions for nocturnal enuresis in children (Review)
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Data about wet nights during treatment were conflicting: children
had fewer wet nights during combination treatment in three par-
allel group trials (WMD 0.77, 95% CI 0.44 to 1.09, Comparison
05.01.05) (Bradbury 1995; Gibb 2004; Ng 2005) but more wet
nights in another which failed to report SDs (Other Data Tables
05.02.03) (Leebeek 2001). Failure rates during treatment were
not significantly different and there was heterogeneity (RR 1.32,
95% CI 0.80 to 2.16 using random effects, Comparison 05.03.03)
(Bradbury 1995; Gibb 2004; Ng 2005; Rodriguez 2001). Subse-
quent failure or relapse rates were similar in four trials (RR 1.10,
95% CI 0.92 to 1.31, Comparison 05.05.02) (Bradbury 1995;
Gibb 2004; Leebeek 2001; Ng 2005) but the confidence intervals
were wide. The number of wet nights at follow up was higher in
the combined treatment group in one trial without SDs (Other
Data Tables 05.04.03) (Leebeek 2001) and similar in one new trial
(WMD -0.1, 95% CI -1.55 to 1.35, Comparison 05.06.02) (Ng
2005).
Alarm versus tricyclics alone
Although there were fewer wet nights during alarm treatment com-
pared with imipramine, amitriptyline or clomipramine in four tri-
als arms out of five (Comparison 05.01.01, 05.01.02, Other Data
Tables 05.02.04) (Fournier 1987; Kolvin 1972; Motavalli 1994;
Wagner 1982); this did not reach statistical significance in any of
them. Although fewer children failed during alarm treatment in
three trials involving imipramine (61of 105 (58%) versus 82 of
103 (80%), RR for failure 0.59, 95% CI 0.32 to 1.09, Compar-
ison 05.03.04) (McKendry 1975; Netley 1984; Wagner 1982),
these differences were not significant as a random effects model
was used due to heterogeneity. After treatment stopped, fewer chil-
dren failed or relapsed after alarms in one small trial (RR 0.58,
95% CI 0.36 to 0.94, Comparison 05.05.03) (Wagner 1982) and
fewer had wet nights at follow up in another (Other Data Tables
05.04.02) (Kolvin 1972).
Alarm versus alarm combined with tricyclics
There was no clear evidence that supplementing alarm treatment
with a tricyclic was better than the alarm treatment alone (Com-
parisons 05.03.06, 05.05.04 (Scholander 1968), Other Data Ta-
ble 05.02.05 (Fournier 1987)) but each comparison was addressed
in single small trials.
Alarm versus drugs other than desmopressin or tricyclics
There was too little information about a mixture of drugs (am-
phetamine, ephedrine and atropine) or methedrine compared with
alarms (Other Data Table 05.02.06, (Wright 1974); Compar-
ison 05.03.07) (Kennedy 1968)) although amphetamine alone
was worse than alarms in one small trial (Comparison 05.03.08)
(Forrester 1964).
Standard alarm versus electric shock alarms
In two trials (involving imipramine in other groups), children were
frightened of receiving shocks from a body-worn alarm which de-
livered skin shocks (the Mozes detector), and in one of them, some
reported burns or ulceration (McKendry 1975; Netley 1984).
Some parents refused to let their children use these alarms.
6. Alarms compared with other / miscellaneous
treatments (Comparison 06, Other Data Tables 06)
Five trials compared alarms with interventions other than be-
havioural or drugs:
• cognitive therapy or psychotherapy (Ronen 1992; Sacks
1974; Werry 1965);
• ritual shaming (Danquah 1975); and
• restricted diet (McKendry 1975).
During treatment
Although the number of wet nights during treatment was sim-
ilar (Comparison 06.01) (Ronen 1992) more children achieved
14 dry nights during alarm treatment compared with cognitive or
psychotherapy (RR for failure 0.68, 95% CI 0.52 to 0.90, Com-
parison 06.03.02) (Ronen 1992; Sacks 1974; Werry 1965) and re-
stricted diet (Comparison 06.03.01) (McKendry 1975). There was
statistically significant heterogeneity (P equals 0.0007). Amongst
the three trials comparing alarms with cognitive or psychotherapy,
one used a disproportionate method of allocation of children to
groups, resulting in very small control and psychotherapy groups;
there were also differences in baseline characteristics amongst the
controls (Sacks 1974). Excluding this trial removed the statistical
heterogeneity but also the significant difference in the chance of
failure (RR 0.93, 95% CI 0.67 to 1.30): however, both remain-
ing trials used quasi-randomised methods of allocation to groups
(Ronen 1992; Werry 1965).
After treatment stops
Follow up data after the end of treatment were only available for
two small trials: the RR for failure or relapse was higher in the alarm
group than after cognitive therapy (9 of 15 (60%) versus 3 of 18
(17%), RR 3.60, 95% CI 1.18 to 10.95, Comparison 06.04.01) (
Ronen 1992). Children had fewer wet nights after alarm treatment
than after ritual shaming, but SDs were not provided (Other Data
Table 06.05.01, Danquah 1975).
Adverse events and side effects
Thirteen trials of conventional pad-and-buzzer alarms triggered
by wetting included information about adverse effects (Baker
1969; Fournier 1987; Gibb 2004; Jehu 1977; Lovibond 1964a;
McKendry 1975; Moffatt 1987; Netley 1984; Scholander 1968;
11Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Tobias 2001; Turner 1970; Wagner 1985; Wille 1986). Only one
trial stated explicitly that there were no adverse events (Leebeek
2001). The remainder did not mention this outcome. The adverse
events or side effects included: alarm failure; false alarms; fright;
failing to wake the child; and waking others causing family disrup-
tion. A vibrating alarm was reported to be uncomfortable (Tobias
2001), and in a drug trial one headache and one nosebleed were
reported (Gibb 2004). In two trials, non-compliance or dropout
was attributed to the equipment being too difficult or complicated
to use (Moffatt 1987; Turner 1970).
It was quite clear that the alarms which delivered electric shocks
to the children’s skin had unacceptable side effects (the Mozes de-
tector, McKendry 1975; Netley 1984; the Uristop (Elinder 1985;
Hojsgaard 1979) and the Crosby Dri-Nite (Lovibond 1964a). Not
only were children (especially the younger ones) frightened of
them (Netley 1984), there were incidents of skin burns and other
damage (Lovibond 1964a; McKendry 1975).
D I S C U S S I O N
This review updates two previous versions (Lister-Sharp 1997;
Glazener 2001). In the previous update, 20 new trials were added,
as were 12 trials which were previously included only in sensitivity
analyses. The 12 previously excluded trials had failed to report
on either baseline wetting or exclusion of organic causes, but it
was decided to include them in this update as they were otherwise
properly randomised controlled trials. In the current update, three
new trials were added.
Data for several important outcomes were only reported in sin-
gle small trials (such as failure and relapse rates following alarm
treatment compared to desmopressin treatment, Wille 1986). The
sample sizes were generally small. The lack of a sufficiently large
sample can result in failure to detect a real treatment difference
(because the confidence intervals are wide), or conversely, finding
an exaggerated difference to be statistically significant by chance.
Quality of randomisation and follow-up data
Amongst the 53 included trials, the method of concealment of
allocation to groups was only of good methodological quality in
eight trials. Seven others used a suboptimal (quasi-randomised)
method of randomisation. Only 26 of the 53 included trials pro-
vided longer term results after treatment was finished. This is a
serious shortcoming of the research, as continued effectiveness is
the main aim of treatment. However, in some cases, it reflected
the clinical situation in which families whose children continue to
wet the bed ask for alternative treatment.
Differential dropout
In three trials, dropout rates were different from different trial
arms. In two trials, drop-out was related to unacceptability of treat-
ment (Bollard 1981b; McKendry 1975). In these trials, dropouts
have been counted as failures. In a third trial, trial data were not
used in analyses because children were switched between groups,
making the data unreliable (Turner 1970). In the remaining trials,
dropout rates were evenly distributed amongst the trial arms and
results excluded dropouts. The meta-analyses also excluded drop-
outs in these cases.
Organic causes and daytime wetting
It is likely that the underlying pathologies of night-only
(monosymptomatic) bedwetting and mixed night and day (diur-
nal) wetting differ. Those with diurnal wetting are more likely to
have an organic cause for their problem, and may be less likely
to respond to treatment unless the underlying disease is treated
(Jarvelin 1989; Jarvelin 1990). Although the focus of the review
was on monosymptomatic nocturnal enuresis, only 16 trials specif-
ically excluded children with daytime wetting and six included at
least some such children (the remainder provided no information
about this issue). However, of the six, four specifically excluded
children with organic causes. In total, 48 trials specifically excluded
children with known organic causes for their enuresis. Of the seven
trials which did not specify whether they excluded children with
organic causes or not, only two trials included some children with
daytime wetting. Therefore the majority of included trials (51)
were likely to be amongst children without a recognised physical
cause for their problem. To have included only the 16 trials which
explicitly excluded all children with daytime wetting would have
limited the review. The results should be interpreted with this in
mind.
Settings for treatment
Most of the included trials have recruited children from enuresis
clinics or are hospital based. Participating families may be espe-
cially motivated to tackle the bed wetting. In addition, strict inclu-
sion / exclusion criteria have been imposed in many of the trials.
Consequently, the children involved are not necessarily represen-
tative of the wider population of those who wet the bed. Only
three small trials included children who were learning disabled or
from residential homes. The two larger of these trials favoured
alarm treatment (Jehu 1977; Sloop 1973) but the data were too
few to be generalisable.
Effectiveness of alarms
Alarms versus no treatment
12Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Alarm treatment was clearly better than no treatment or waiting
list control interventions, both during treatment and in terms of
continuing success rates after treatment was finished. About half
the children fail or relapse after alarms compared with almost all
who have a control treatment. Blinding of alarm treatment is dif-
ficult even if non-functioning equipment is used (as the patient
will be aware that the alarm does not go off ), and trials of conven-
tional pad-and-buzzer alarms compared with sham alarms were
not found. One trial of an electric shock device did use a sham
alarm but the active treatment was not acceptable.
Different types of alarms
There was some evidence that an immediate alarm (compared to
a delayed alarm or one which woke the parents rather than the
child) was better. In another trial, children preferred a body-worn
alarm to a bed pad, and an audio body-worn alarm to a vibrating
body-worn alarm, but in general there was insufficient evidence
to suggest that one type of alarm was better than another.
Alarms versus behavioural interventions
There was insufficient evidence to demonstrate a difference be-
tween alarms and simple behavioural interventions such as lifting,
wakening or reward systems, because each intervention was ad-
dressed only by single small trials. Alarms resulted in fewer wet
nights than stop-start training (teaching children to contract their
pelvic floor muscles) but the single trial was too small to show
reliably whether there was a difference in cure rates. Children were
less likely to fail or relapse after alarm treatment alone than dry
bed training alone in another small trial. There was some evidence
that rewards increased the effectiveness of alarms whereas penalties
after bed wetting appeared to reduce the likelihood of success.
Supplementing alarms with behavioural interventions
Although 16 trials addressed the issue of supplementing alarm
treatment by reinforcing it with behavioural interventions, there
was not much evidence to say whether or not this improved per-
formance of the alarm: the trials were all small, many did not
report SDs, and the confidence intervals, where available, were
wide. However, two small trials suggested that overlearning after
successful alarm treatment halved the relapse rate from 49% to
25% (Taylor 1975; Young 1965). Similarly, in two other trials,
supplementing alarms with dry bed training reduced the relapse
rate from 63% to 27% (Bollard 1981b; Nawaz 2002). Finally, one
small trial suggested that giving children penalties for wet beds
was unhelpful (van Londen 1993). These findings need to be con-
firmed in further research as the trials were small and some had
methodological flaws. Retention control training (gradually trying
to increase bladder capacity by teaching children to ’hold on’) in
addition to an alarm was detrimental during treatment, although
it was not associated with significant differences in relapse rates
after treatment stopped.
Alarms versus drugs
Limited evidence suggested that alarms were better than placebo
drug treatment, but direct comparisons with desmopressin or tri-
cyclics alone were conflicting, in contrast with the findings of an
earlier version of this review (Glazener 2005a). These findings were
based on single or small trials, and need to be confirmed in future
research. However, two larger reviews (of desmopressin Glazener
2002) and tricyclics (Glazener 2003a) suggest that drug treatment
alone, while effective for some children during treatment, is un-
likely to be followed by sustained cure as almost all the children
relapsed.
Supplementing alarms with drugs
There is a move towards combining alarms with drug interven-
tions (Howe 1992). The rationale is that the rapid onset of action
of drugs is then combined with the more gradual treatment effect
of alarms (Sukhai 1989 #). Low doses of desmopressin as an ad-
junct to alarm treatment may also be used to ensure that the child
only wets the bed once each night to minimise changes of bedding
(Djurhuus 1992). There was insufficient evidence to support this:
while supplementing alarms with desmopressin did decrease the
initial number of wet nights in four trials, success rates while on
treatment or afterwards were not significantly different compared
to an alarm alone. There was insufficient information about sup-
plementing alarms with tricyclics.
Alarms versus other treatments
Limited evidence suggested that alarms were generally better than
any of a variety of other classes of interventions while on treatment,
but follow up data were only available from two small trials.
Acceptability of alarms
High dropout rates in some of the trials suggest that there were
problems with compliance, often reflecting the unacceptability
of the treatment. Potential difficulties, such as the time needed
to attain success and the initial disruption to the family, need to
be discussed with families before embarking on alarm treatment.
Some child or family variables have been shown to predict dropout,
such as parental intolerance, behavioural problems or the child’s
negative self image (Wagner 1982; Butler 1988; Wagner 1988;
Butler 1994). These may be useful for identifying which treatment
is most likely to succeed, or where the chances of success may be
increased by giving the family extra attention.
13Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Adverse events
Adverse events with standard pad-and-bell alarms which woke the
children on wetting were limited to minor inconvenience due to
alarm malfunction or disturbance to the family. In contrast, side
effects with drugs may have more serious implications (Glazener
2002; Glazener 2003a). For example, tricyclics may have serious
side-effects such as arrhythmias and heart block, convulsions, and
hepatic and haematological reactions. These may present a partic-
ular risk of overdose to the children treated or other family mem-
bers (Fitzwater 1992; Parkin 1972; Rushton 1993).
However, the alarms which delivered electric shocks to the chil-
dren’s skin on wetting were clearly unacceptable, in terms of fright-
ening the children and causing burns and ulceration.
Costs
In the UK, 16 weeks of drug treatment (the usual time allowed
for fourteen consecutive dry nights to be attained using an alarm,
Butler 1991) would cost (BNF 2002):
• £78 for desmopressin nasal spray (20 µg per night) or £116
for desmopressin tablets (200 µg);
• £4 for imipramine hydrochloride (25 mg tablet per night)
or £14 for imipramine syrup (25 mg); and
• enuresis alarms (including batteries & sensor) typically cost
£33.60, although alarms but not sensors (£12) may be re-used
several times.
This information relates only to some of the direct costs to the
health service. Although treatment with tricyclic or related drugs
is considerably less expensive than alarms or desmopressin, this
does not take into account the administrative or the human costs
involved in using alarms. Alarm systems may not be returned to
clinics and have to be followed up. Alarm treatment is accompa-
nied by broken nights for various family members until success
is attained. Staff must be trained to teach the children and their
parents how to use the alarms (particularly that the child must be
fully wakened) and ensure that the equipment is working. Staff
also need time to teach the parents and provide support during
treatment.
The Guidelines on Minimum Standards of Practice (Morgan
1993) suggest that follow-up supervisory contacts should occur
at least every three weeks, with management reviewed at least
monthly. Against this must be set the possible reduced risk of re-
lapse after stopping alarms compared with after stopping treat-
ment with desmopressin, tricyclics or related drugs, and the po-
tential for adverse events with tricyclics.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
Using an audio alarm system on its own to condition children
to wake before they wet the bed appears effective after treatment
stops for about half of children with nocturnal enuresis. Supple-
menting alarm treatment with overlearning (giving children extra
fluids at bedtime after successfully becoming dry using an alarm),
dry bed training and avoiding penalties may reduce the relapse
rate. Although the evidence suggests that desmopressin has a more
immediate effect than alarms, alarms seem better than desmo-
pressin or tricyclics in reducing the number of wet nights by the
end of a course of treatment. There is no reliable evidence that
the drugs are effective after treatment has stopped (Glazener 2002;
Glazener 2003a) whereas half the children remain dry after alarm
treatments.
Although the cost of alarm treatment is intermediate between
desmopressin and tricyclics, greater motivation and time are
needed by families until alarm treatment is successful. However,
the finding that effects are better sustained after alarm treatment,
and the risks of side effects associated with drugs, suggest that
alarms may be preferable to the pharmacological options.
The limited evidence suggested that alarms on their own were as
good as or better than most other behavioural or other classes of
interventions.
Implications for research
Although treatment with alarms, desmopressin and tricyclics have
each been shown to be effective in a number of trials, there are few
direct comparisons between them, or between different types of
alarms (e.g. loudness, type of stimulus). These need further inves-
tigation. Current evidence on which to judge behavioural or other
interventions is limited, and further trials of these compared with
alarms, desmopressin or tricyclics are needed. Such trials should
allow comparison in different populations and for different pur-
poses (such as in primary care, or as a short-term measure to cover
nights away from home), in order to inform choice of treatment.
They should include formal testing to identify pre-treatment fac-
tors which might modify or determine treatment effects. Impor-
tant factors include age, presence of organic causes or daytime
wetting and family circumstances.
Future trials should focus on children without organic causes of
bedwetting, and should include adequate assessment of baseline
levels of wetting. The difficulty in comparing interventions is ex-
acerbated by the lack of uniformity in outcome measures, which
should include: the number of wet nights during treatment and af-
ter the end of treatment; the number of children failing to achieve
14 consecutive dry nights; adverse events; acceptability of treat-
ment; compliance; and especially relapse rates after treatment has
stopped (expressed as a composite outcome of failure to achieve
14 dry nights and subsequent relapse). It is crucial to be able to
14Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
assess the success rates of different treatments at least three months
after they have finished.
Children with daytime enuresis are more likely to have specific
pathology such as bladder dysfunction or urinary tract infections.
Alternative managements for this condition need to be assessed in
a separate Cochrane Review.
A C K N O W L E D G E M E N T S
This review was originally written for the National Health Service
Centre for Reviews & Dissemination (CRD), University of York,
UK, by Deborah Lister-Sharp, Susan O’Meara, Matthew Bradley
and Trevor A Sheldon. It was published as: A Systematic Review of
the Effectiveness of Interventions for Managing Childhood Noc-
turnal Enuresis, CRD Report 11, NHS Centre for Reviews and
Dissemination, University of York (Lister-Sharp 1997). We were
especially grateful to Deborah Lister-Sharp for transfer of data,
trials and expertise, and were sad to learn of her death.
The CRD reviewers obtained information from a variety of
sources, including organisations, manufacturers and individuals.
These are listed in the original report, and we acknowledge their
contribution to this review.
We are grateful to Penny Dobson (Enuresis Resource and Infor-
mation Centre, ERIC, Bristol, UK) for help and encouragement,
and also facilitating consumer reviewing. We would like to thank
the external peer reviewers. We would also like to thank the Con-
sumer Network at the Australasian Cochrane Centre for help with
the synopsis.
R E F E R E N C E S
References to studies included in this review
Azrin 1974 {published data only}
Azrin NH, Sneed TJ, Foxx RM. Dry-bed training: rapid
elimination of childhood enuresis. Behaviour Research &
Therapy 1974;12(3):147–56. [MEDLINE: 75054129]
Azrin 1978 {published data only}
Azrin NH, Thienes PM. Rapid elimination of enuresis
by intensive learning without a conditioning apparatus.
Behaviour Therapy 1978;9:342–54.
Baker 1969 {published data only}
Baker BL. Symptom treatment and symptom substitution
in enuresis. Journal of Abnormal Psychology 1969;74(1):
42–9. [MEDLINE: 69166759]
Bennett 1985 {published data only}
Bennett GA, Walkden VJ, Curtis RH, Burns LE, Rees J,
Gosling JA, et al.Pad-and-buzzer training, dry-bed training,
and stop-start training in the treatment of primary nocturnal
enuresis. Behavioural Psychotherapist 1985;13:309–19.
Bollard 1981a {published data only}
Bollard J. A 2-year follow-up of bedwetters treated by dry-
bed training and standard conditioning. Behaviour Research
& Therapy 1982;20(6):571–80. [MEDLINE: 83126391]∗ Bollard J, Nettelbeck T. A comparison of dry-bed training
and standard urine-alarm conditioning treatment of
childhood bedwetting. Behaviour Research & Therapy 1981;
19(3):215–26. [MEDLINE: 82045721]
Bollard 1981b {published data only}
Bollard J. A 2-year follow-up of bedwetters treated by dry-
bed training and standard conditioning. Behaviour Research
& Therapy 1982;20(6):571–80. [MEDLINE: 83126391]∗ Bollard J, Nettelbeck T. A comparison of dry-bed training
and standard urine-alarm conditioning treatment of
childhood bedwetting. Behaviour Research & Therapy 1981;
19(3):215–26. [MEDLINE: 82045721]
Bollard 1982a {published data only}
Bollard J, Nettelbeck T. A component analysis of dry-bed
training for treatment for bedwetting. Behaviour Research &
Therapy 1982;20(4):383–90. [MEDLINE: 83022183]
Bradbury 1995 {published data only}
Bradbury M. Combination therapy for nocturnal enuresis
with desmopressin and an alarm device. Scandinavian
Journal of Urology & Nephrology 1997;Supplementum.
183:61–3. [MEDLINE: 97308385]∗ Bradbury MG, Meadow SR. Combined treatment with
enuresis alarm and desmopressin for nocturnal enuresis.
Acta Paediatrica 1995;84(9):1014–8. [MEDLINE:
96112940]
Butler 1988 {published data only}
Butler RJ, Brewin CR, Forsythe WI. A comparison of two
approaches to the treatment of nocturnal enuresis and the
prediction of effectiveness using pre-treatment variables.
Journal of Child Psychology & Psychiatry & Allied Disciplines
1988;29(4):501–9. [MEDLINE: 89109292]
Butler 1990a {published data only}
Butler RJ, Forsythe WI, Robertson J. The body-worn alarm
in the treatment of childhood enuresis. British Journal
of Clinical Practice 1990;44(6):237–41. [MEDLINE:
91001782]
Butler 1990b {published data only}
Butler RJ, Forsythe WI, Robertson J. The body-worn alarm
in the treatment of childhood enuresis. British Journal
of Clinical Practice 1990;44(6):237–41. [MEDLINE:
91001782]
15Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Caceres 1982 {published data only}∗ Caceres J. Comparative efficacy between two methods for
the treatment of enuresis. Revista de Psicologia General y
Aplicada 1980;35(4):597–616.
Caceres J. Enuresis: Cortical control or social reinforcement?
. Behaviour Therapist 1982;5(2):65–7.
Caceres J. Enuresis: Cortical control or social reinforcement?
. Revista de Psicologia General y Aplicada 1979;34(161):
1067.
Danquah 1975 {published data only}
Danquah SA. Comparative treatment of nocturnal enuresis
among Ghanaian school children. Psychopathologie Africaine
1975;11(3):363–73.
Elinder 1985 {published data only}
Elinder G, Soback S. Effect of Uristop on primary
nocturnal enuresis. A prospective randomized double-blind
study. Acta Paediatrica Scandinavica 1985;74(4):574–8.
[MEDLINE: 85275411]
Faraj 1999 {published data only}
Faraj G, Cochat P, Cavailles ML, Chevallier C. [Treatment
of isolated nocturnal enuresis: alarm or desmopressin?
]. [French]. Archives de Pediatrie 1999;6(3):271–74.
[MEDLINE: 99207616]
Fielding 1980 {published data only}
Fielding D. The response of day and night wetting children
and children who wet only at night to retention control
training and the enuresis alarm. Behaviour Research &
Therapy 1980;18(4):305–17. [MEDLINE: 81062334]
Finley 1973 {published data only}
Finley WW, Besserman RL, Bennett LF, Clapp RK, Finley
PM. The effect of continuous, intermittent, and “placebo”
reinforcement on the effectiveness of the conditioning
treatment for enuresis nocturna. Behaviour Research &
Therapy 1973;11(3):289–97. [MEDLINE: 73243969]
Finley 1977 {published data only}
Finley WW, Wansley RA. Auditory intensity as a variable in
the conditioning treatment of enuresis nocturna. Behaviour
Research & Therapy 1977;15(2):181–5. [MEDLINE:
77201389]
Forrester 1964 {published data only}
Forrester RM, Stein Z, Susser MW. A trial of conditioning
therapy in nocturnal enuresis. Developmental Medicine &
Child Neurology 1964;6:158–66.
Fournier 1987 {published data only}
Fournier JP, Garfinkel BD, Bond A, Beauchesne H,
Shapiro SK. Pharmacological and behavioral management
of enuresis. Journal of the American Academy of Child &
Adolescent Psychiatry 1987;26(6):849–53. [MEDLINE:
88115081]
Geffken 1986a {published data only}
Geffken G, Johnson SB, Walker D. Behavioral interventions
for childhood nocturnal enuresis: the differential effect of
bladder capacity on treatment progress and outcome. Health
Psychology 1986;5(3):261–72. [MEDLINE: 86300621]
Geffken 1986b {published data only}
Geffken G, Johnson SB, Walker D. Behavioral interventions
for childhood nocturnal enuresis: the differential effect of
bladder capacity on treatment progress and outcome. Health
Psychology 1986;5(3):261–72. [MEDLINE: 86300621]
Gibb 2004 {published data only}
Gibb S, Nolan T, South M, Noad L, Bates G, Vidmar S.
Evidence against a synergistic effect of desmopressin with
conditioning in the treatment of nocturnal enuresis. Journal
of Pediatrics 2004;144(3):351–7.
Hojsgaard 1979 {published data only}
Hojsgaard A, Genster H. Effect of Uristop in children with
enuresis. A prospective randomized clinical trial. [Danish].
Ugeskrift for Laeger 1979;141(10):647–8. [MEDLINE:
79139924]
Houts 1986 {published data only}
Houts AC, Peterson JK, Whelan JP. Prevention of relapse
in full-spectrum home training for primary enuresis: A
components analysis. Behaviour Therapy 1986;17:462–9.
Jehu 1977 {published data only}
Jehu D, Morgan RT, Turner RK, Jones A. A controlled trial
of the treatment of nocturnal enuresis in residential homes
for children. Behaviour Research & Therapy 1977;15(1):
1–16. [MEDLINE: 77111772]
Kennedy 1968 {published data only}
Kennedy WA, Sloop EW. Methedrine as an adjunct to
conditioning treatment of nocturnal enuresis in normal
and institutionalized retarded subjects. Psychological Reports
1968;22:997–1000. [MEDLINE: 68274635]
Kolvin 1972 {published data only}
Kolvin I, Taunch J, Currah J, Garside RF, Nolan J, Shaw
WB. Enuresis: a descriptive analysis and a controlled trial.
Developmental Medicine & Child Neurology 1972;14(6):
715–26. [MEDLINE: 73066897]
Leebeek 2001 {published data only}
Leebeek-Groenewegen ANJA, Blom J, Sukhai R, van der
Heijden B. Efficacy of desmopressin combined with alarm
therapy for monosymptomatic nocturnal enuresis. Journal
of Urology 2001;166(6):2456–8. [MEDLINE: 21553449]
Longstaffe 2000 {published data only}
Longstaffe S, Moffatt ME, Whalen JC. Behavioral and self-
concept changes after six months of enuresis treatment: a
randomized, controlled trial. Pediatrics 2000;105(4:Pt 2):
935–40. [MEDLINE: 20209556]
Lovibond 1964a {published data only}
Lovibond SH. Field experiment I: Experimental comparison
of twin signal, Crosby and Mowrer instruments.
Conditioning and Enuresis. New York: MacMillan
(Pergamon Press), 1964:94–101.
Lovibond 1964b {published data only}
Lovibond SH. Field experiments on the reduction of
the relapse rate. Conditioning and Enuresis. New York:
MacMillan (Pergamon Press), 1964:121–31.
16Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Lovibond 1964c {published data only}
Lovibond SH. Field experiments on the reduction of
the relapse rate. Conditioning and Enuresis. New York:
MacMillan (Pergamon Press), 1964:121–31.
Lynch 1984 {published data only}
Lynch NT, Grunert BK, Vasudevan SV, Severson RA.
Enuresis: comparison of two treatments. Archives of
Physical Medicine & Rehabilitation 1984;65(2):98–100.
[MEDLINE: 84127291]
McKendry 1975 {published data only}
McKendry JB, Stewart DA, Khanna F, Netley C. Primary
enuresis: relative success of three methods of treatment.
Canadian Medical Association Journal 1975;113(10):953–5.
[MEDLINE: 76063959]
Moffatt 1987 {published data only}
Moffatt ME, Kato C, Pless IB. Improvements in self-
concept after treatment of nocturnal enuresis: randomized
controlled trial. Journal of Pediatrics 1987;110(4):647–52.
[MEDLINE: 87168949]
Motavalli 1994 {published data only}
Motavalli N, Tuzun U, Tuna S, Yargic I, Aydogmus K.
Comparison of the effectiveness of three different treatment
modalities in enuresis nocturna. Noropsikiyatri Arsivi
(Archives of Neuropsychiatry - Turkish) 1994;31(3):146–50.
Nawaz 2002 {published data only}
Nawaz S, Griffiths P, Tappin D. Parent-administered
modified dry-bed training for childhood nocturnal enuresis:
Evidence for superiority over urine-alarm conditioning
when delivery factors are controlled. Behavioral Interventions
2002;17(4):247–60.
Netley 1984 {published data only}
Netley C, Khanna F, McKendry JB, Lovering JS. Effects
of different methods of treatment of primary enuresis on
psychologic functioning in children. Canadian Medical
Association Journal 1984;131(6):577–9. [MEDLINE:
85001664]
Ng 2005 {published data only}
Ng CF-N, Wong SN, Hong Kong Childhood Enuresis
Study Group. Comparing alarms, desmopressin, and
combined treatment in Chinese enuretic children. Pediatric
Nephrology 2005;20(2):163–9.
Rodriguez 2001 {published data only}
Rodriguez Do FA, Ariceta IG. Results of a therapeutic
strategy against monosymptomatic nocturnal enuresis
background. Anales Espanoles de Pediatria 2001;54(1):
38–43.
Ronen 1992 {published data only}
Ronen T, Rahav G, Wozner Y. Self-control and enuresis.
Journal of Cognitive Psychotherapy : An International
Quarterly 1995;9:249–58.∗ Ronen T, Wozner Y, Rahav G. Cognitive intervention in
enuresis. Child & Family Behaviour Therapy 1992;14(2):
1–14.
Sacks 1974 {published data only}
Sacks S, De Leon G, Blackman S. Psychological changes
associated with conditioning functional enuresis. Journal
of Clinical Psychology 1974;30(3):271–76. [MEDLINE:
74306370]
Scholander 1968 {published data only}
Scholander T. [Treating enuresis nocturna by a combination
of medicines and conditioning]. [Swedish]. Lakartidningen
1968;65(46):4552–6. [MEDLINE: 70200421]
Sloop 1973 {published data only}
Sloop EW, Kennedy WA. Institutionalized retarded
nocturnal enuretics treated by a conditioning technique.
American Journal of Mental Deficiency 1973;77(6):717–21.
[MEDLINE: 73241944]
Sukhai 1989 # {published data only}
Sukhai RN, Mol J, Harris AS. Combined therapy of enuresis
alarm and desmopressin in the treatment of nocturnal
enuresis. European Journal of Pediatrics 1989;148(5):465–7.
[MEDLINE: 89153190]
Taylor 1975 {published data only}
Taylor PD, Turner RK. A clinical trial of continuous,
intermittent and overlearning ’bell and pad’ treatments for
nocturnal enuresis. Behaviour Research & Therapy 1975;13
(4):281–93. [MEDLINE: 76061221]
Tobias 2001 {published data only}
Tobias NE, McCain GC. A comparison of two enuresis
alarms. Urologic Nursing 2001;21(5):349–53.
Turner 1970 {published data only}
Turner RK, Young GC, Rachman S. Treatment of nocturnal
enuresis by conditioning techniques. Behaviour Research &
Therapy 1970;8(4):367–91. [MEDLINE: 71062269]
van Londen 1993 {published data only}∗ van Londen A, van Londen-Barentsen MW, van Son
MJ, Mulder GA. Arousal training for children suffering
from nocturnal enuresis: a 2 1/2 year follow-up. Behaviour
Research & Therapy 1993;31(6):613–5. [MEDLINE:
93349306]
van Londen A, van Londen-Barentsen MW, van Son
MJ, Mulder GA. Relapse rate and subsequent parental
reaction after successful treatment of children suffering
from nocturnal enuresis: a 2 1/2 year follow-up of
bibliotherapy. Behaviour Research & Therapy 1995;33(3):
309–11. [MEDLINE: 95243898]
Wagner 1982 {published data only}
Wagner W, Johnson SB, Walker D, Carter R, Wittner J.
A controlled comparison of two treatments for nocturnal
enuresis. Journal of Pediatrics 1982;101(2):302–7.
[MEDLINE: 82241436]
Wagner 1985 {published data only}
Wagner WG, Matthews R. The treatment of nocturnal
enuresis: a controlled comparison of two models of urine
alarm. Journal of Developmental & Behavioral Pediatrics
1985;6(1):22–6. [MEDLINE: 85131790]
Werry 1965 {published data only}
Werry JS, Cohrssen J. Enuresis - an etiologic and therapeutic
study. Journal of Pediatrics 1965;67(3):423–31.
17Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wille 1986 {published data only}∗ Wille S. Comparison of desmopressin and enuresis alarm
for nocturnal enuresis. Archives of Disease in Childhood
1986;61(1):30–3. [MEDLINE: 86157697]
Wille S. Primary nocturnal enuresis in children. Background
and treatment. Scandinavian Journal of Urology &
Nephrology Supplementum 1994;156:1–48. [MEDLINE:
95025668]
Wright 1974 {published data only}
Wright L, Craig SC. A comparative study of amphetamine,
ephedrine-atropine mixture, placebo and behavioral
conditioning in the treatment of nocturnal enuresis. Journal
- Oklahoma State Medical Association 1974;67(10):430–3.
[MEDLINE: 75078843]
Young 1972 {published data only}∗ Young GC, Morgan RT. Overlearning in the conditioning
treatment of enuresis. Behaviour Research & Therapy 1972;
10(2):147–51. [MEDLINE: 72194405]
Young GC, Morgan RT. Overlearning in the conditioning
treatment of enuresis: a long-term follow-up study.
Behaviour Research & Therapy 1972;10(4):419–20.
[MEDLINE: 73051336]
References to studies excluded from this review
Azrin 1973 {published data only}
Azrin NH, Sneed TJ, Foxx RM. Dry bed: a rapid method of
eliminating bedwetting (enuresis) of the retarded. Behaviour
Research & Therapy 1973;11(4):427–34. [MEDLINE:
74097620]
Bollard 1977 {published data only}
Bollard RJ, Woodroffe P. The effect of parent-administered
Dry-Bed training on nocturnal enuresis in children.
Behaviour Research & Therapy 1977;15:159–65.
[MEDLINE: 77201386]
Bollard 1982b {published data only}
Bollard J, Nettelbeck T, Roxbee L. Dry-bed training
for childhood bedwetting: a comparison of group with
individually administered parent instruction. Behaviour
Research & Therapy 1982;20(3):209–17. [MEDLINE:
82231116]
Butler 2001 {published data only}
Butler RJ, Holland P, Robinson J. Examination of the
structured withdrawal program to prevent relapse of
nocturnal enuresis. Journal of Urology 2001;166(6):2463–6.
[MEDLINE: 21553451]
Collins 1973 {published data only}
Collins RW. Importance of the bladder-cue buzzer
contingency in the conditioning treatment for enuresis.
Journal of Abnormal Psychology 1973;82(2):299–308.
[MEDLINE: 74033838]
Crisp 1984 {published data only}∗ Crisp AH, Sireling LI, Faizey J. Nocturnal activity and the
enuresis alarm device. Postgraduate Medical Journal 1984;60
(702):280–1. [MEDLINE: 84221695]
Macaulay AJ, Gupta M, Crisp AH, Bhat AV. The
relationship between nocturnal motility and the enuresis
alarm device. Journal of Psychosomatic Research 1986;30(1):
63–5. [MEDLINE: 86199808]
de Leon 1966 {published data only}
De Leon G, Mandell W. A comparison of conditioning
and psychotherapy in the treatment of functional
enuresis. Journal of Clinical Psychology 1966;22(3):326–30.
[MEDLINE: 67014937]
Finley 1982 {published data only}
Finley WW, Rainwater AJ, Johnson G 3d. Effect of varying
alarm schedules on acquisition and relapse parameters in the
conditioning treatment of enuresis. Behaviour Research &
Therapy 1982;20(1):69–80. [MEDLINE: 82159985]
Fordham 1989 {published data only}
Fordham KE, Meadow SR. Controlled trial of standard
pad and bell alarm against mini alarm for nocturnal
enuresis. Archives of Disease in Childhood 1989;64(5):
651–6. [MEDLINE: 89272170]
Forsyth 1970 {published data only}
Forsythe WI, Redmond A. Enuresis and the electric alarm:
study of 200 cases. British Medical Journal 1970;1(690):
211–3. [MEDLINE: 70105005]
Freyman 1963 {published data only}
Freyman R. Follow-up study of enuresis treated with a bell
apparatus. Journal of Child Psychology and Psychiatry 1963;
4:199–206.
Gillison 1958 {published data only}
Gillison TH, Skinner JL. Treatment of nocturnal enuresis by
the electric alarm. British Medical Journal 1958;ii:1268–72.
Goel 1984 {published data only}
Goel KM, Thomson RB, Gibb EM, McAinsh TF.
Evaluation of nine different types of enuresis alarms.
Archives of Disease in Childhood 1984;59(8):748–55.
[MEDLINE: 84305992]
Halliday 1987 {published data only}
Halliday S, Meadow SR, Berg I. Successful management
of daytime enuresis using alarm procedures: a randomly
controlled trial. Archives of Disease in Childhood 1987;62
(2):132–7. [MEDLINE: 87155424]
Hansen 1995 {published data only}
Hansen AF, Jorgensen TM. Treatment of nocturnal
enuresis with the bell-and-pad system. Scandinavian
Journal of Urology & Nephrology 1995;Suppl 173:101–2.
[MEDLINE: 96363554]
Hanson 1988 {published data only}
Hanson RH, Thompson T, Wieseler NA. Methodological
considerations in enuresis-treatment research. A three-
treatment comparison. Behavior Modification 1988;12(3):
335–52. [MEDLINE: 89149651]
Kahane 1955 {published data only}
Kahane M. An experimental investigation of a conditioning
treatment and a preliminary study of the psychoanalytic
theory of the etiology of nocturnal enuresis. American
Psychologist 1955;10:369–70.
Kaplan 1988 {published data only}
Kaplan SL, Breit M, Gauthier B, Busner J. A comparison of
three nocturnal enuresis treatment methods. Journal of the
18Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
American Academy of Child & Adolescent Psychiatry 1988;28
(2):282–6. [MEDLINE: 89174422]
Kooijman 1986 {published data only}
Kooijman MJ, Bosch JD. Supportive research on treatment
of enuresis with a urine alarm [dutch]. Nederlands Tijdschrift
voor Psychology en haar Grensgebieden 1986;41(7):325–8.
Kyneb 1975 {published data only}
Kyneb P, Biorn-Henriksen T. Treatment of enuresis of
schoolchildren with ’waking-apparatus’ [Behandling af
enuresis hos skoleborn ved vaekkeapparat]. Maanedsskrift
for Praktisk Laegegerning 1975;53(5):250–9.
Lovibond 1964d {published data only}
Lovibond SH. Field experiments on the reduction of
the relapse rate. Conditioning and Enuresis. New York:
MacMillan (Pergamon Press), 1964:121–31.
McConaghy 1969 {published data only}
McConaghy N. A controlled trial of imipramine,
amphetamine, pad-and-bell conditioning and random
awakening in the treatment of nocturnal enuresis. Medical
Journal of Australia 1969;2(5):237–9. [MEDLINE:
69296582]
Monda 1995 {published data only}
Monda JM, Husmann DA. Primary nocturnal enuresis: a
comparison among observation, imipramine, desmopressin
acetate and bed-wetting alarm systems. Journal of Urology
1995;154(2 Pt 2):745–8. [MEDLINE: 95333405]
Peterson 1969 {published data only}
Peterson RA, Wright RL, Hanlon CC. The effects on
extending the CS-UCS interval of the effectiveness of the
conditioning treatment for nocturnal enuresis. Behaviour
Research & Therapy 1969;7(4):351–57. [MEDLINE:
70138893]
Philpott 1970 {published data only}
Philpott MG. The treatment of enuresis; further clinical
experience with imipramine. British Journal of Clinical
Practice 1970;24(8):327–9. [MEDLINE: 71041622]
Said 1991 {published data only}
Said JA, Wilson PH, Hensley VR. Primary versus secondary
enuresis: differential response to urine-alarm treatment.
Child & Family Behaviour Therapy 1991;13(2):1–13.
Shulz 1978 {published data only}
Shulz D, Sureth H, Lubisch G. A comparison of two
behaviour therapeutic methods in the treatment of enuresis.
Zeitschrift fur Klinische Psychologie 1978;7(2):141–8.
Taylor 1963 {published data only}
Taylor IO. A scheme for the treatment of enuresis by electric
buzzer apparatus. Medical Officer 1963;110:139–340.
Wickes 1958 {published data only}
Wickes IG. Treatment of persistent enuresis with the electric
buzzer. Archives of Disease in Childhood 1958;33:160–4.
Young 1965 {published data only}
Turner RK. CNS stimulant drugs and conditioning
treatment of nocturnal enuresis: a long term follow-up
study. Behaviour Research & Therapy 1966;4(3):225–8.
[MEDLINE: 66171102]∗ Young GC, Turner RK. CNS stimulant drugs and
conditioning treatment of nocturnal enuresis. Behaviour
Research & Therapy 1965;3:93–101.
References to ongoing studies
Bryant 2002 {published data only}
Bryant C, Fairbrother G. Randomised trial of bladder
training versus enuresis alarm versus combined bladder
training/enuresis alarm in children with nocturnal enuresis.
personal communication 2002.
Additional references
APA 1980
American Psychiatric Association. Functional enuresis.
Diagnostic and Statistical Manual of Mental Disorders. 3rd
Edition. Washington: American Psychiatric Association,
1980.
Bakwin 1971
Bakwin H. Enuresis in twins. American Journal of Diseases
of Childhood 1971;121(3):222–5. [MEDLINE: 71158021]
Bakwin 1973
Bakwin H. The genetics of enuresis. In: Kolvin I, MacKeith
RC, Meadow SR editor(s). Bladder control and enuresis.
London: William Heinemann Medical Books, 1973.
Berlin 1989
Berlin JA, Laird NM, Sacks HS, Chalmers TC. A
comparison of statistical methods for combining event rates
from clinical trials. Statistics in Medicine 1989;8(2):141–51.
[MEDLINE: 89203035]
Blackwell 1989
Blackwell C. A guide to enuresis: A guide to treatment of
enuresis for professionals. Bristol: ERIC, 1989.
BNF 2002
Joint Formulary Committee. British National Formulary.
3rd Edition. London: British Medical Association and the
Royal Pharmaceutical Society of Great Britain, 2002.
Butler 1991
Butler RJ. Establishment of working definitions in nocturnal
enuresis. Archives of Disease in Childhood 1991;66:267–71.
[MEDLINE: 91158344]
Butler 1994
Butler RJ, Redfern EJ, Holland P. Children’s notions about
enuresis and the implications for treatment. Scandinavian
Journal of Urology & Nephrology 1994;Supplementum.
163:39–47. [MEDLINE: 95183920]
de Jonge 1973
de Jonge GA. Epidemiology of enuresis: A survey of
the literature. In: Kolvin I, MacKeith RC, Meadow SR
editor(s). Bladder control and enuresis. London: William
Heinemann Medical Books, 1973.
Deeks 2006
Deeks JJ, Higgins JPT, Altman DG, editors. Analysing
and Presenting Results. In: Higgins JPT, Green S, editor
19Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(s). Cochrane Handbook for Systematic Reviews of
Interventions 4.2.6 [updated September 2006]; Section
8 Available from: http://www.cochrane.org/resources/
handbook/hbook.htm (accessed 6th October 2006).
Devlin 1991
Devlin JB. Prevalence and risk factors for childhood
nocturnal enuresis. Irish Medical Journal 1991;84(4):
118–20. [MEDLINE: 92283629]
Djurhuus 1992
Djurhuus JC, Norgaard JP, Rittig S. Monosymptomatic
bedwetting. Scandinavian Journal of Urology and Nephrology
1992;141(Suppl):7–19. [MEDLINE: 92302804]
Doleys 1977
Doleys DM. Behavioural treatments for nocturnal enuresis
in children: a review of the recent literature. Psychological
Bulletin 1977;84(1):30–54. [MEDLINE: 77149408]
Eiberg 1995
Eiberg H, Berendt I, Mohr J. Assignment of dominant
inherited nocturnal enuresis (ENUR1) to chromosome
13q. Nature Genetics 1995;10(3):354–6. [MEDLINE:
95400306]
Feehan 1990
Feehan M, McGee R, Stanton W, Silva PA. A 6 year follow-
up of childhood enuresis: prevalence in adolescence and
consequences for mental health. Journal of Paediatrics &
Child Health 1990;26(2):75–9. [MEDLINE: 90298066]
Fitzwater 1992
Fitzwater D, Macknin ML. Risk/benefit ratio in enuresis
therapy. Clinical Pediatrics (Philadelphia) 1992;31(5):
308–10. [MEDLINE: 92257832]
Forsythe 1974
Forsythe WI, Redmond A. Enuresis and spontaneous cure
rate. A study of 1129 enuretics. Archives of Disease in
Childhood 1974;49(4):259–63. [MEDLINE: 74169219]
Forsythe 1989
Forsythe WI, Butler RJ. Fifty years of enuretic alarms.
Archives of Disease in Childhood 1989;64(6):879–85.
[MEDLINE: 89373048]
Glazener 2002
Glazener CMA, Evans JHC. Desmopressin for nocturnal
enuresis in children. Cochrane Database of Systematic Reviews
2002, Issue 3. [Art. No.: CD002112. DOI: 10.1002/
14651858.CD002112]
Glazener 2003a
Glazener CMA, Evans JHC, Peto R. Tricyclic and related
drugs for nocturnal enuresis in children. Cochrane Database
of Systematic Reviews 2003, Issue 3. [Art. No.: CD002117.
DOI: 10.1002/14651858.CD002117]
Glazener 2003b
Glazener CMA, Evans JHC, Peto RE. Drugs for nocturnal
enuresis in children (other than desmopressin and tricyclics).
Cochrane Database of Systematic Reviews 2003, Issue 4. [Art.
No.: CD002238. DOI: 10.1002/14651858.CD002238]
Glazener 2004a
Glazener CMA, Evans JHC, Peto RE. Complex behavioural
and educational interventions for nocturnal enuresis
in children. Cochrane Database of Systematic Reviews
2004, Issue 1. [Art. No.: CD004668. DOI: 10.1002/
14651858.CD004668]
Glazener 2004b
Glazener CMA, Evans JHC. Simple behavioural
and physical interventions for nocturnal enuresis in
children. Cochrane Database of Systematic Reviews 2004,
Issue 2. [Art. No.: CD003637. DOI: 10.1002/
14651858.CD003637.pub2]
Glazener 2005b
Glazener CMA, Evans JHC, Cheuk DKL. Complementary
and miscellaneous interventions for nocturnal enuresis
in children. Cochrane Database of Systematic Reviews
2005, Issue 2. [Art. No.: CD005230. DOI: 10.1002/
14651858.CD005230]
Higgins 2003
Higgins JPT, Thompson SG, Deeks JJ, Altman DG.
Measuring inconsistency in meta-analyses. British Medical
Journal 2003;327:557–60.
Howe 1992
Howe AC, Walker CE. Behavioral management of toilet
training, enuresis, and encopresis. Pediatric Clinics of North
America 1992;39(3):413–32. [MEDLINE: 92244694]
Jarvelin 1989
Jarvelin MR. Developmental history and neurological
findings in enuretic children. Developmental Medicine
and Child Neurology 1989;31(6):728–36. [MEDLINE:
90092792]
Jarvelin 1990
Jarvelin MR, Huttunen NP, Seppanen J, Seppanen U,
Moilanen I. Screening of urinary tract abnormalities among
day and nightwetting children. Scandinavian Journal of
Urology and Nephrology 1990;24(3):181–9. [MEDLINE:
91047829]
Koff 1995
Koff SA. Why is desmopressin sometimes ineffective at
curing bedwetting?. Scandinavian Journal of Urology
and Nephrology 1995;173(Suppl):103–8. [MEDLINE:
96363555]
Krantz 1994
Krantz I, Jylkas E, Ahlberg BM, Wedel H. On the
epidemiology of nocturnal enuresis-a critical review of
methods used in descriptive epidemiological studies on
nocturnal enuresis. Scandinavian Journal of Urology
and Nephrology 1994;163(Suppl):75–82. [MEDLINE:
95183925]
Maizels 1993
Maizels M, Gandhi K, Keating B, Rosenbaum D. Diagnosis
and treatment for children who cannot control urination.
Current Problems in Pediatrics 1993;23(10):402–50.
[MEDLINE: 94116304]
Moffatt 1989
Moffatt ME. Nocturnal enuresis: psychologic implications
of treatment and nontreatment. Journal of Pediatrics 1989;
114(4 Pt 2):697–704. [MEDLINE: 89177838]
20Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Moffatt 1994
Moffatt ME. Nocturnal enuresis-is there a rationale for
treatment?. Scandinavian Journal of Urology & Nephrology
1994;163(Suppl):55–66. [MEDLINE: 95183922]
Morgan 1970
Morgan R. The treatment of enuresis amongst child clients
of a social services department. British Journal of Social
Work 1970;9(2):217–31.
Morgan 1993
Morgan R. Guidelines in the minimum standards of practice
in the treatment of enuresis. Bristol, UK: Enuresis Resource
and Information Centre, 1993.
Mowrer 1938
Mowrer OH, Mowrer WM. Enuresis - a method for its study
and treatment. The American Journal of Orthopsychiatry
1938;8:436–59.
Norgaard 1993
Norgaard JP, Djurhuus JC. The pathophysiology of enuresis
in children and young adults. Clinical Pediatrics 1993;Spec
No:5–9. [MEDLINE: 94313804]
Novello 1987
Novello AC, Novello JR. Enuresis. Pediatric Clinics of North
America 1987;34(3):719–33. [MEDLINE: 87230588]
Parkin 1972
Parkin JM, Fraser MS. Poisoning as a complication of
enuresis. Developmental Medicine & Child Neurology 1972;
14(6):727–30. [MEDLINE: 73066898]
Rushton 1993
Rushton HG. Older pharmacologic therapy for nocturnal
enuresis. Clinical Pediatrics 1993;Spec No:10–3.
[MEDLINE: 94313796]
Rutter 1973
Rutter M, Yule W, Graham P. Enuresis and behavioural
deviance. Some epidemiological considerations. In: Kolvin
I, MacKeith RC, Meadow SR editor(s). Bladder control and
enuresis. London: William Heinemann Medical Books,
1973.
Shaffer 1977
Shaffer D. Enuresis. In: Rutter M editor(s). Child
psychiatry: Modern approaches. Oxford: Blackwell Scientific
Publications, 1977.
Verhulst 1985
Verhulst FC, van der Lee JH, Akkerhuis GW, Sanders-
Woudstra JA, Timmer FC, Donkhorst ID. The prevalence
of nocturnal enuresis: do DSM III criteria need to be
changed? A brief research report. Journal of Child Psychology
& Psychiatry & Allied Disciplines 1985;26(6):989–93.
[MEDLINE: 86059824]
Wagner 1988
Wagner WG, Johnson JT. Childhood nocturnal enuresis:
the prediction of premature withdrawal from behavioral
conditioning. Journal of Abnormal Child Psychology 1988;
16(6):687–92. [MEDLINE: 89109804]
Warzak 1992
Warzak WJ. Psychosocial implications of nocturnal enuresis.
Clinical Pediatrics 1992;Spec No:38–40. [MEDLINE:
94313803]
Warzak 1994
Warzak WJ, Friman PC. Current concepts in Pediatric
Primary Nocturnal Enuresis. Child and Adolescent Social
Work Journal 1994;11(6):507–23.
WHO 1992
WHO. Nonorganic enuresis. In: WHO editor(s). The
ICD-10 classification of mental and behavioural disorders:
Clinical descriptions and diagnostic guidelines. Geneva:
WHO, 1992.
References to other published versions of this review
Glazener 2001
Glazener CMA, Evans JHC. Alarm interventions for
nocturnal enuresis in children. The Cochrane Database of
Systematic Reviews 2001, Issue 1.
Glazener 2003c
Glazener CMA, Evans JHC, Peto RE. Alarm interventions
for nocturnal enuresis in children. The Cochrane Database
of Systematic Reviews 2003, Issue 2.
Glazener 2005a
Glazener CMA, Evans JHC. Alarm interventions for
nocturnal enuresis in children. The Cochrane Database of
Systematic Reviews 2005, Issue 2.
Lister-Sharp 1997
Lister-Sharp D, O’Meara S, Bradley M, Sheldon TA. A
Systematic Review of the Effectiveness of Interventions for
Managing Childhood Nocturnal Enuresis. NHS Centre for
Reviews and Dissemination. Vol. CRD Report 11, York,
UK: University of York, 1997.∗ Indicates the major publication for the study
21Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Azrin 1974
Methods RCT - coin flip used to randomise each of pairs of children
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting: Not mentioned
Setting: respondents to a newspaper advertisement for enuretics
Participants No. of children (boys): 26 (19)
Excl: medical causes
Ages: 3+, mean 8 years
Baseline frequency 7 days/week.
Interventions Experiment 1
A (7): DBT (parent-and-child alarm; PP; W; increasing fluid intake; rewards; CT; training in inhibiting
urination
B (7): Child-only alarm for first 2 weeks only, then DBT
Experiment 2
C (6): DBT, parent-only alarm
D (6): Child-only alarm
Outcomes Fewer wet nights in first 2 weeks with A+C (median 1 vs B+D 5 in second week, P<0.005).
More children achieving 6 dry nights in A
Notes Pairs matched for age, sex and frequency of wetting
No useable data.
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
Azrin 1978
Methods RCT (details not given)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Participants No. of children (boys): 55 (41)
Incl: Age at least 3 years; no daytime wetting; wetting at least 4x/week; able to understand instructions;
medical examination and treatment
Age: mean 7 years (range 3-14) (20 less than 6 years)
Baseline wetting: 91% of nights
22Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Azrin 1978 (Continued)
Interventions A (28): Intensive DBT (PP, CT) plus rehearsing during the day with increased fluid intake, stream inter-
ruption exercises, Retention Control Training, repeated awakening, rewards for dry nights or compliance
but NO ALARM
B (27): Alarm (pad-and-buzzer)
Duration of trial: 2 weeks, after which parents could swap to other arm
Outcomes Per cent wet nights during 2 weeks: A, 15%; B, 76%
No. of children swapping to other group after 2 w: A, 0/27; B, 23/27
Notes Comparability of groups at baseline not reported
No follow up possible after 2 weeks
No SDs
Very young children (20 under age 6 years) included
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Baker 1969
Methods RCT
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: recruited from newspaper advertisement
Participants No. of children (boys): 30 (20)
Incl: primary (26) and secondary (4) enuresis
Age median 8 years, range 6-12
Baseline wetting: half wetting every night
Interventions A: (10) Alarm
B: (10) Wake up using alarm clock, and star chart
C: (10) Waiting list control
Duration of treatment: 10 weeks, or 50 wet episodes
Outcomes Mean no. wet nights per week in last 3 weeks of treatment: A, 1.8; B, 3.1; C, 5.9 (no SDs)
Minor behavioural adverse events, self limiting
Notes Waiting list controls subsequently given an intervention, results not presented separately
No SDs given
Risk of bias
Item Authors’ judgement Description
23Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Baker 1969 (Continued)
Allocation concealment? Unclear B - Unclear
Bennett 1985
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Not mentioned
Daytime wetting excluded: Yes if only negligible
Participants No. of children (boys): 40 (25)
Dropouts: 32 (A,9; B,11; C,10; D,3)
Incl: primary nocturnal enuresis, referred to enuresis service by GP, negligible daytime wetting
Excl: encopresis, previous behavioural intervention, gross psychopathology
Age mean 8.5 years (SD 3.2) range 5-12
Baseline wetting: dry nights, boys 3/14; girls 2.4/14
Interventions A: (9) Alarm (pad and buzzer)
B: (12) Stop-start training (sphinchter muscle exercises, bladder training)
C: (10) Dry Bed Training including alarm
D: (9) Waiting list control (used star chart after first dry night)
Duration of treatment: 10 weeks
Outcomes Mean dry nights in last 2 weeks of 12 weeks treatment: A, 12 (SD 3.9); B, 7.5 (5.2); C, 11.2 (3.6); D, 3.
7 (3.0)
No. achieving 14 dry nights:
A, 4/9; B, 2/12; C, 5/10; D, 0/9
Mean dry nights at followup:
A, 12.3 (3.1); B, 7.1 (5.8); C, 9.3 (5.3). (D treated after 12 weeks)
Adverse events: not mentioned
Notes All children got star charts after their first dry night
High dropout rate
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Bollard 1981a
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
24Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Bollard 1981a (Continued)
Participants Experiment 1
No. of children (boys): 45 (A:11, B:11, C:10)
No. of dropouts: A:0, B:3, C: 0
Incl: No underlying organic pathology
Previous treatment: no details
Mean age (years.months): A: 9.10 B: 9.9 C: 9.5
Baseline wetting: Mean number of wet nights per week: A: 5.3 B: 5.4 C: 4.2
Interventions Experiment 1
A (15): enuresis alarm - supervised (weekly followup) B (15): enuresis alarm - unsupervised
C (15): waiting list control
Duration of treatment: until achievement of 14 consecutive dry nights or 20 weeks
Follow up: 3, 6 and 12 months
Outcomes Experiment 1
Mean number of wet nights at end of 20 weeks: A:0.8, B:2.2, C:4.6
2 treatment groups did not differ significantly in number of wet beds at end of 20 weeks or number of
days taken to reach dryness criterion
Number achieving 14 consecutive dry nights: A:12, B:9, C:0
Number relapsing at 12 m followup: A:4, B:5
Notes Experiment 1
No blinding
Comparability of groups not reported
Graphical data
No SDs
No baseline data for control group
Two analyses provided:
a) intention to treat basis;
b) excluding dropouts
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Bollard 1981b
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants Experiment 2
No. of children: 100
No. of boys: A:14 B:13 C:16 D:14 E:14 F:11
No. of dropouts: 12 from D
25Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Bollard 1981b (Continued)
Incl: thorough medical examination; regularly wetting at least one night per week; no other treatment
during trial
Previous treatment: no details
Mean age (years.months): A:9.3 B:8.11 C:9.7 D:8.6 E:8.8 F:8.10
Baseline wetting: mean number of wet nights: A:5.8 B:5.2 C:6.0 D:5.7 E:6.0 F:4.7
Interventions Experiment 2
A (20): DBT (A + W + CT + PP) with therapist at home
B (20): DBT (A + W + CT + PP) with therapist at hospital
C (20): DBT (A + W + CT + PP) with parents as therapists at home
D (20): DBT (W + CT + PP) with parents as therapists at home WITHOUT enuresis alarm
E (20): alarm
F (20): waiting list control
Duration of treatment: until 14 consecutive dry nights or 20 weeks
Follow up at 3, 6 and 12 months
Outcomes Experiment 2
Comparing DBT with alarm only - DBT significantly more effective in terms of number of wet nights
and days to dryness
Mean number of wet nights per week at end of week 20
(incl dropouts) A:0, B:0, C:0, D: (n=20) 3.8, E: 0.6, F: 4.4
(excl dropouts) A:0, B:0, C:0, D:(n=8) 1.3, E:0.6, F:4.4
No. achieving 14 consecutive dry nights: A:20, B:20, C:20, D:5, E:16, F:2
(p < 0.05)
No. relapsing: A:5, B:6, C:4, D:2, E:6, F:2 NS
ie no. failing or relapsing: A: 5/20, B: 6/20, C: 4/20, D: 17/20, E: 10/20, F: 20/20
Notes Experiment 2
No details of blinding
DBT no alarm group (D) younger than others and
more girls in waiting list control group (F)
No SDs
Analysed on intention to treat basis and with dropouts included
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Bollard 1982a
Methods Mainly RCT but also comparison with previous study [A] and [H] from another study
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
26Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Bollard 1982a (Continued)
Participants No. of children (2 groups combined) (boys): 127 (88)
Incl: no underlying organic pathology
Previous treatment: many had previously sought help but none undergoing any form of enuresis related
drug or psychotherapy at the time of the study.
Mean age: 9 yrs 10 m
Baseline wetting: Overall mean number of wet nights per week = 5.5
Interventions [A (35): alarm only (A)]
B (12): alarm (A) + waking schedule (W)
C (12): A+retention control training
D (12): A+ positive practice (PP)+ cleanliness training (CT)
E (12): A+W+retention control training
F (12): A+W+PP +CT
G (12): A+retention control training+PP +CT
[H (20): Full DBT]
Duration of treatment: 20 weeks
Follow up: none
Outcomes Mean no. of wet nights during 20 week treatment period:
A: 27 B: 13 C: 24 D: 23 E: 14 F: 10 G: 21 H: 11
Number of cases becoming dry: A: 31 B: 12 C: 11 D: 10 E: 12 F: 12 G: 11 H: 20
Significant difference in response rate of group with waking schedule vs those without (Chi squared = 13.
04, df = 3, p < 0.01)
Notes Groups A and H from another trial, data not used
No analysis of comparability of groups
No blinding
No SDs
No follow up
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Bradbury 1995
Methods RCT (quota allocation system based on age, baseline wetting, family or housing problems, gender, previous
alarm use, daytime wetting and previous dry periods)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: No
Participants No. of children: 71 (boys 48)
Dropouts A: 3, B: 8
Incl: nocturnal enuresis at least 1 night per wk (40/71 = severe, >4x/week);
Excl: neuropathic bladder, urinary tract abnormalities, cystic fibrosis, allergic rhinitis, deafness/learning
27Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Bradbury 1995 (Continued)
difficulties, UTI
Previous treatment: 29 had used alarms
Interventions A (36): desmopressin 40 mcg intranasally + alarm (bell-and-pad or Mini Drinite)
B (35): alarm alone
Duration of treatment: 6 weeks or until dry
Follow up: 6 months
Outcomes Mean DRY nights/week: A: n=33, mean = 6.1 95% CI 5.6-6.7; B: 27, 4.8, 4.0-5.6
No. not achieving 4 dry nights: A: 6/33; B: 11/27
No. failing + no. relapsing: A: 10/33; B: 14/27
Side effects: none reported
Subgroup analysis in more severe group: A still better than B
Notes Mini Drinite = body-worn alarm
Relapsing = >2 wet nights in 2 weeks after 4 weeks dry
Authors recommend using combined desmopressin + alarm only for children with severe wetting problems
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
Butler 1988
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children (boys): 74(A: 18, B: 29)
Dropouts: 11 excluded after baseline assessments
Incl: age at least 6 years;wetting at least five nights a week for a month; normal clinical exam; normal
urine on microscopy; normal intelligence (assessed by reference to educational background and parental-
child interview); not having any form of enuresis related drug or psychotherapeutic treatment
Previous treatment: 36 (48.6%) enuresis alarm
Mean age: A: 8.99 B: 9.86
Baseline wetting: mean number of dry nights during 4 weeks
A: 1.07 B: 1.02
Interventions A (28): Standard enuresis alarm treatment (A)
B (35): Modified DBT + alarm (A + W + PP + retention control training) WITHOUT reprimands during
CT
Duration of treatment: 16 weeks
Follow up: none
28Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Butler 1988 (Continued)
Outcomes Mean number of dry nights in last 4 weeks
A:20.76 B:23.79 F(1,46) = 1.77
Number of children achieving 14 dry night criterion
A:20/28 (71%) B: 25/35 (71%) no significant difference
Mothers in dropout group significantly more angry with bedwetting than other groups
Notes No significant difference between groups for demographic factors but modified-DBT group more likely
to have previously used alarm. Analysis of covariance adjusted for the effects of previous experience with
enuresis alarm
No blinding
Not intention to treat
No SDs
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Butler 1990a
Methods CCT (alternate allocation)
Experiment 1
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants Experiment 1
No. of children: 40 (boys A: 14 B: 11)
Dropouts A: 3 B: 2
Incl: wetting at least 4 nights a week for a month; normal physical examination; normal urine microscopy;
normal intelligence (assessed by reference to educational background and parent\child interview)
Previous treatment: None
Mean age: A: 8.2 B: 9.1
Baseline wetting: mean number of DRY nights per week: A: 1.2 B: 0.7
No significant difference between groups on any variable
Interventions Experiment 1
A (20): pad and bell alarm
B (20): body worn alarm
Duration of treatment: 16 weeks
FU after 6 months
Outcomes Experiment 1
Mean number of wet nights in 16 weeks: A: 18.9 B: 15.3
Number (%) children achieving 14 consecutive dry nights: A: 14 (70) B: 14 (70)
Mean number of wet nights until achievement of 14 consecutive dry nights A: 54.8 B: 35.3 (t = 2.8, df =
26, p < 0.01)
29Alarm interventions for nocturnal enuresis in children (Review)
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Butler 1990a (Continued)
Number (%) children relapsing A: 4/14 (29) B: 3/14 (21)
The majority of children preferred body-worn alarm to pad and bell
Notes Small groups
Experiment 1
No blinding
Unclear if intention to treat analysis
Poor randomisation
No SDs
Risk of bias
Item Authors’ judgement Description
Allocation concealment? No C - Inadequate
Butler 1990b
Methods CCT (alternate allocation)
Experiment 2
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Participants Experiment 2
No. of children: 48 (boys A: 20 B:20)
Number of dropouts: A: 2 B 1
Incl: wetting at least 4 nights a week for a month; nomal physical examination; normal urine microscopy;
normal intelligence (assessed by reference to educational background and parent\child interview); no
associated diurnal enuresis
Previous treatment: unsuccessful treatment with pad and bell alarm
Mean age (years): A: 10.2 B: 11.2
Severity at baseline: mean number of DRY nights per week: A: 1.2 B: 1.3
Groups did not differ significantly on any variable
Interventions Experiment 2
A (24): Modified DBT + pad-and-bell alarm (A + W + retention control training)
B (24): body-worn alarm (A)
Duration of treatment: 16 weeks
FU after 6 months
Outcomes Experiment 2
Mean number of wet nights in 16 weeks A: 28.7 B: 25.0
Number (%) attaining 14 consecutive dry nights A: 14 (58) B: 20 (83)
Mean number of wet nights to achievement of 14 consecutive dry nights A: 53.7 B: 40.7
Number (%) children relapsing: A: 7 (50) B: 9 (45)
30Alarm interventions for nocturnal enuresis in children (Review)
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Butler 1990b (Continued)
Notes Experiment 2
Unclear if intention to treat analysis
Poor randomisation
No SDs
Dry bed training included a pad-and-bell alarm, a waking schedule and retention control training
Risk of bias
Item Authors’ judgement Description
Allocation concealment? No C - Inadequate
Caceres 1982
Methods RCT ’double blind’
Systematic baseline measure of wetting: Yes
Organic causes excluded: No
Daytime wetting excluded: No
Participants No. of children (boys): 14 (9)
Incl: enuresis, or behaviour problem + enuresis. Some were not daytime toilet trained
Previous treatment: all had failed with psychotherapy, drugs or fluid restriction
Age: mean 9 years (range 6-14)
Baseline wetting: every night
Interventions A (7): Enuresis alarm (Mowrer’s pad-and-bell)
B (7): DBT (but WITHOUT alarm) + rewards
Duration: 1 m, then crossed over to other arm if not 50% improved
Outcomes Not cured on original treatment: A: 0/7, B: 5/7
Notes Children crossed over to alternative treatment if not successful (5 of B group changed to A). Cure rates
given while on first treatment
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
31Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Danquah 1975
Methods RCT - but mention of matching
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: Ghanian fishing community
Participants No. of children (boys): 30 (all boys)
Excl: more than a week of traditional treatment
Mean age: 10 .4 years
Mean frequency of wetting at baseline: A: 5.6 B: 4.00 C: 3.20
Interventions A (10): traditional shaming
B (10): amitriptyline hydrochloride
C (10): alarm
Duration of treatment: 7 weeks
Follow up after 3 months
Outcomes Mean frequency of wetting after treatment: A: 5.6; B: 4.00; C: 3.2
Subjects of traditional shaming seemed depressed and evidence of loss of self esteem and patients isolating
themselves from friends.
Drug treatment was said to cause drowsiness at first. Parents not disturbed by alarm because they slept
outside
Notes No details of dropouts
No SDs
No details of previous treatment
Groups comparable in age and intelligence
Traditional shaming consisted of being carried from home by a singing mob and being thrown into the
lagoon
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Elinder 1985
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Participants No. of children (boys): 53 (45)
No. of dropouts: A:9; B:6 due to technical problems or discomfort
Incl: Age at least 7 years; primary nocturnal enuresis; at least 3 wet nights/week; no daytime wetting
Excl: physical or psychological /psychiatric disease
Previous treatment: tricyclics (A:20, B:7); alarm (1, 2)
32Alarm interventions for nocturnal enuresis in children (Review)
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Elinder 1985 (Continued)
Ages: 39 7-11 years; 14 over 11 years
Interventions A (36): Functioning Uristop device
B: (17) Non-functioning Uristop device
Duration of treatment: 6 weeks
Follow up 12 months
Outcomes No. not cured: A: 0/36, B: 0/17
Notes Device delivers electric impulse to pudendal nerve in groin when urine is passed
Power calculation given
Groups comparable at baseline except more upsetting life events and psychiatric contact in B
Failure ascribed to incorrect theory or incorrect construction (wrong placement of electrodes or impulse
too low)
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Faraj 1999
Methods RCT (random number tables, details not given)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Participants No. of children: 135
Dropouts: 23 excluded for non-compliance, and 39 lost to follow up including 12 failed with alarms
Incl: monosymptomatic nocturnal enuresis, age >5 years
Excl: previous treatment with desmopressin or alarm, urological pathology, diurnal enuresis, UTI
Age mean 11.2 years
Baseline wetting A 21% dry nights, B 14% dry nights
Interventions A (62): Desmo 20 µg intranasally increasing to 40 µg if response partial
B (73): alarm (pad-and-bell)
Duration of treatment 3 m. If failed at that time, changed to alternative arm Follow up: none
Outcomes DRY nights at 3 months: A 85%; B: 90%
No. not achieving 14 dry nights: A 12/39; B: 6/37
Side effects: not mentioned
Notes
Risk of bias
Item Authors’ judgement Description
33Alarm interventions for nocturnal enuresis in children (Review)
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Faraj 1999 (Continued)
Allocation concealment? Unclear B - Unclear
Fielding 1980
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Participants No. of children (boys): 45 (6 lost at baseline) (30)
Dropouts: 11
Incl: age 5 to 15; no urinary tract infection; no evidence of organic pathology; not treated within previous
12 months; no daytime wetting
Age range: 5 years 2 months to 13 years 10 months
Baseline wetting: mean number of wet nights in 4 weeks: A: 23.5 B: 24.7
Interventions A: (16) retention control training and enuresis alarm
B: (17) enuresis alarm alone
Duration of treatment: retention control training 4 weeks and alarm 14 weeks
Follow up after 3, 6 and 12 months
Outcomes Mean number of wet nights in 3rd month of alarm: A, 6.2; B, 2.3
Number achieving 14 consecutive dry nights: A, 11/16; B, 14/17
Number (%) relapsing after 3 months: A, 3 (28); B, 4 (29)
after 6 months: A, 3 (28); B, 5 (36)
after 12 months: A, 4 (36); B, 8 (57)
Adverse events: not mentioned
Notes Analysed on intention to treat basis
Parallel study specifically includes diurnal wetters (results not given here)
No blinding
Not reported if comparable groups
No SDs
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
34Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Finley 1973
Methods RCT
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: Children’s Medical Centre, Tulsa, Oklahoma USA
Participants No. of children (boys): 30 (30)
Incl: primary nocturnal enuresis, at least 3 wet nights/week, own room and bed
Excl: daytime wetting, organic cause for enuresis, emotional disturbance
Ages: 6 to 8 years
Baseline wetting: 3x/week, 7 to 8 wet episodes per week
Interventions A (10): enuresis alarm (105 dB bell) + light
B (10): enuresis alarm (80 dB bell), intermittent action (70% active)
C (10): alarm (78 dB) in parents’ room 20 mins after wetting
Duration of treatment 6 weeks
Follow up 3 months
Outcomes Mean wet episodes during 6th week: A: 0.2, B: 0.6, C: 8
No. not achieving 7 dry nights: A: 1/10, B: 2/10, C: 10/10
No. failing or relapsing after ’cure’: A: 5/10, B: 3/10 (C all failed: 10/10)
Notes No SDs
Data estimated from graph
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Finley 1977
Methods RCT
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: Children’s Medical Centre, Tulsa, Oklahoma USA
Participants No. of children (boys): 20 (20)
Incl: primary nocturnal enuresis
Excl: emotional disturbance, organic causes, daytime wetting
Age: 6-9 years
Baseline wetting: 6-7 wet nights/week
Interventions A (10): alarm with 105 dB bell
B (10): alarm with 80 dB bell
Duration of treatment: 7 weeks
35Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Finley 1977 (Continued)
Follow up 16-24 months
Outcomes No. not achieving 14 dry nights: A: 3/10, B: 6/10
Relapse rate: A: 3/7, B: 1/4
Failed or relapsed: A: 6/10, B: 7/10
Notes Group comparability at baseline not stated
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Forrester 1964
Methods RCT
Systematic baseline measure of wetting: No
Organic causes excluded: No
Daytime wetting excluded: Not mentioned
Setting: children recruited from community survey
Participants No. of children 118 (33 properly included in trial)
Dropouts: 25 cured before trial, 32 improved, 9 not suitable, 15 defaulted, 4 received wrong intervention
Incl: aged 8-14, wet at least 1x/week, suitable family circumstances
Ages: 8-14 years
Interventions A (16): Alarm (+ amphetamine for some children if not wakened by bell)
B (17): Amphetamine 2.5 to 5mg, increasing weekly if no response, decreasing if response, stopped if
sleepless or restless
Duration of treatment: up to 6 months
Outcomes No. not achieving 21 dry nights: A: 6/16, B: 14/17
Failure to comply with treatment properly: A: 4/17, B: 6/16
Notes Successful treatment requires the families to understand the commitment involved
Results including failure to comply in group as allocated
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
36Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Fournier 1987
Methods RCT (double-blind)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting: Not mentioned
Participants No. of children (boys): 64 (47) completed the study
5 extra children dropped out
Incl: no treatment in past 3 months
Mean age: 8 years 5 months
Baseline wetting: mean number of wet nights in week 2: A, 5.3; B, 6; C, 4.5; D, 4.2; E, 4.5
Interventions A (8): imipramine
B (8): enuresis alarm
C (8): placebo
D (8): random awakening
E (8): alarm + imipramine
[F (8): Alarm + placebo
G (8): random awakening + placebo
H (8): imipramine + random awakening]
Duration of treatment: 6 weeks
Follow up 3 months but some children continued on treatments
Outcomes Mean number of wet nights per week:
A: 1.9 B: 2.5 C: 5 D: 3.3
E: 1
No results for F, G or H
4 boys dropped out because of side-effects or non-compliance, 1 girl with UTI
Notes Parallel groups
No SDs
Differences in baseline severity of wetting - MANOVA used
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Geffken 1986a
Methods RCT
Children were stratified by maximal functional bladder capacity
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children (boys): initially 50
(Boys: A: 8 C: 6)
37Alarm interventions for nocturnal enuresis in children (Review)
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Geffken 1986a (Continued)
10 dropouts
Incl: nocturnal enuresis of at least 3 months duration; at least 2 wetting episodes a week
Mean age A: 9.0 C: 9.4
Baseline wetting: Mean (SD) number of wet nights per week
A: 4.9 (1.7) C: 5.4 (1.1)
Interventions Large maximal functional bladder capacity:
A (10): alarm
C (10): alarm + retention control training
Duration of treatment: 14 weeks
Follow up after 8 or more weeks
Outcomes Mean (SD) number of wet nights per week A: 1.7 (1.2) C: 2.5 (0.9)
Significant interaction between maximal functional bladder capacity and treatment F(1, 33) = 4.90, p 0.
03
Number of children achieving initial arrest during 14 weeks treatment A: 9 C: 9
Number of children relapsing during follow up A: 3 C: 4
Notes Not intention to treat analysis
Short follow up
No details of previous treatment
Payment required
For those who completed treatment there were no significant difference between the groups in terms of
sex, age, child adjustment measures or the Tolerance and Nuisance Scales
Retention control training consisted of increasing fluid intake and delaying urination for increasing periods
of time to expand bladder capacity
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Geffken 1986b
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children (boys): initially 50
(Boys: B: 5 D: 6)
10 dropouts
Incl: nocturnal enuresis of at least 3 months duration; at least 2 wetting episodes a week
Mean age B: 7.7 D: 8.0
Baseline wetting: Mean (SD) number of wet nights per week
B: 5.7 (1.3) D: 4.9 (1.2)
38Alarm interventions for nocturnal enuresis in children (Review)
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Geffken 1986b (Continued)
Interventions Small maximal functional bladder capacity:
B (10): alarm
D (10): alarm + retention control training
Duration of treatment: 14 weeks
Follow up after 8 or more weeks
Outcomes Mean (SD) number of wet nights per week
B: 2.3 (1.0) D: 1.6 (1.1)
Significant interaction between maximal functional bladder capacity and treatment F(1, 33) = 4.90, P=0.
03
Number of children achieving initial arrest during 14 weeks treatment B: 10 D: 9
Number of children relapsing during follow up B: 6 D: 3
Notes Not intention to treat analysis
Short follow up
No details of previous treatment
Payment required
For those who completed treatment there were no significant differences between the groups in terms of
sex, age, child adjustment measures or the Tolerance and Nuisance Scales
Retention control training consisted of increasing fluid intake and delaying urination for increasing periods
of time to expand bladder capacity
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Gibb 2004
Methods RCT (drug dispensed randomly by pharmacist)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: No
Setting: Paediatric outpatients, Children’s Hospital, Melbourne, Australia
Participants Number of children (boys): 207/210 (A:64, B:78)
Dropouts: 10 eligible children declined, incomplete data on A:9/101, B:17/106 but dropouts counted as
failures for analysis
Inclusion criteria: Non-responders to desmopressin treatment (<50% reduction in wet nights), age 6-16
years, wetting at least twice per week, some daytime wetting (A:11, B:8)
Exclusion criteria: Neuropathic bladder, urinary tract abnormality, cystic fibrosis, allergic rhinitis, UTI in
previous 2 weeks, imipramine or diuretics
Previous treatment: some had alarm (A:37, B:32) or desmopressin (A:31, B:28)
Age: mean 9.4 years (SD 2.08)
Baseline wet nights in 28 days: A: 23.9 (SD 5.05), B: 23.7 (5.83)
39Alarm interventions for nocturnal enuresis in children (Review)
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Gibb 2004 (Continued)
Interventions A (84/101): desmopressin (40 µg nasal spray) + alarm (pad and bell)
B (85/106): placebo (nasal spray) + alarm (pad and bell)
Duration of treatment: 8 weeks
Follow up: 2 months
Outcomes Cure = 28 dry nights, relapse = 2 wet nights in 2 weeks
Wet nights during treatment (number, mean (SD)): A: 101, 1.8 (1.13), B: 106, 2.4 (1.53)
Cure during treatment: A: 52/101, B: 51/106 P=0.63 (failed: A: 49/101, B: 55/106)
Relapse after treatment stopped: A: 7, B: 3
Failed or relapsed: A: 56/101, B: 58/106
Adverse effects: A: 1 (headache), B: 1 (nose bleed)
Other: compliance same in both groups
Cure in daytime wetting: A: 6/11, B: 3/8
Notes Intention to treat analysis
Groups comparable at baseline on age, wetting, gender, family history, secondary enuresis, daytime wetting
and previous treatment
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Hojsgaard 1979
Methods RCT
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children (boys): 62
Interventions A (32): Uristop device
B (30): no treatment
Outcomes Cured: A: 20/32, B: 17/30
Improved: A: 5/32, B: 6/30
Notes Norwegian language
Uristop device gives ’electrical stimulation’ to the children
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
40Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Houts 1986
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: No
Daytime wetting excluded: Not mentioned
Setting: media recruitment and paediatric referrals
Participants No. of children (boys): 45 (35)
Dropouts: A: 2, B: 2, C: 3
Incl: Primary enuresis
Age 5-13 years
Baseline wetting: mean 5.41 (SD 1.63) wet nights/week
Interventions A (15): Enuresis alarm + over-learning + retention control training (Full Spectrum Home Training Package)
B (15): Enuresis alarm + retention control training
C (15): Enuresis alarm alone
D (11): Waiting list control
Duration of treatment: 16 weeks
Follow up: 1 year
Outcomes A: cured 9, failed 4, dropout 2; B: cured 13, dropped out 2; C: cured 9, failed 3, dropped out 3; D none
cured (11/11 failed)
Relapse at end of study after retreatment if necessary: A: 1, B: 6, C: 3
ie. failed or relapsed: A 5/13, B: 6/13, C: 6/12
Notes Groups comparable at baseline
A, B + C received 1 hour group training and CT
Relapses were retreated with initial treatment allocated
Children who failed were older, and dropouts were younger
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Jehu 1977
Methods RCT
Analysis curtailed after 12 weeks to accomodate the loss of some control children
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: Children resident in Children’s Homes but attending normal rather than special school so that
treatment not impractical -eg children only spent weekends or school holidays at the home
Participants No. of children (boys): 39 (boys A: 8 B: 17)
1 dropout
Incl: age 4 years or over; wetting frequency of at least 4 nights per week during baseline; not previously
41Alarm interventions for nocturnal enuresis in children (Review)
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Jehu 1977 (Continued)
treated by alarm within last year; no gross physical handicap
Previous treatment: drug therapy (7), alarm treatment (2)
Mean age 9 years 4 months (range 4 years 9 montha to 14 years 7 months)
Baseline wetting: For treatment group only mean no. wet nights per week = 4
Interventions A (19): enuresis alarm
B (20): no treatment control
Duration of treatment: 3 or 4 months - until success achieved (achieved 14 dry nights)
Follow up: after 6 months then 20 months
Outcomes Mean number of wet nights in week 12: A: 0.3 B: 5.3
Achieved 14 dry nights: A: 18/19 B: 0/20
One had absconded (counted as failure)
3 children had relapsed at 6 months and another at 8 months (needed repeat treatment)
Notes Comparability of groups not reported
No baseline for control - probably should compare from week 4 for control to compensate for this
Not intention to treat
More girls in alarm group
No SDs
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Kennedy 1968
Methods RCT (alternate allocation)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: A+B clinic attenders and paediatric referrals; C+D residents in Sunland Training Centre, Florida
Participants No. of children (boys): A+B 10 (8); C+D 8
Incl: C+D had learning difficulties
Excl: organic cause for enuresis
Age: A+B 6-12 years; C+D 9-12 years
Interventions A (5): Alarm + methedrine 5mg
B (5): Alarm only
C (3): Alarm + methedrine 5mg
D (5): Alarm only
Duration of treatment: 8 weeks
Follow up: 13 months
Outcomes No. not achieving 14 dry nights: A: 0/5, B: 0/5, C: 0/3, D: 4/5
42Alarm interventions for nocturnal enuresis in children (Review)
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Kennedy 1968 (Continued)
Notes Groups A+C and B+D combined for analysis
Baseline comparability not mentioned
Drug did not affect outcome but numbers too small to be reliable
Risk of bias
Item Authors’ judgement Description
Allocation concealment? No C - Inadequate
Kolvin 1972
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children (boys): 94 (56)
2 dropouts
Incl: wetting at least 3 nights a week; age range (not stated); not receiving treatment elsewhere
Previous treatment: no details
Mean age: 9 years 4 months (range 8 to 10)
Baseline wetting: mean number of wet nights per month A: 22.7 B: 22.0 C: 20.9
Interventions A (35): imipramine
B (32): pad and buzzer alarm
C (27): placebo
Duration of treatment: 2 months
Follow up: after 4 months
Outcomes Mean number of wet night in final month (% improvement)
A: 9.3 (64) B: 9.1 (62) C: 11.0 (53)
At follow up mean number of wet nights per month (% improvement)
A: 13.4 (43) B: 9.3 (64) C: 11.3 (54)
Notes No details of blinding
Not reported if comparable groups
Not intention to treat
No SDs
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
43Alarm interventions for nocturnal enuresis in children (Review)
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Leebeek 2001
Methods RCT (double blind parallel group study)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Participants No. of children (boys): 93 (62)
Incl: at least 6 wet nights/week
Excl: treatment in previous 2 weeks; daytime wetting/pollakisuria; urological or psycholigical disease; poor
motivation to use alarm
Previous treatment: none in previous 2 weeks
Age: 6-14 years
Baseline wetting: mean number of wet nights: A: 6.14, B: 6.12 (not significant)
Interventions A (47) alarm + desmo 40 µg intranasal for 3 weeks, then alarm + desmopressin 20 µg for 3 weeks, then
alarm alone for 3 weeks
B (46): alarm + placebo for 6 weeks, then alarm alone for 3 weeks
Follow up: at 2 weeks and 6 months after end of trial
Outcomes (Number), mean wet nights:
1st 3 weeks: A: (47), 2.93, B: (45), 3.86 (P=0.014)
Last 3 weeks, alarm only: A: 43, 2.77, B: 39, 2.21
Cured 2 weeks after end of trial: A: 15/47, B: 17/46
Cured 6 months after end of trial: A: 17/47, B: 17/46
ie failed at 6 months: A: 20/47, B: 21/46
Mean wet nights at 6 months: A: 41, 2.72, B: 37, 1.90
Adverse events: none in either group
Notes Power calculation provided
SDs not given (authors contacted for more information)
Groups comparable for sex and age
Study supported by drug company (Ferring)
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
Longstaffe 2000
Methods RCT (computer generated randomisation)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: recruited from hospital clinic and advertising
44Alarm interventions for nocturnal enuresis in children (Review)
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Longstaffe 2000 (Continued)
Participants No. of children: 182
At 6 months 17 withdrew due to failure (A 8; B 5; C 4)
Incl: primary monosymptomatic nocturnal enuresis, age >7 years, wet >3 x/week, normal bladder capacity
Excl: daytime wetting, CNS disorder, developmental delay, current alarm or desmopressin treatment,
encopresis, other medical problems
Interventions A (61): alarm
B (60): desmopressin intranasally
C (61): placebo
Duration of treatment: 6 months, then failures crossed over to alternative arm for 6 months (not ran-
domised)
Outcomes No. not achieving 14 dry nights after 6 months: A: 26/61; B: 31/60; C: 38/61
All children improved psychologically, e.g. behaviour and self concept, regardless of outcome or treatment
assignment
Side effects: not mentioned
Notes Dose of desmopressin not given
No follow up as failures assigned alternative treatment
Blinding to method not possible for alarm group
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
Lovibond 1964a
Methods RCT (stratified by age and sex)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: school children and GP referrals
Participants No. of children (boys): 36 (20)
Dropouts: B: 2
Incl: wet at least 3x/week; co-operative families
Excl: organic causes
Ages: 6 to 7 years 5 months: 7 years 6 months to 10 years 5 months: 10 years 6 months to 14
Interventions Experiment 1
A (12): Twin signal alarm (hooter then buzzer) + ’escape training’
B (12): Crosby Dri-nite (pad electrode but no genital electrode)
C (12): Mowrer pad-and-bell
Duration of treatment: until 14 dry nights achieved, fluid intake increased if dry for 7 nights (=overlearning)
or 50 days
Follow up: 31 months
45Alarm interventions for nocturnal enuresis in children (Review)
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Lovibond 1964a (Continued)
Outcomes Experiment 1
No. not achieving 14 dry nights: A 0/12, B: 6/12, C: 1/12
No. failing or relapsing after trial: A: 5/12, B: 6/12, C: 5/12
Adverse events: B: corrosive skin burns (3); discontinued due to fear of shocks (2)
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Lovibond 1964b
Methods RCT (stratified by age, sex and wetting frequency)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children (boys) 20 (12)
Incl: wet at least 3x/week; co-operative families
Excl: organic causes
Ages: 8-12 years
Interventions Experiment 2
A1 (5): Twin signal alarm triggered by wetting
A2 (5): Twin signal alarm but parents (not wetting) triggered the alarm after 2 dry nights (false alarm)
B1 (5): Mowrer pad-and-bell alarm triggered by wetting
B2 (5): Mowrer pad-and-bell alarm but parents (not wetting) triggered the alarm after 2 dry nights (false
alarm)
Duration: until 14 dry nights achieved including increased fluid intake after 7 dry nights (=overlearning)
or 50 days
Follow up: 24 m
Outcomes Experiment 2
No. not achieving 14 dry nights: A1: 0/5, A2: 0/5, B1: 0/5, B2: 0/5
No. failing or relapsing after 24 months: A1: 3/5, A2: 3/5, B1: 3/5, B2: 2/5 or:
Standard (A1 + B1) 6/10 vs False (A2 + B2) 5/10
Notes ’False’ alarm equivalent to ’waking’ by parents
Data from ’standard’ vs ’false’ only used
Risk of bias
Item Authors’ judgement Description
46Alarm interventions for nocturnal enuresis in children (Review)
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Lovibond 1964b (Continued)
Allocation concealment? Unclear B - Unclear
Lovibond 1964c
Methods RCT (stratified by age and sex)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children (boys) 24 (12)
Incl: wet at least 3x/week; co-operative families
Excl: organic causes
Interventions Experiment 3
A (12): Modified Twin Signal (bell instead of buzzer, then second weaker alarm)
B (12): Mowrer pad-and-bell alarm
Duration: until 14 dry nights achieved including increased fluid intake after 7 dry nights (=overlearning)
or 50 days
Follow up: 24 months
Outcomes Experiment 3
No. not achieving 14 dry nights: A: 0/12, B: 2/12
No. failing or relapsing: A: 5/12, B: 6/12
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Lynch 1984
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: No
Daytime wetting excluded: Yes
Setting: School or paediatric referrals
Participants No. of children (boys): 60
No. of dropouts: A:2, B:2, C:2
Incl: at least 2 wet nights/week
Excl: daytime wetting
Ages: 5-12
Baseline wetting in 14 nights, mean (SD): A: 11.11 (2.9), B: 11.33 (2.99), C: 11.55
47Alarm interventions for nocturnal enuresis in children (Review)
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Lynch 1984 (Continued)
Interventions A (20): star chart for 2 weeks then enuresis alarm - immediate
B (20): star chart for 2 weeks then enuresis alarm - 3 minute delay + CT
C (20): control, no treatment
Duration of treatment: 10 weeks
Follow up: None
Outcomes Wet nights in last 2 weeks, n, mean (SD): A: 18, 3.38 (4.55), B: 18, 8.38 (4.55), C: 18, 8.11 (3.25)
No. not achieving 14 dry nights: A: 11/18, B: 17/18, C: 18/18
Notes Groups comparable at baseline
One dropout from alarm group due to stress from alarm
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
McKendry 1975
Methods RCT
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: No
Setting: Paediatric outpatients, Toronto, Canada
Participants No. of children (boys): 222 (151)
No. of dropouts: 53 (A: 9, B:12, C:32)
Incl: primary nocturnal enuresis, ’a few’ had diurnal wetting
Excl: organic causes
Ages: Mean 9 years (range 5-17)
Baseline wetting (self reported): A: 83.4%, B: 82.3%, C: 87.4%
Interventions A (73): restricted diet
B (74): imipramine 10 mg at bedtime, increased to max 40 mg for age 5-9, up to 60 mg for 10+
C (75): Mozes Detector (body-worn detector, sounds alarm + delivers electric shock when a few drops of
urine pass)
Duration of treatment: 2 months
Follow up: A: 3 months, B: 19 months, C: 14 months
Outcomes No. not achieving 14 dry nights: A: 63/64, B: 49/62, C: 20/43
Adverse events: A: 2/12 children became aggressive; B: 3/16 had headaches, abdominal pain or fatigue,
C: 10/16 showed fear or anxiety about the machine. For C, electric shocks resulted in skin erythema,
discolouration, painless cold burns and ulceration
Notes Diet = no dairy, eggs, citrus, tomato, chocolate
A: most parents requested transfer to another treatment within 1-2 months due to finding diet unsuccessful
48Alarm interventions for nocturnal enuresis in children (Review)
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McKendry 1975 (Continued)
and restricting
C: high dropout rate was due to parents refusing to allow their child to use the Mozes detector,
or finding it too expensive, or children fearing it especially if under age 8y
Data entered counting dropouts as failures (for above reasons)
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Moffatt 1987
Methods RCT (opaque envelopes)
Systematic baseline measure of wetting: Yes
Organic causes excluded: No
Daytime wetting excluded: No
Setting: Enuresis clinic, Montreal Children’s Hospital
Participants No. of children: 121
No. of dropouts: A: 5
Incl: primary nocturnal enuresis, spoke English or French, 7 had daytime urgency (treated with retention
control training or anticholinergic drugs)
Ages: 8-14 years
Baseline wetting: 64% wet nights in each group
Interventions A (66): enuresis alarm + overlearning if successful
B (55): waiting list control
Duration of treatment mean (SD): A: 18.4 weeks (5.8), B: 13.2 weeks (1.9)
Outcomes No. not achieving 14 dry nights: A: 19/61, B: 54/55
Adverse events: 4 of A could not cope with alarm method
Notes Groups comparable at baseline but A assessed later if likely to be successful
Children’s self-concept improved when they were successful
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
49Alarm interventions for nocturnal enuresis in children (Review)
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Motavalli 1994
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children (boys): 29 (A: 6 B: 4 C: 4)
Incl: age 5 - 14; no organic causes; normal intelligence; wetting 2+ times a week; no treatment in previous
2 months
Mean age A: 9.1 years B: 9.2 C: 8.3
Baseline wetting: mean (SD) number of wet nights in 15 days: A: 9.1 (4.1) B: 11.2 (3.8) C: 10.9 (3.3)
Interventions A (10): imipramine - dose depended on age
B (9): clomipramine
C (10): alarm
Duration of treatment: 8 weeks
Follow up: none
Outcomes Mean (SD) frequency of wetting during final two weeks of treatment
A: 4.1 (2.6) B: 6.6 (5.5) C: 2.8 (4.3)
Notes Turkish language
No significant difference between groups in terms of age or IQ
Not blinded
Unclear if intention to treat
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
Nawaz 2002
Methods RCT (random allocation to groups following matching on age and sex)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: community health centres in Glasgow, Scotland
Participants No. of children (boys): 36 (18)
Dropouts: 0
Incl: Age 7-12 years, baseline wetting at least twice per months, attending mainstream school and willing
to be randomised
Excl: medical, physiological or psychiatric pathology, diurnal enuresis, encopresis
Previous treatment: some, but stopped during trial
Age: Mean 9.9 years (SD 1.83)
Baseline wetting: mean 5.67 per week (SD 1.26) for 4 weeks
50Alarm interventions for nocturnal enuresis in children (Review)
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Nawaz 2002 (Continued)
Interventions A (12): DBT + alarm
B (12): alarm only
C (12): untreated controls continued recording wet nights for 16 weeks, then offered treatment they
preferred
A + B also received standardised instructions (manual and videotape) and had 2 weekly telephone calls
Duration of treatment: 16 weeks or until 14 dry nights if earlier
Follow up: 6 months
Outcomes Wet nights per week during trial (final week): A: mean 0.83 (SD 1.40), B: 3.25 (2.67), C: 5 (2.26)
No. not achieving 14 dry nights: A: 4/12, B: 9/12, C: 11/12
No. relapsing after end of trial: A: 1, B: 1
Fail or relapse rate: A: 5/12, B: 10/12
Notes Groups comparable on age, sex, baseline wetting and DepCat (deprivation) scores
DBT described as: intensive first night, arousing child and taking him to toilet, accident contingencies
and normal routine
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Netley 1984
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: Hospital for Sick Children Enuresis Clinic, Toronto
Participants No. of children (boys): 62
No. of dropouts: 27
Incl: primary nocturnal enuresis, age 6-12 years
Ages: mean A: 9 years, B: 10.7
Interventions A (31): imipramine
B (31): Mozes detector (buzzer + electric shock to abdominal wall on wetting)
Duration of treatment unclear, ? till dry for 2 months
Outcomes Final outcome, after 2 dry months: A: 13/17 failed, B: 7/18 failed
Notes High dropout rate (44%)
Groups not comparable on age at baseline
Younger children (<8 years) apprehensive about detector
Authors conclude Mozes detector is suitable for children >8 years
51Alarm interventions for nocturnal enuresis in children (Review)
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Netley 1984 (Continued)
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Ng 2005
Methods RCT ’randomly allocated’ by consecutive sealed envelopes
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: Department of Pediatrics and Adolescent Medicine, Pamela Youde Nethersole Eastern Hospital,
Hong Kong SAR, China
Participants Number of children 105
Dropouts: 12 (defaulted from treatment: A7, B2, C3; defaulted from follow up A2, B2, C5)
Inclusion: primary nocturnal enuresis
Exclusion: UTI in previous 3 months, daytime wetting, polyuric disorders, abnormal urinalysis, renal
disease, previous diuretics, unwilling to be randomised
Previous treatment: none (excluded if had desmopressin, alarms or tricyclics)
Age: range 7-12 years
Baseline wetting: at least 3 wet nights in baseline 2 weeks
Interventions A (35): alarm only (’Wet-Stop’ alarm)
B (38): oral desmopressin 200 µg, increased to 400 µg if > 1 wet night
C (32): both treatments
Duration of treatment: 12 weeks
Follow up: 12 weeks
Outcomes Wet nights during trial (N, mean (SD)): A: 28, 2.8 (2.2), B: 36, 2.6 (2.4), C: 29, 1.3 (1.9)
Not achieving 14 dry nights: A: 27/35, B: 22/38, C: 12/32 (ITT, dropouts = failure)
Wet nights after trial (N, mean (SD)): A: 24, 2.5 (2.4), B: 34, 3.4 (2.5), C: 24, 2.6 (2.7)
Not achieving 14 dry nights or relapsing after: A: 25/35, B: 30/38, C: 19/32 (ITT, dropouts = failure)
Adverse effects: none
All children who responded completely to the alarm stayed dry afterwards
Notes All children had star charts and kept wetting diaries
Comparable at baseline on wetting frequency, age, gender, urine osmolality
More children failed to comply in Group A (alarm only), these were included as failures in the dry night
analyses
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
52Alarm interventions for nocturnal enuresis in children (Review)
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Rodriguez 2001
Methods RCT (method not specified)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: Hospital clinic, Spain
Participants No. of children: 84 (80% boys)
3 dropouts after 3 months
Incl: wetting at least 1x/week, age >7 years
Excl: diurnal enuresis, encopresis, neurological abnormalities
Previous treatment: 38% of children
Age range 7-14 years
Interventions A (30): bed alarm
B (29): alarm + desmopressin 20 µg or 40 µg for more frequent wetters (>2x/week)
Duration of treatment: 4-6 months
Outcomes Response: A: 73.3%; B: 58.6%
[=no. not achieving 14 dry nights: A: 8/30; B: 12/29]
All children treated with desmopressin if not cured at 6 months, therefore follow up not possible
Side effects: not reported
Notes Spanish language
No follow up
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Ronen 1992
Methods RCT (assigned chronologically in order of application)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting: Not mentioned
Setting: children attending a community mental health clinic
Participants No. of children (boys): 77 (39)
Dropouts: 23 (A, 2; B, 4; C, 6; D, 11)
Incl: primary enuresis
Excl: medical or developmental problems; age <5 years
Age: mean 10.05 years (SD 2.28)
Baseline wetting: mean wet nights in 3 week (SD): A, 19.8 (1.73); B, 19.8 (2.14); C, 18.9 (2.21); D, 18
(8.72)
53Alarm interventions for nocturnal enuresis in children (Review)
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Ronen 1992 (Continued)
Interventions A (20): Cognitive + behavioural self-control education therapy counselling
B (19): enuresis alarm (bell and pad)
C (20): token economy (star chart + rewards)
D (18): control (waiting list for 3 months)
Duration of treatment: 18 weeks
Follow up: at 6 months
Outcomes Cured (3 consecutive dry weeks): A, 15/20; B, 12/19; C, 6/20; D, 0/18
Failed (intention to treat, including dropouts as failures): A, 5/20; B, 7/19; C, 14/20; D, 18/18
No. of wet nights in 3 weeks at end of treatment: A, (18 children) mean 1.03, (SD2.15); B, (15) 1.23 (5.
28); C, (14) 3.33 (5.8); D, (16) 17.22 (9)
Actual failure or relapse after 6 months (excluding dropouts): A, 3/18; B, 9/15; C, 8/14
Adverse events: not mentioned
Notes A (cognitive treatment) had lowest dropout, highest success and lowest relapse compared with B, C or D
Risk of bias
Item Authors’ judgement Description
Allocation concealment? No C - Inadequate
Sacks 1974
Methods RCT (random but disproportionate allocation)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children: 83 (from previous study)
Excl: severe psychosis or organic causes
Ages: 5.5 to 14 years
Interventions A (64): conditioning (? alarm)
B (10): psychotherapy, counselling (12 weekly 40 min sessions + 20 min with mother)
C (9): Control
Duration of treatment: B 12 weeks
Outcomes No. not achieving 14 dry nights: A: 13/64, B: 8/10, C: 7/9
Notes Control group was older and had fewer boys
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
54Alarm interventions for nocturnal enuresis in children (Review)
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Scholander 1968
Methods RCT (double-blind)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children (boys): 30 (23)
No dropouts
Previous treatment: all had received imipramine, amitriptyline or nortriptyline
Age range 7 to 17 years
Severity of wetting at baseline: wet bed between 2 and twelve times a week
Interventions Third week:
A (15): enuresis alarm + placebo
B (15): enuresis alarm + nortrityline 25-50 mg
Duration of treatment: 5 weeks
FU after 6 to 12 months
Outcomes Number with no wet nights in third week (during drug/placebo treatment):
A: 3/15
B: 0/15
Number with no wet nights in fifth week (after drug/placebo treatment):
A: 6/15
B: 9/15
Side effects: 1 child frightened of the mattress, ’a few’ children on nortrityline had dry mouth or troubled
sleep
Notes Swedish language
No details of inclusion\exclusion criteria
Groups comparable in age and frequency of wet nights
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Sloop 1973
Methods Initially RCT
Subjects paired on IQ, sex, age and number of wet nights during baseline then one from each pair randomly
allocated to conditions
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Setting: residential training centres for learning disabled children
Participants No. of children: 42 (boys: A: 11 B: 11)
Excl: epileptics; severe behaviour problems; encopretics;
55Alarm interventions for nocturnal enuresis in children (Review)
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Sloop 1973 (Continued)
residents in beds with side rails which prevent them arising; residents on nightly tranquilising medications;
measured IQ below 20; not wetting bed at least once during baseline
Previous treatment: none
Mean age: A: 13 years, B: 12 (range 7 to 18)
Baseline wetting: mean number of wet nights: Boys: A: 4.18 B: 4 Girls: A: 3.64 B: 3.54
Interventions A (21): enuresis alarm
B (21): control - usual “potting” procedure - taken to the toilet twice a night
Duration of treatment: 11 weeks
Outcomes Number of wet nights in 7 weeks (boys, n=11) A: 46 B: 108
No significant difference for girls (no data)
Number (%) dry: A: 11/21 (52) B: 1/21 (5)
Number relapsed: A: 4/11 B: 0/1
Notes Males and females analysed separately
Not clear if intention to treat
One pair of boys switched after 3 nights of treatment
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Sukhai 1989 #
Methods RCT (double blind randomised cross-over with 2 weeks washout)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Participants No. of children: 28 (21 boys)
Dropouts: none
Incl: Normal urine concentration capacity of 800 mosmol/kg or higher; 3 or more wet nights per week
during observation period; informed parental consent; no urological or renal disorder; no history of
daytime wetting; no chronic urinary tract infection; no neurological or cardiovascular disease
Mean age: 11 years (range 7 to 16)
Previous treatment: 19 had previous attempts at treatment, including alarm (n=9) and tricyclic antide-
pressants (n=10)
Severity at baseline: mean (SEM) number of dry nights per week = 1.4 (0.3)
Interventions A: (28) enuresis alarm and bedtime dose of 20 µg DDAVP (desmopressin)
B: (28) enuresis alarm and bedtime dose of placebo
2 week washout period
Duration of treatment: 2 weeks in each arm
Follow up: 4 weeks to 6 months
56Alarm interventions for nocturnal enuresis in children (Review)
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Sukhai 1989 # (Continued)
Outcomes Mean (SEM) DRY nights during treatment: A: 5.1 (0.4) B: 4.1 (0.4)
6wk follow up: 14 dry, 5 relapsed
4.5 month follow up: 9 remained dry
Side effects: none reported
Mean urine osmolality significantly increased from baseline
Significantly higher urine osmolality with DDAVP than placebo
Steady significant increase in body weight
Notes Very good study
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
Taylor 1975
Methods CCT - sequential allocation
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: No
Participants No. of children (boys): 82 (68)
No. of dropouts unclear because some replaced by next admission to enuresis clinic
Incl: aged between 4-16; parents saw enuresis as a problem; no relevant organic pathology
Previous treatment: no details
Age range 4 to 15 years: mean boys = 8.8; mean girls = 9.3
Daytime wetting: 16 children
Baseline wetting: no details
Severity of wetting at baseline: no details
number of dropouts unclear because some subjects replaced by next admission to enuresis clinic
Interventions A (21): continuous alarm - bed alarm triggered as soon as bed wet
B (18): alarm + intermittent reinforcement schedule - continuous alarm for 14 days then parents told
to switch alarm off whenever indicated by reinforcement schedule (50% of the time). Child unaware of
reinforcement schedule
C (22): alarm + overlearning - when patient achieved 7 consecutive dry nights, fluid intake increased by
1-2 pints prior to going to bed. This regime continued until success criterion achieved
Duration of treatment: Until success criterion met ie no more than 1 wetting incidence in 28 days
Follow up: after 3 m
Outcomes Number (%) achieving no more than one wetting incidence in 28 days: A: 13/21 (62) B: 9/18 (50) C:
13/22 (59)
Chi sq = 0.6 df = 2 not significant.
Number (%) of successes who relapsed A: 9/13 (69) B: 4/9 (44) C: 3/13 (23)
Chi sq = 5.6 df = 2 P=0.001
57Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Taylor 1975 (Continued)
Notes Results from 61 participants analysed
Number of subjects at any given stage unclear
Probably atypical population due to referral process.
Comparability of groups at baseline not reported
Not intention to treat
No details of previous treatment
Includes children with diurnal wetting (n=6), encopresis (n=10) and both (n=6)
Over-learning is initiated after successful alarm treatment (eg achievement of 14 consecutive dry nights).
Extra drinks are given at bed-time to cause additional stress to the detrusor muscles in the bladder. Alarm
treatment is then continued until 14 consecutive dry nights are again achieved
Risk of bias
Item Authors’ judgement Description
Allocation concealment? No C - Inadequate
Tobias 2001
Methods RCT (random numbers table)
Systematic baseline measure of wetting: No
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: urban paediatric medical centre
Participants No. of children (boys): 54 (33)
No. of dropouts: 7 lost to follow up or did not comply with treatment
Inclusion: primary or secondary enuresis, 3 wet nights of 7, age 6 to 12 years
Exclusion: Daytime wetting, chronic illness, UTI, urinary tract pathology
Previous treatment: yes but children asked to stop these while in trial
Age: mean 8.6 years (SD 1.9)
Interventions A (23): body worn audio alarm
B(24): body worn vibrating alarm
Duration of treatment: 90 nights or until 14 dry nights achieved
Follow up: none
Outcomes No. not achieving 14 dry nights: A: 10/23, B: 14/24
Adverse events: some children did not wake, some were upset when woken, false alarm
Vibrating alarm was reported to be more uncomfortable than the audio alarm
Notes All children used star charts to record wet and dry nights but rewards for dry nights were not mentioned
Risk of bias
Item Authors’ judgement Description
58Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Tobias 2001 (Continued)
Allocation concealment? Unclear B - Unclear
Turner 1970
Methods RCT (stratified by age (4-7 and 7-15) and sex (12:8 M:F))
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting: Not mentioned
Participants No. of children (boys): 115 (80)
Dropouts: 39 of 81 allocated to an alarm (A, B or C), due to failure to use equipment properly, disruption
or domestic problems. 1/32 from D or E
Incl: primary (103) and secondary (12) enuresis
Excl: organic pathology; adverse home conditions; bedwetting <3x/week; previous alarm treatment
Age: mean 7.5 years (SD 2.6)
Interventions A: (15) alarm, continuous signal
B: (15) alarm, twin signal
C: (12) Alarm, intermittent twin signal (after first 2 wks, alarm sometimes disconnected)
D: (15) random wakening
E: (17) Placebo tablet
Duration: 4 weeks for D and E only: if no success, withdrawn from study for alternative treatment)
Mean duration: A, 6.8 wk; B, 6.2 wk; C, 10.2 wks
Outcomes Failed at 4 weeks: A, 12/15; B, 13/15; D, 14/15; E, 13/17
Mean wet nights per week at 4 wks: A, 2.9 (SD 2.27); B, 3.58 (2.07); D, 3.23 (2.09); E, 4.22 (2.37)
Failure at end of treatment: A, 3/15; B, 4/15; C, 1/12
Longterm failure at 3 yrs: A+B combined, 13/20; C, 3/11
Adverse events: non-compliance, failure or family disruption caused high dropout rate
Notes Dropouts replaced by next child referred to the clinic. Some failures treated with methedrine. Trial unable
to reach required sample size of 20 children per group during 5 year recruitment period
Therefore unreliable trial and data not useable
Adverse events caused high dropout rate in alarm groups due to inability to use the equipment or family
disruption or strife
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
59Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
van Londen 1993
Methods RCT (sequential random allocation in order of contact)
Systematic baseline measure of wetting: No
Organic causes excluded: No
Daytime wetting excluded: Not mentioned
Setting: parents who contacted an alarm rental agency, Utrecht, Holland
Participants No. of children (boys): 127 (89)
No. of dropouts: 14 (A:3, B:2, C:9)
Incl: Primary (110) or secondary (17) enuresis
Ages: mean 8.6 y (range 6-12)
Interventions A (38): alarm + reward stickers for correct behaviour at the time (’arousal therapy’ = turning off alarm in
3 mins, going to bathroom to empty bladder, resetting alarm)
B (39): alarm + reward stickers in morning for dry bed and penalty (1 sticker) for wet bed
C (36): alarm only
Duration of treatment: 20 weeks
FU at two and a half years
Outcomes No. not achieving 14 dry nights during trial: A:1/38, B:6/39, C:10/36
Failure + relapse rate during FU period: A: 11/38, B:21/39, C:10/36
Final failure + relapse rate at FU *: A:1/38, B:2/39, C:4/36
* but children who failed or relapsed received further treatment (repeat of trial arm, other alarm method,
desmopressin, imipramine, homeopathy, hospital referral, reduced drinking, regular ’wake-up’ alarm clock,
chiropractic, iriscopist, acupuncture, supervised child care) more often in B+C than A
Notes Groups comparable at baseline on age, gender, diagnosis and frequency of wetting
’Arousal therapy’ described as ’bibliotherapy’ beacuse parents received their instructions in written form
Risk of bias
Item Authors’ judgement Description
Allocation concealment? No C - Inadequate
Wagner 1982
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Setting: referrals from paediatric cinics, doctors, schools and newspaper advertisements
Participants No. of children (boys): 49 (40)
Dropouts: 13
Incl: age 6-16 years, IQ >70, primary nocturnal enuresis
Excl: daytime wetting, physical or neurological disorders, treatment with drugs or alarms in previous year
Ages: 6-16
Baseline wetting: min 3x/week, A: 75%, B: 77%, C: 64%
60Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wagner 1982 (Continued)
Interventions A (12): alarm (pad-and-bell /buzzer)
B (12): imipramine (if <32 kg, 25 mg/day, if >32 kg, 50 mg/day)
C (12): waiting list
Duration of treatment: 14 week or until dry for 14 nights
FU: max 44 days
Outcomes Per cent wet nights in 14th week: A: 8.25%, B: 39.25%, C: 60.83% (A significantly better than B or C)
No. not achieving 14 dry nights: A:2/12, B:8/12, C:11/12
No. not achieving 14 dry nights or relapsing: A: 7/12, B: 12/12, C:12/12
Time from cure to relapse: A: 37.8 days (range 25-44), B: 17 (3-27)
Notes Groups comparable on baseline wetting
No SDs or means
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Wagner 1985
Methods CCT (alternate allocation to groups)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children (boys): 39 (20)
No dropouts
Incl: between 5 and 16 years old; IQs not less than 70; no physical or neurologic disorders as assessed by
the child’s physician; wet the bed at least 3 nights a week before treatment; not had conditioning treatment
for at least a year; agreed to random assignment
Previous treatment: No details
Mean age: 7.9 years (range: 5 to 14)
Severity at baseline: % wet nights per week: A: 80 B: 83 C: 90
Interventions A (13): contiguous enuresis alarm
B (13): delayed response enuresis alarm - 3 second delay
C (13): waiting list control
Duration of treatment: 12 weeks
Follow up: after 6 months
Outcomes Percentage of wet nights per week in week 12
A: 5.38 B: 20.67 C: 72.90
Number achieving 14 consecutive dry nights:
A: 8 B: 7 C: 1
Number relapsing
A: 2/8 B: 5/7 C: 1/1
61Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wagner 1985 (Continued)
Malfunction significantly greater problem for delayed alarm as compared with contiguous model
Notes Clinicians blind to specific purpose of the study
CCT rather than RCT
No significant differences in groups in terms of age, sex, recruitment source, psychological measures,
baseline wetting frequencies
No SDs or means
Contiguous alarm sounds as soon as wetting occurs
Delayed alarm sounds after a 3 second delay
Risk of bias
Item Authors’ judgement Description
Allocation concealment? No C - Inadequate
Werry 1965
Methods RCT (initial allocation by random numbers, in second half of trial stratified by age and sex)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: not mentioned
Setting: enuresis clinic, Paediatric Hospital, Montreal, Canada
Participants No. of children (boys): 70 (46)
No. of dropouts: 10 (A:1, B:4, C:5)
Incl: primary enuresis
Excl: dry more than 3 months, organic causes
Ages: mean 9.99 years (SD 2.5)
Baseline wetting: min 1 x/week (mean 5-6 x/week)
Interventions A (27): Control (no treatment for 4 m)
B (21): brief psychotherapy (6-8 sessions over 3 months)
C (22): alarms (bed buzzer) once per night
Duration of treatment: 3-4 months
Follow up: none
Outcomes Failure to achieve 14 dry nights (defined as no wet beds in preceding month): A: 26/27, B:19/21, C:15/
21
(C significantly better than A or B)
C (alarm) most economic as required least professional input
Notes Groups comparable on age, class, wetting severity and psychopathology
Majority of enuretic children were not emotionally disturbed (compared with, and found similar to, non-
enuretic siblings)
Risk of bias
62Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Werry 1965 (Continued)
Item Authors’ judgement Description
Allocation concealment? No C - Inadequate
Wille 1986
Methods RCT
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Yes
Distribution of social class of parents in 2 groups was similar
Dropouts not included in analysis
Participants No. of children: 50
Incl: age over 6 years; not dry for more than 6 months (= ’primary enuresis’); at least 3 wet nights per
week at baseline; written informed parental consent
Excl: treatment for enuresis during previous year; daytime wetting; cardiovascular disease; renal disorder;
neurological disease; urinary tract infection
Age: over 6 years
Baseline wetting: mean number of dry nights per week: A:2.1, B:1.9
Number completing treatment: A:24, B:22
Interventions A (25): intranasal desmopressin (20 µg)
B (25): enuresis alarm
Duration of treatment: 3 months
Failures crossed over to alternative, relapses continued on same treatment
Outcomes Mean (SEM) number of dry nights per week
In first week of treatment: A: 4.5 (0.4), B: 2.4 (0.4)
In 14th week: A: 4.9 (0.4), B: 5.9 (0.4)
No. failing during treatment (>5 wet nights in 28 or no change in enuresis score): A: 7/24, B: 3/22
A: 10 relapses given 3 months more desmopressin treatment. Successful for 7/10 but 4/7 relapsed imme-
diately and 1/7 after 2 months
B: 1 relapsed and further alarm treatment unsuccessful
No. not cured after treatment (failed or relapsed): A: 16/24, B: 4/22
Mean (SEM) dry nights after trial: A: 3.5 (0.4), B: 5.7 (0.4)
Side effects: A: nasal discomfort (5); nose bleeds (1); bad taste in throat (2); B: false alarms (21); alarm
did not go off (5); alarm did not wake child (15); other family members woken (15); child frightened by
alarm (1).
Lab tests: urine osmolality and density higher during treatment with desmopressin and urine osmolality
in alarm group lower during treatment than before
Notes Direct comparison of desmopressin and alarm
Results estimated from graph
Cure/relapse rates based on less strict definition of cure than usual
Risk of bias
63Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wille 1986 (Continued)
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Wright 1974
Methods RCT
Medications on double blind basis
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: Not mentioned
Participants No. of children: 23
Dropouts: A: 0 B: 0 C: 2 D: 0
Age range 4 to 10 years
Baseline wetting: mean number of wettings per week: A + B: 4.9 C: 3.0 D: 6.6
Interventions A (3): amphetamine sulphate (2.5mg)
B (5): ephedrine sulphate (75mg) + atropine sulphate (Enuretrol, 1.15mg)
C (5): placebo twice daily
D (10): enuresis alarm
Duration of treatment: 5 weeks
Follow up: after 4 weeks
Outcomes Mean number of wet nights in final week of treatment
A+ B: 4.1 C: 3.5 D: 1.7
Notes Groups seem very different at baseline
More likely to detect more wettings per night in pad and bell group
All active drugs groups combined
No details of inclusion\exclusion criteria
Data estimated from graph
No SDs
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
64Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Young 1972
Methods RCT (children chosen at random from children cured on alarm treatment)
Systematic baseline measure of wetting: Yes
Organic causes excluded: Yes
Daytime wetting excluded: not mentioned
Setting: Local authority enuresis clinic, UK
Participants No. of children (boys): 144 (99)
Dropouts: A:6 B:37
Incl: primary and secondary nocturnal enuresis, age >4 years, already cured using alarm treatment
Ages: 4-15 years
Baseline wetting: min 2 wet nights per week before cure
Interventions A (61): alarm + overlearning
B (83): alarm alone (already cured)
Duration of treatment: 3 months or until relapse or cured again
Follow up: at 3 + 6 months, then 6-monthly till 2 years
Outcomes No. relapsing (failing to remain dry or regain dryness): A:7/55, B: 16/46
Notes A further 6 were withdrawn from A due to severe recurrence of enuresis with overlearning, but they then
regained dryness
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
A = Alarm; Alarm = enuresis alarm triggered by wetting; cc = cubic centilitres; CCT = controlled clinical trial with quasi-randomised
method of allocation; Clock Alarm = clock set to ring at specified time after going to bed irrespective of wetting; CT = Cleanliness
Training (changing the bed); dB = decibels (measure of volume); DBT = Dry Bed Training (training night, CT, PP and W); Excl =
Exclusion criteria; FSHT = Full Spectrum Home Training (A + CT + Overlearning + Retention Control Training; Incl = Inclusion
criteria; IQ = intelligence quotient; No. = number; Overlearning = giving extra fluids at bedtime to child already cured using alarm
treatment; PP = Positive Practice (practising getting up and voiding repeatedly); Random Wakening = wakening the child to urinate
at random times; RCT = randomised controlled trial; Retention Control Training = increasing fluid intake and delaying urination
for increasing periods of time to expand bladder capacity; SD = Standard Deviation; SEM = standard error of the mean; Stream
interruption exercises = practising interruption of urination; UTI = urinary tract infection; Volume Alarm = alarm triggered by
ultrasound measurement of bladder volume, triggered at prespecified volume before wetting occurs; W = Waking (waking child to
void, earlier on subsequent nights if dry).
65Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Azrin 1973 Excluded because participants were adults, and no useable data provided.
RCT: Yes
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: Yes
Systematic outcome measure: Yes
Intervention: Alarms, dry bed training in adults with severe learning difficulties in a state hospital
Bollard 1977 RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measure: Yes
Intervention: Dry bed training
Bollard 1982b RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: Yes
Systematic outcome measure: Yes
Intervention: Dry bed training with and without alarm + control group
Butler 2001 RCT: No
Comparison group: No
Intervention: Withdrawal from desmopressin or imipramine treatment, use of alarms optional
Collins 1973 RCT: No
Comparison group: Yes
Organic causes excluded: No
Systematic baseline measurement of wetting: No
Systematic outcome measure: Yes
Intervention: Pad-and-bell alarm, delayed alarm and no-treatment control group
Crisp 1984 RCT: Yes
Comparison group: Yes
Systematic Baseline: No
Systematic outcome measure: No
Organic causes excluded: No
Intervention: Alarms vs wire mesh in adults
de Leon 1966 RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: Yes
Systematic outcome measures: Yes
Interventions: Alarm (pad and buzzer), psychotherapy (counselling), no treatment control
66Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
Finley 1982 RCT: No
Comparison group: Yes
Organic causes excluded: No
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Varying alarm schedules
Fordham 1989 RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: Yes
Systematic outcome measures: Yes
Interventions: Alarms (bed based bell and pad, pants based sensor and mini-alarm)
Forsyth 1970 RCT: No
Comparison group: No
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms
Freyman 1963 RCT: No
Comparison group: No
Organic causes excluded: No
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms
Gillison 1958 RCT: No
Comparison group: No
Organic causes excluded: No
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms
Goel 1984 RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: No
Interventions: Alarms
Halliday 1987 RCT: Yes
Comparison group: Yes
Interventions: Pants alarm for daytime enuresis
Hansen 1995 RCT: No
Comparison group: No
Organic causes excluded: No
67Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms (pad and bell)
Hanson 1988 RCT: Yes but population young adults (age 13-29) with learning difficulties in residential centre
Comparison group: Yes
Organic causes excluded: No
Systematic baseline measurement of wetting: Yes
Systematic outcome measures: Yes
Interventions: Alarms, DBT, yoked awakening, rewards
Kahane 1955 RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline: No
Systematic outcome measure: Yes
Intervention: Alarms
Kaplan 1988 RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms, dry bed training, motivation
Kooijman 1986 RCT: No
Comparison group: Yes (from another study)
Organic causes excluded: No
Systematic baseline: No
Systematic outcome measure: Yes
Intervention: Alarms with and without parental supervision
Kyneb 1975 RCT: No
Comparison group: No
Organic causes excluded: Yes
Systematic baseline: No
Systematic outcome measure: Yes
Intervention: Alarms
Lovibond 1964d RCT: No
Comparison group: No
Organic causes excluded: Yes
Systematic baseline: No
Systematic outcome measure: Yes
Intervention: Twin Signal alarm
McConaghy 1969 RCT: Yes
Comparison group: Yes
Organic causes excluded: No
68Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
Systematic baseline: No
Systematic outcome measure: Yes
Interventions: Imipramine, amphetamine, alarms, behavioural method
Excluded because children moved between trial arms, data therefore unreliable
Monda 1995 RCT: No
Comparson group: Yes
Organic causes excluded: Yes
Systematic baseline: No
Systematic outcome measures: Yes
Intervention: desmopressin, imipramine, alarms
Peterson 1969 RCT: No (unclear method, close group matching)
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline: Yes
Systematic outcome measure: Yes
Interventions: Alarms (no delay, delay)
Philpott 1970 RCT: No
Comparison group: No
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Imipramine, alarms
Said 1991 RCT: No
Comparison group: No
Systematic baseline: Yes
Organic causes excluded: Yes
Intervention: Alarms, overlearning
Shulz 1978 RCT: No
Comparison group: yes
Systematic baseline: no
Organic causes excluded: yes
Systematic outcome measure: yes
Intervention: DBT, alarms
Taylor 1963 RCT: No
Comparison group: No
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms
Wickes 1958 RCT: No
Comparison group: No
Organic causes excluded: Yes
69Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Alarms
Young 1965 RCT: No
Comparison group: Yes
Organic causes excluded: Yes
Systematic baseline measurement of wetting: No
Systematic outcome measures: Yes
Interventions: Central nervous system stimulants and conditioning (alarms)
DBT = Dry Bed Training (complex behavioural intervention)
Characteristics of ongoing studies [ordered by study ID]
Bryant 2002
Trial name or title Randomised trial of bladder training versus enuresis alarm versus combined bladder training/enuresis alarm
in children with nocturnal enuresis
Methods
Participants 106 children with nocturnal enuresis
Interventions Bladder training, alarms
Outcomes
Starting date 1st July 2001
Contact information Charmaine Bryant, Prince of Wales Hospital Sydney
Notes Recruitment finishes 30th June 2002
70Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
D A T A A N D A N A L Y S E S
Comparison 1. ALARM vs CONTROL
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Mean number of wet nights per
week
4 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 alarm vs control 4 109 Mean Difference (IV, Fixed, 95% CI) -3.34 [-4.14, -2.55]
1.2 delayed alarm vs control 1 36 Mean Difference (IV, Fixed, 95% CI) 0.13 [-1.16, 1.42]
2 Mean number of wet nights per
week (no SDs)
Other data No numeric data
2.1 Alarm vs control Other data No numeric data
2.2 delayed alarm vs control Other data No numeric data
2.3 unsupervised alarm vs
control
Other data No numeric data
3 Number not achieving 14
consecutive dry nights
16 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 alarm vs control 14 576 Risk Ratio (M-H, Fixed, 95% CI) 0.39 [0.33, 0.45]
3.2 delayed alarm vs control 2 62 Risk Ratio (M-H, Fixed, 95% CI) 0.77 [0.62, 0.96]
3.3 unsupervised alarm vs
control
1 30 Risk Ratio (M-H, Fixed, 95% CI) 0.42 [0.23, 0.76]
3.4 electric stimulation alarm
(Uristop) vs control
1 62 Risk Ratio (M-H, Fixed, 95% CI) 0.87 [0.47, 1.59]
3.5 functioning electric
stimulation alarm (Uristop) vs
non-functioning alarm
1 53 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
4 Numbers not achieving 14 dry
nights or relapsing
5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4.1 alarm vs control 5 162 Risk Ratio (M-H, Fixed, 95% CI) 0.57 [0.47, 0.70]
4.2 delayed alarm vs control 1 26 Risk Ratio (M-H, Fixed, 95% CI) 0.85 [0.65, 1.11]
4.3 unsupervised alarm vs
control
1 30 Risk Ratio (M-H, Fixed, 95% CI) 0.74 [0.54, 1.02]
Comparison 2. COMPARING ALARMS
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Mean number of wet nights per
week
1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
1.1 immediate alarm vs
delayed alarm
1 Mean Difference (IV, Fixed, 95% CI) Not estimable
2 Mean number of wet nights per
week (no SDs)
Other data No numeric data
2.1 bed alarm vs body alarm Other data No numeric data
71Alarm interventions for nocturnal enuresis in children (Review)
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2.2 immediate alarm vs
delayed alarm
Other data No numeric data
2.3 supervised alarm vs
unsupervised alarm
Other data No numeric data
2.4 loud alarm vs quiet alarm Other data No numeric data
2.5 alarm with 105 dB bell +
light vs alarm with 78 dB bell
in parents’ room
Other data No numeric data
2.6 alarm with intermittent
80 dB bell vs alarm with 78 dB
bell in parents’ room
Other data No numeric data
3 Numbers not achieving 14 dry
nights
10 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 bed alarm vs body alarm 1 40 Risk Ratio (M-H, Fixed, 95% CI) 1.0 [0.39, 2.58]
3.2 continuous alarm vs
intermittent alarm
1 39 Risk Ratio (M-H, Fixed, 95% CI) 0.76 [0.37, 1.56]
3.3 immediate alarm vs
delayed alarm
2 62 Risk Ratio (M-H, Fixed, 95% CI) 0.70 [0.48, 1.01]
3.4 supervised alarm vs
unsupervised alarm
1 30 Risk Ratio (M-H, Fixed, 95% CI) 0.5 [0.15, 1.64]
3.5 loud alarm vs quiet alarm 2 40 Risk Ratio (M-H, Fixed, 95% CI) 0.5 [0.19, 1.33]
3.6 alarm with 105 dB bell +
light vs alarm with 78 dB bell
in parents’ room
1 20 Risk Ratio (M-H, Fixed, 95% CI) 0.14 [0.03, 0.64]
3.7 alarm with intermittent
80 dB bell vs alarm with 78 dB
bell in parents’ room
1 20 Risk Ratio (M-H, Fixed, 95% CI) 0.24 [0.08, 0.71]
3.8 normal alarm vs twin
signal alarm
2 48 Risk Ratio (M-H, Fixed, 95% CI) 4.0 [0.48, 33.42]
3.9 normal alarm vs electric
stimulation (Crosby Dri-nite)
alarm
1 24 Risk Ratio (M-H, Fixed, 95% CI) 1.0 [0.07, 14.21]
3.10 body worn audio alarm
vs body worn vibrating alarm
1 47 Risk Ratio (M-H, Fixed, 95% CI) 0.75 [0.42, 1.33]
4 Numbers not achieving 14 dry
nights or relapsing
8 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4.1 bed alarm vs body alarm 1 40 Risk Ratio (M-H, Fixed, 95% CI) 1.11 [0.58, 2.14]
4.2 continuous alarm vs
intermittent alarm
1 39 Risk Ratio (M-H, Fixed, 95% CI) 1.12 [0.79, 1.60]
4.3 immediate alarm vs
delayed alarm
1 26 Risk Ratio (M-H, Fixed, 95% CI) 0.64 [0.37, 1.11]
4.4 supervised alarm vs
unsupervised alarm
1 30 Risk Ratio (M-H, Fixed, 95% CI) 0.64 [0.34, 1.18]
4.5 loud alarm vs quiet alarm 2 40 Risk Ratio (M-H, Fixed, 95% CI) 1.1 [0.62, 1.96]
4.6 alarm with 105 dB bell +
light vs alarm with 78 dB bell
in parents’ room
1 20 Risk Ratio (M-H, Fixed, 95% CI) 0.52 [0.29, 0.96]
4.7 alarm with intermittent
80 dB bell vs alarm with 78 dB
bell in parents’ room
1 20 Risk Ratio (M-H, Fixed, 95% CI) 0.33 [0.14, 0.80]
72Alarm interventions for nocturnal enuresis in children (Review)
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4.8 normal alarm vs twin
signal alarm
2 48 Risk Ratio (M-H, Fixed, 95% CI) 1.1 [0.58, 2.09]
4.9 normal alarm vs electric
stimulation (Crosby Dri-nite)
alarm
1 24 Risk Ratio (M-H, Fixed, 95% CI) 0.83 [0.35, 2.00]
Comparison 3. ALARM vs BEHAVIOURAL INTERVENTIONS
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Mean number of wet nights per
week
2 Mean Difference (IV, Fixed, 95% CI) Totals not selected
1.1 alarm vs star chart +
rewards
1 Mean Difference (IV, Fixed, 95% CI) Not estimable
1.2 alarm vs stop-start training 1 Mean Difference (IV, Fixed, 95% CI) Not estimable
2 Mean number of wet nights per
week (no SDs)
Other data No numeric data
2.1 alarm vs random wakening Other data No numeric data
2.2 alarm vs star chart +
wake-up alarm clock
Other data No numeric data
2.4 alarm vs dry bed training
(no alarm)
Other data No numeric data
3 Numbers not achieving 14 dry
nights
5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 alarm vs star chart +
rewards
1 39 Risk Ratio (M-H, Fixed, 95% CI) 0.53 [0.27, 1.01]
3.2 alarm vs stop-start training 1 21 Risk Ratio (M-H, Fixed, 95% CI) 0.67 [0.35, 1.26]
3.3 alarm vs dry bed training
(no alarm)
3 108 Risk Ratio (M-H, Fixed, 95% CI) 1.33 [0.79, 2.24]
4 Mean number of wet nights at
follow-up
1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
4.1 alarm vs stop-start training 1 Mean Difference (IV, Fixed, 95% CI) Not estimable
5 Numbers not achieving 14 dry
nights or relapsing
3 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
5.1 alarm vs waking / lifting 1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
5.2 alarm vs star chart +
rewards
1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
5.3 alarm vs dry bed training
(no alarm)
1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
73Alarm interventions for nocturnal enuresis in children (Review)
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Comparison 4. ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Mean number of wet nights per
week
4 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 alarm vs alarm + retention
control training
2 40 Mean Difference (IV, Fixed, 95% CI) -0.04 [-0.70, 0.61]
1.2 alarm vs alarm + dry bed
training
2 43 Mean Difference (IV, Fixed, 95% CI) 1.00 [-0.20, 2.20]
2 Mean number of wet nights per
week (no SDs)
Other data No numeric data
2.1 unsupervised alarm vs
supervised
Other data No numeric data
2.2 alarm vs alarm + retention
control training
Other data No numeric data
2.3 alarm vs alarm + dry bed
training
Other data No numeric data
3 Number not achieving 14
consecutive dry nights
13 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 unsupervised alarm vs
supervised
1 30 Risk Ratio (M-H, Fixed, 95% CI) 2.0 [0.61, 6.55]
3.2 alarm vs alarm + retention
control training
5 122 Risk Ratio (M-H, Fixed, 95% CI) 0.39 [0.20, 0.77]
3.3 alarm vs alarm +
overlearning + retention
control training
1 25 Risk Ratio (M-H, Fixed, 95% CI) 0.81 [0.23, 2.91]
3.4 continuous alarm vs alarm
+ overlearning
1 43 Risk Ratio (M-H, Fixed, 95% CI) 0.93 [0.44, 1.95]
3.5 intermittent alarm vs
alarm + overlearning
1 40 Risk Ratio (M-H, Fixed, 95% CI) 1.22 [0.62, 2.42]
3.6 alarm vs alarm + dry bed
training
5 234 Risk Ratio (M-H, Fixed, 95% CI) 1.21 [0.82, 1.81]
3.7 alarm vs alarm + dry
bed training SENSITIVITY
ANALYSIS
4 186 Risk Ratio (M-H, Fixed, 95% CI) 1.67 [1.06, 2.62]
3.8 alarm vs alarm + reward
for correct behaviour at time of
wetting
1 74 Risk Ratio (M-H, Fixed, 95% CI) 10.56 [1.42, 78.34]
3.9 alarm vs alarm + reward
for dry bed, penalty for wet bed
1 75 Risk Ratio (M-H, Fixed, 95% CI) 1.81 [0.73, 4.46]
3.10 alarm + reward for
correct behaviour at time of
wetting vs alarm + reward for
dry bed, penalty for wet bed
1 77 Risk Ratio (M-H, Fixed, 95% CI) 0.17 [0.02, 1.35]
4 Numbers not achieving 14 dry
nights or relapsing
11 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4.1 unsupervised alarm vs
supervised
1 30 Risk Ratio (M-H, Fixed, 95% CI) 1.57 [0.84, 2.92]
74Alarm interventions for nocturnal enuresis in children (Review)
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4.2 alarm vs alarm + retention
control training
4 98 Risk Ratio (M-H, Fixed, 95% CI) 1.12 [0.77, 1.64]
4.3 alarm vs alarm +
overlearning + retention
control training
1 25 Risk Ratio (M-H, Fixed, 95% CI) 1.3 [0.53, 3.17]
4.4 continuous alarm vs alarm
+ overlearning
2 144 Risk Ratio (M-H, Fixed, 95% CI) 1.92 [1.27, 2.92]
4.5 intermittent alarm vs
alarm + overlearning
1 40 Risk Ratio (M-H, Fixed, 95% CI) 1.32 [0.82, 2.13]
4.6 alarm vs alarm + dry bed
training
3 152 Risk Ratio (M-H, Fixed, 95% CI) 1.29 [0.94, 1.77]
4.7 alarm vs alarm + dry
bed training SENSITIVITY
ANALYSIS
2 104 Risk Ratio (M-H, Fixed, 95% CI) 2.0 [1.25, 3.20]
4.8 alarm vs alarm + reward
for correct behaviour at time of
wetting
1 74 Risk Ratio (M-H, Fixed, 95% CI) 0.96 [0.46, 1.98]
4.9 alarm vs alarm + reward
for dry bed, penalty for wet bed
1 75 Risk Ratio (M-H, Fixed, 95% CI) 0.52 [0.28, 0.94]
4.10 alarm + reward for
correct behaviour at time of
wetting vs alarm + reward for
dry bed, penalty for wet bed
1 77 Risk Ratio (M-H, Fixed, 95% CI) 0.54 [0.30, 0.96]
5 Mean number of wet nights at
follow-up
1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
5.1 alarm vs alarm + dry bed
training
1 Mean Difference (IV, Fixed, 95% CI) Not estimable
Comparison 5. ALARM vs DRUGS
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Mean number of wet nights per
week
5 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 alarm vs imipramine 1 20 Mean Difference (IV, Fixed, 95% CI) -0.65 [-2.21, 0.91]
1.2 alarm vs clomipramine 1 19 Mean Difference (IV, Fixed, 95% CI) -1.9 [-4.14, 0.34]
1.3 alarm vs desmopressin
(first week)
1 46 Mean Difference (IV, Fixed, 95% CI) 2.10 [0.99, 3.21]
1.4 alarm vs desmopressin
(last week)
2 110 Mean Difference (IV, Fixed, 95% CI) -0.41 [-1.20, 0.38]
1.5 alarm vs alarm +
desmopressin
3 324 Mean Difference (IV, Fixed, 95% CI) 0.77 [0.44, 1.09]
2 Mean number of wet nights
per week (no SDs or crossover
trials)
Other data No numeric data
2.1 alarm vs placebo Other data No numeric data
2.2 alarm vs desmopressin Other data No numeric data
75Alarm interventions for nocturnal enuresis in children (Review)
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2.3 alarm vs alarm +
desmopressin
Other data No numeric data
2.4 alarm vs imipramine Other data No numeric data
2.5 alarm vs alarm +
imipramine
Other data No numeric data
2.6 alarm vs amphetamine
sulphate\Enetrol (ephedrine +
atropine)
Other data No numeric data
3 Numbers not achieving 14 dry
nights during treatment
13 Risk Ratio (M-H, Random, 95% CI) Subtotals only
3.1 alarm vs placebo 1 122 Risk Ratio (M-H, Random, 95% CI) 0.68 [0.48, 0.97]
3.2 alarm vs desmopressin 4 316 Risk Ratio (M-H, Random, 95% CI) 0.85 [0.53, 1.37]
3.3 alarm vs alarm +
desmopressin
4 393 Risk Ratio (M-H, Random, 95% CI) 1.32 [0.80, 2.16]
3.4 alarm vs imipramine 3 208 Risk Ratio (M-H, Random, 95% CI) 0.59 [0.32, 1.09]
3.6 alarm + placebo vs alarm +
nortriptyline
1 30 Risk Ratio (M-H, Random, 95% CI) 0.81 [0.61, 1.06]
3.7 alarm vs alarm +
methedrine
1 18 Risk Ratio (M-H, Random, 95% CI) 7.36 [0.45, 119.38]
3.8 alarm vs amphetamine 1 33 Risk Ratio (M-H, Random, 95% CI) 0.46 [0.23, 0.89]
4 Number of wet nights at
follow-up (no SDs)
Other data No numeric data
4.1 alarm vs placebo Other data No numeric data
4.2 alarm vs alarm +
desmopressin
Other data No numeric data
4.3 alarm vs imipramine Other data No numeric data
4.4 alarm vs amitriptyline Other data No numeric data
5 Number not achieving 14 dry
nights or relapsing
7 Risk Ratio (M-H, Random, 95% CI) Subtotals only
5.1 alarm vs desmopressin 2 119 Risk Ratio (M-H, Random, 95% CI) 0.53 [0.14, 2.06]
5.2 alarm vs alarm +
desmopressin
4 427 Risk Ratio (M-H, Random, 95% CI) 1.10 [0.92, 1.31]
5.3 alarm vs imipramine 1 24 Risk Ratio (M-H, Random, 95% CI) 0.6 [0.37, 0.97]
5.4 alarm + placebo vs alarm +
nortriptyline
1 30 Risk Ratio (M-H, Random, 95% CI) 1.5 [0.71, 3.16]
6 Mean number of wet nights at
follow-up
2 Mean Difference (IV, Random, 95% CI) Subtotals only
6.1 alarm vs desmopressin 2 104 Mean Difference (IV, Random, 95% CI) -1.59 [-2.86, -0.32]
6.2 alarm vs alarm +
desmopressin
1 48 Mean Difference (IV, Random, 95% CI) -0.10 [-1.55, 1.35]
76Alarm interventions for nocturnal enuresis in children (Review)
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Comparison 6. ALARM vs OTHER / MISCELLANEOUS TREATMENTS
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Mean number of wet nights per
week
1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
1.1 alarm vs cognitive therapy 1 Mean Difference (IV, Fixed, 95% CI) Not estimable
3 Numbers not achieving 14 dry
nights
4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 alarm vs restricted diet 1 150 Risk Ratio (M-H, Fixed, 95% CI) 0.70 [0.60, 0.82]
3.2 alarm vs cognitive therapy
/ psychotherapy
3 155 Risk Ratio (M-H, Fixed, 95% CI) 0.68 [0.52, 0.90]
4 Number not achieving 14 dry
nights or relapsing
1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
4.1 alarm vs cognitive therapy 1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
5 Mean number of wet nights per
week at follow up (no SDs)
Other data No numeric data
5.1 alarm vs shaming Other data No numeric data
Analysis 1.1. Comparison 1 ALARM vs CONTROL, Outcome 1 Mean number of wet nights per week.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 1 ALARM vs CONTROL
Outcome: 1 Mean number of wet nights per week
Study or subgroup alarm augmented alarmMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 alarm vs control
Bennett 1985 9 1 (1.95) 9 5.15 (1.5) 24.5 % -4.15 [ -5.76, -2.54 ]
Lynch 1984 18 1.69 (2.28) 18 4.06 (1.63) 37.8 % -2.37 [ -3.66, -1.08 ]
Nawaz 2002 12 3.25 (2.67) 12 5 (2.26) 16.2 % -1.75 [ -3.73, 0.23 ]
Ronen 1992 15 0.41 (1.76) 16 5.74 (3) 21.5 % -5.33 [ -7.05, -3.61 ]
Subtotal (95% CI) 54 55 100.0 % -3.34 [ -4.14, -2.55 ]
Heterogeneity: Chi2 = 10.76, df = 3 (P = 0.01); I2 =72%
Test for overall effect: Z = 8.23 (P < 0.00001)
2 delayed alarm vs control
Lynch 1984 18 4.19 (2.28) 18 4.06 (1.63) 100.0 % 0.13 [ -1.16, 1.42 ]
-10 -5 0 5 10
favours alarm favours control
(Continued . . . )
77Alarm interventions for nocturnal enuresis in children (Review)
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(. . . Continued)
Study or subgroup alarm augmented alarmMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Subtotal (95% CI) 18 18 100.0 % 0.13 [ -1.16, 1.42 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.20 (P = 0.84)
Test for subgroup differences: Chi2 = 20.04, df = 1 (P = 0.00), I2 =95%
-10 -5 0 5 10
favours alarm favours control
Analysis 1.2. Comparison 1 ALARM vs CONTROL, Outcome 2 Mean number of wet nights per week (no
SDs).
Mean number of wet nights per week (no SDs)
Study Alarm Control
Alarm vs control
Baker 1969 1.8 wet nights, n=10 5.9 wet nights, n=10
Bollard 1981a 0.8 wet nights, n=15 4.6 wet nights, n=15
Bollard 1981b 0.6 wet nights (n=20) 4.4 wet nights (n=20)
Jehu 1977 0.3 wet nights, n=19 5.3 wet nights, n=20
Wagner 1982 0.58 wet nights, n=12 4.26 wet nights, n=12
Wagner 1985 0.38 wet nights, n=13 5.1 wet nights, n=13
delayed alarm vs control
Wagner 1985 1.45 wet nights, n=13 5.10 wet nights, n=13
unsupervised alarm vs control
Bollard 1981a 2.2 wet nights, n=15 4.6 wet nights, n=15
78Alarm interventions for nocturnal enuresis in children (Review)
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Analysis 1.3. Comparison 1 ALARM vs CONTROL, Outcome 3 Number not achieving 14 consecutive dry
nights.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 1 ALARM vs CONTROL
Outcome: 3 Number not achieving 14 consecutive dry nights
Study or subgroup alarm control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 alarm vs control
Bennett 1985 5/9 9/9 0.58 [ 0.32, 1.03 ]
Bollard 1981a 3/15 15/15 0.23 [ 0.09, 0.57 ]
Bollard 1981b 4/20 18/20 0.22 [ 0.09, 0.54 ]
Houts 1986 3/12 11/11 0.28 [ 0.11, 0.69 ]
Jehu 1977 1/19 20/20 0.08 [ 0.02, 0.36 ]
Lynch 1984 11/18 18/18 0.62 [ 0.43, 0.90 ]
Moffatt 1987 19/61 54/55 0.32 [ 0.22, 0.46 ]
Nawaz 2002 9/12 11/12 0.82 [ 0.57, 1.18 ]
Ronen 1992 7/19 18/18 0.39 [ 0.22, 0.68 ]
Sacks 1974 13/64 7/9 0.26 [ 0.14, 0.47 ]
Sloop 1973 10/21 20/21 0.50 [ 0.32, 0.79 ]
Wagner 1982 2/12 11/12 0.18 [ 0.05, 0.65 ]
Wagner 1985 5/13 12/13 0.42 [ 0.21, 0.84 ]
Werry 1965 15/21 26/27 0.74 [ 0.56, 0.98 ]
Subtotal (95% CI) 316 260 0.39 [ 0.33, 0.45 ]
Total events: 107 (alarm), 250 (control)
Heterogeneity: Chi2 = 56.57, df = 13 (P<0.00001); I2 =77%
Test for overall effect: Z = 12.04 (P < 0.00001)
2 delayed alarm vs control
Lynch 1984 17/18 18/18 0.95 [ 0.81, 1.10 ]
Wagner 1985 6/13 12/13 0.50 [ 0.27, 0.92 ]
Subtotal (95% CI) 31 31 0.77 [ 0.62, 0.96 ]
Total events: 23 (alarm), 30 (control)
Heterogeneity: Chi2 = 9.04, df = 1 (P = 0.003); I2 =89%
Test for overall effect: Z = 2.35 (P = 0.019)
3 unsupervised alarm vs control
Bollard 1981a 6/15 15/15 0.42 [ 0.23, 0.76 ]
Subtotal (95% CI) 15 15 0.42 [ 0.23, 0.76 ]
0.001 0.01 0.1 1 10 100 1000
favours alarm favours control
(Continued . . . )
79Alarm interventions for nocturnal enuresis in children (Review)
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(. . . Continued)Study or subgroup alarm control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Total events: 6 (alarm), 15 (control)
Heterogeneity: not applicable
Test for overall effect: Z = 2.84 (P = 0.0045)
4 electric stimulation alarm (Uristop) vs control
Hojsgaard 1979 12/32 13/30 0.87 [ 0.47, 1.59 ]
Subtotal (95% CI) 32 30 0.87 [ 0.47, 1.59 ]
Total events: 12 (alarm), 13 (control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.47 (P = 0.64)
5 functioning electric stimulation alarm (Uristop) vs non-functioning alarm
Elinder 1985 0/36 0/17 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 36 17 0.0 [ 0.0, 0.0 ]
Total events: 0 (alarm), 0 (control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.001 0.01 0.1 1 10 100 1000
favours alarm favours control
80Alarm interventions for nocturnal enuresis in children (Review)
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Analysis 1.4. Comparison 1 ALARM vs CONTROL, Outcome 4 Numbers not achieving 14 dry nights or
relapsing.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 1 ALARM vs CONTROL
Outcome: 4 Numbers not achieving 14 dry nights or relapsing
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 alarm vs control
Bollard 1981a 7/15 15/15 18.9 % 0.48 [ 0.29, 0.82 ]
Bollard 1981b 10/20 20/20 25.0 % 0.51 [ 0.33, 0.79 ]
Sloop 1973 14/21 20/21 24.4 % 0.70 [ 0.51, 0.96 ]
Wagner 1982 7/12 12/12 15.2 % 0.60 [ 0.37, 0.97 ]
Wagner 1985 7/13 13/13 16.5 % 0.56 [ 0.34, 0.91 ]
Subtotal (95% CI) 81 81 100.0 % 0.57 [ 0.47, 0.70 ]
Total events: 45 (Treatment), 80 (Control)
Heterogeneity: Chi2 = 2.23, df = 4 (P = 0.69); I2 =0.0%
Test for overall effect: Z = 5.57 (P < 0.00001)
2 delayed alarm vs control
Wagner 1985 11/13 13/13 100.0 % 0.85 [ 0.65, 1.11 ]
Subtotal (95% CI) 13 13 100.0 % 0.85 [ 0.65, 1.11 ]
Total events: 11 (Treatment), 13 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.19 (P = 0.23)
3 unsupervised alarm vs control
Bollard 1981a 11/15 15/15 100.0 % 0.74 [ 0.54, 1.02 ]
Subtotal (95% CI) 15 15 100.0 % 0.74 [ 0.54, 1.02 ]
Total events: 11 (Treatment), 15 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.83 (P = 0.067)
0.2 0.5 1 2 5
favours alarm favours control
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Analysis 2.1. Comparison 2 COMPARING ALARMS, Outcome 1 Mean number of wet nights per week.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 2 COMPARING ALARMS
Outcome: 1 Mean number of wet nights per week
Study or subgroup alarm augmented alarmMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 immediate alarm vs delayed alarm
Lynch 1984 18 1.69 (2.28) 18 4.19 (2.28) -2.50 [ -3.99, -1.01 ]
-4 -2 0 2 4
favours alarm 1 favours alarm 2
Analysis 2.2. Comparison 2 COMPARING ALARMS, Outcome 2 Mean number of wet nights per week (no
SDs).
Mean number of wet nights per week (no SDs)
Study Alarm 1 Alarm 2
bed alarm vs body alarm
Butler 1990a 1.2 wet nights, n=17 1 wet night, n=18
immediate alarm vs delayed alarm
Wagner 1985 0.38 wet nights, n=13 1.45 wet nights, n=13
supervised alarm vs unsupervised alarm
Bollard 1981a 0.8 with supervised alarm, n=15 2.2 with unsupervised alarm, n=15
loud alarm vs quiet alarm
Finley 1973 0.2 wet nights, n=10 0.6 wet nights, n=10
alarm with 105 dB bell + light vs alarm with 78 dB bell in parents’ room
Finley 1973 0.2 wet episodes, n=10 8 wet episodes, n=10
alarm with intermittent 80 dB bell vs alarm with 78 dB bell in parents’ room
Finley 1973 0.6 wet episodes, n=10 8 wet episodes, n=10
82Alarm interventions for nocturnal enuresis in children (Review)
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Analysis 2.3. Comparison 2 COMPARING ALARMS, Outcome 3 Numbers not achieving 14 dry nights.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 2 COMPARING ALARMS
Outcome: 3 Numbers not achieving 14 dry nights
Study or subgroup alarm 1 alarm 2 Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 bed alarm vs body alarm
Butler 1990a 6/20 6/20 100.0 % 1.00 [ 0.39, 2.58 ]
Subtotal (95% CI) 20 20 100.0 % 1.00 [ 0.39, 2.58 ]
Total events: 6 (alarm 1), 6 (alarm 2)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P = 1.0)
2 continuous alarm vs intermittent alarm
Taylor 1975 8/21 9/18 100.0 % 0.76 [ 0.37, 1.56 ]
Subtotal (95% CI) 21 18 100.0 % 0.76 [ 0.37, 1.56 ]
Total events: 8 (alarm 1), 9 (alarm 2)
Heterogeneity: not applicable
Test for overall effect: Z = 0.75 (P = 0.46)
3 immediate alarm vs delayed alarm
Lynch 1984 11/18 17/18 73.9 % 0.65 [ 0.44, 0.95 ]
Wagner 1985 5/13 6/13 26.1 % 0.83 [ 0.34, 2.06 ]
Subtotal (95% CI) 31 31 100.0 % 0.70 [ 0.48, 1.01 ]
Total events: 16 (alarm 1), 23 (alarm 2)
Heterogeneity: Chi2 = 0.29, df = 1 (P = 0.59); I2 =0.0%
Test for overall effect: Z = 1.89 (P = 0.059)
4 supervised alarm vs unsupervised alarm
Bollard 1981a 3/15 6/15 100.0 % 0.50 [ 0.15, 1.64 ]
Subtotal (95% CI) 15 15 100.0 % 0.50 [ 0.15, 1.64 ]
Total events: 3 (alarm 1), 6 (alarm 2)
Heterogeneity: not applicable
Test for overall effect: Z = 1.14 (P = 0.25)
5 loud alarm vs quiet alarm
Finley 1973 1/10 2/10 25.0 % 0.50 [ 0.05, 4.67 ]
Finley 1977 3/10 6/10 75.0 % 0.50 [ 0.17, 1.46 ]
Subtotal (95% CI) 20 20 100.0 % 0.50 [ 0.19, 1.33 ]
Total events: 4 (alarm 1), 8 (alarm 2)
Heterogeneity: Chi2 = 0.0, df = 1 (P = 1.00); I2 =0.0%
Test for overall effect: Z = 1.39 (P = 0.17)
6 alarm with 105 dB bell + light vs alarm with 78 dB bell in parents’ room
Finley 1973 1/10 10/10 100.0 % 0.14 [ 0.03, 0.64 ]
0.01 0.1 1 10 100
favours alarm 1 favours alarm 2
(Continued . . . )
83Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(. . . Continued)Study or subgroup alarm 1 alarm 2 Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Subtotal (95% CI) 10 10 100.0 % 0.14 [ 0.03, 0.64 ]
Total events: 1 (alarm 1), 10 (alarm 2)
Heterogeneity: not applicable
Test for overall effect: Z = 2.55 (P = 0.011)
7 alarm with intermittent 80 dB bell vs alarm with 78 dB bell in parents’ room
Finley 1973 2/10 10/10 100.0 % 0.24 [ 0.08, 0.71 ]
Subtotal (95% CI) 10 10 100.0 % 0.24 [ 0.08, 0.71 ]
Total events: 2 (alarm 1), 10 (alarm 2)
Heterogeneity: not applicable
Test for overall effect: Z = 2.56 (P = 0.010)
8 normal alarm vs twin signal alarm
Lovibond 1964a 1/12 0/12 50.0 % 3.00 [ 0.13, 67.06 ]
Lovibond 1964c 2/12 0/12 50.0 % 5.00 [ 0.27, 94.34 ]
Subtotal (95% CI) 24 24 100.0 % 4.00 [ 0.48, 33.42 ]
Total events: 3 (alarm 1), 0 (alarm 2)
Heterogeneity: Chi2 = 0.06, df = 1 (P = 0.81); I2 =0.0%
Test for overall effect: Z = 1.28 (P = 0.20)
9 normal alarm vs electric stimulation (Crosby Dri-nite) alarm
Lovibond 1964a 1/12 1/12 100.0 % 1.00 [ 0.07, 14.21 ]
Subtotal (95% CI) 12 12 100.0 % 1.00 [ 0.07, 14.21 ]
Total events: 1 (alarm 1), 1 (alarm 2)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P = 1.0)
10 body worn audio alarm vs body worn vibrating alarm
Tobias 2001 10/23 14/24 100.0 % 0.75 [ 0.42, 1.33 ]
Subtotal (95% CI) 23 24 100.0 % 0.75 [ 0.42, 1.33 ]
Total events: 10 (alarm 1), 14 (alarm 2)
Heterogeneity: not applicable
Test for overall effect: Z = 1.00 (P = 0.32)
0.01 0.1 1 10 100
favours alarm 1 favours alarm 2
84Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.4. Comparison 2 COMPARING ALARMS, Outcome 4 Numbers not achieving 14 dry nights or
relapsing.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 2 COMPARING ALARMS
Outcome: 4 Numbers not achieving 14 dry nights or relapsing
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 bed alarm vs body alarm
Butler 1990a 10/20 9/20 100.0 % 1.11 [ 0.58, 2.14 ]
Subtotal (95% CI) 20 20 100.0 % 1.11 [ 0.58, 2.14 ]
Total events: 10 (Treatment), 9 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.32 (P = 0.75)
2 continuous alarm vs intermittent alarm
Taylor 1975 17/21 13/18 100.0 % 1.12 [ 0.79, 1.60 ]
Subtotal (95% CI) 21 18 100.0 % 1.12 [ 0.79, 1.60 ]
Total events: 17 (Treatment), 13 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.63 (P = 0.53)
3 immediate alarm vs delayed alarm
Wagner 1985 7/13 11/13 100.0 % 0.64 [ 0.37, 1.11 ]
Subtotal (95% CI) 13 13 100.0 % 0.64 [ 0.37, 1.11 ]
Total events: 7 (Treatment), 11 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.60 (P = 0.11)
4 supervised alarm vs unsupervised alarm
Bollard 1981a 7/15 11/15 100.0 % 0.64 [ 0.34, 1.18 ]
Subtotal (95% CI) 15 15 100.0 % 0.64 [ 0.34, 1.18 ]
Total events: 7 (Treatment), 11 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.43 (P = 0.15)
5 loud alarm vs quiet alarm
Finley 1973 5/10 3/10 30.0 % 1.67 [ 0.54, 5.17 ]
Finley 1977 6/10 7/10 70.0 % 0.86 [ 0.45, 1.64 ]
Subtotal (95% CI) 20 20 100.0 % 1.10 [ 0.62, 1.96 ]
Total events: 11 (Treatment), 10 (Control)
Heterogeneity: Chi2 = 1.09, df = 1 (P = 0.30); I2 =8%
Test for overall effect: Z = 0.32 (P = 0.75)
6 alarm with 105 dB bell + light vs alarm with 78 dB bell in parents’ room
Finley 1973 5/10 10/10 100.0 % 0.52 [ 0.29, 0.96 ]
0.1 0.2 0.5 1 2 5 10
favours alarm 1 favours alarm 2
(Continued . . . )
85Alarm interventions for nocturnal enuresis in children (Review)
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(. . . Continued)Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Subtotal (95% CI) 10 10 100.0 % 0.52 [ 0.29, 0.96 ]
Total events: 5 (Treatment), 10 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 2.10 (P = 0.036)
7 alarm with intermittent 80 dB bell vs alarm with 78 dB bell in parents’ room
Finley 1973 3/10 10/10 100.0 % 0.33 [ 0.14, 0.80 ]
Subtotal (95% CI) 10 10 100.0 % 0.33 [ 0.14, 0.80 ]
Total events: 3 (Treatment), 10 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 2.46 (P = 0.014)
8 normal alarm vs twin signal alarm
Lovibond 1964a 5/12 5/12 50.0 % 1.00 [ 0.39, 2.58 ]
Lovibond 1964c 6/12 5/12 50.0 % 1.20 [ 0.50, 2.88 ]
Subtotal (95% CI) 24 24 100.0 % 1.10 [ 0.58, 2.09 ]
Total events: 11 (Treatment), 10 (Control)
Heterogeneity: Chi2 = 0.08, df = 1 (P = 0.78); I2 =0.0%
Test for overall effect: Z = 0.29 (P = 0.77)
9 normal alarm vs electric stimulation (Crosby Dri-nite) alarm
Lovibond 1964a 5/12 6/12 100.0 % 0.83 [ 0.35, 2.00 ]
Subtotal (95% CI) 12 12 100.0 % 0.83 [ 0.35, 2.00 ]
Total events: 5 (Treatment), 6 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.41 (P = 0.68)
0.1 0.2 0.5 1 2 5 10
favours alarm 1 favours alarm 2
86Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.1. Comparison 3 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 1 Mean number of
wet nights per week.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 3 ALARM vs BEHAVIOURAL INTERVENTIONS
Outcome: 1 Mean number of wet nights per week
Study or subgroup alarm augmented alarmMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 alarm vs star chart + rewards
Ronen 1992 15 0.41 (1.76) 14 1.11 (1.93) -0.70 [ -2.05, 0.65 ]
2 alarm vs stop-start training
Bennett 1985 9 1 (1.95) 12 3.25 (2.6) -2.25 [ -4.20, -0.30 ]
-10 -5 0 5 10
favours alarm favours behavioural
Analysis 3.2. Comparison 3 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 2 Mean number of
wet nights per week (no SDs).
Mean number of wet nights per week (no SDs)
Study Alarm Behavioural
alarm vs random wakening
Fournier 1987 2.5 wet nights, n=8 3.3 wet nights, n=8
alarm vs star chart + wake-up alarm clock
Baker 1969 1.8 wet nights, n=10 3.1 wet nights, n=10
alarm vs dry bed training (no alarm)
Azrin 1978 5.32 wet nights, n=27 1.05 wet nights, n=28
Bollard 1981b 0.6 wet nights, n=20 3.8 wet nights, n=20
87Alarm interventions for nocturnal enuresis in children (Review)
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Analysis 3.3. Comparison 3 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 3 Numbers not
achieving 14 dry nights.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 3 ALARM vs BEHAVIOURAL INTERVENTIONS
Outcome: 3 Numbers not achieving 14 dry nights
Study or subgroup alarm other behavioural Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 alarm vs star chart + rewards
Ronen 1992 7/19 14/20 100.0 % 0.53 [ 0.27, 1.01 ]
Subtotal (95% CI) 19 20 100.0 % 0.53 [ 0.27, 1.01 ]
Total events: 7 (alarm), 14 (other behavioural)
Heterogeneity: not applicable
Test for overall effect: Z = 1.92 (P = 0.055)
2 alarm vs stop-start training
Bennett 1985 5/9 10/12 100.0 % 0.67 [ 0.35, 1.26 ]
Subtotal (95% CI) 9 12 100.0 % 0.67 [ 0.35, 1.26 ]
Total events: 5 (alarm), 10 (other behavioural)
Heterogeneity: not applicable
Test for overall effect: Z = 1.25 (P = 0.21)
3 alarm vs dry bed training (no alarm)
Azrin 1978 23/27 0/27 2.4 % 47.00 [ 3.00, 736.47 ]
Bollard 1981b 4/20 15/20 71.4 % 0.27 [ 0.11, 0.66 ]
Caceres 1982 0/7 5/7 26.2 % 0.09 [ 0.01, 1.39 ]
Subtotal (95% CI) 54 54 100.0 % 1.33 [ 0.79, 2.24 ]
Total events: 27 (alarm), 20 (other behavioural)
Heterogeneity: Chi2 = 22.13, df = 2 (P = 0.00002); I2 =91%
Test for overall effect: Z = 1.08 (P = 0.28)
0.001 0.01 0.1 1 10 100 1000
favours alarm favours behaviour
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Analysis 3.4. Comparison 3 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 4 Mean number of
wet nights at follow-up.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 3 ALARM vs BEHAVIOURAL INTERVENTIONS
Outcome: 4 Mean number of wet nights at follow-up
Study or subgroup alarm behaviouralMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 alarm vs stop-start training
Bennett 1985 9 0.85 (1.55) 12 3.45 (2.9) -2.60 [ -4.53, -0.67 ]
-10 -5 0 5 10
favours alarm favours behavioural
Analysis 3.5. Comparison 3 ALARM vs BEHAVIOURAL INTERVENTIONS, Outcome 5 Numbers not
achieving 14 dry nights or relapsing.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 3 ALARM vs BEHAVIOURAL INTERVENTIONS
Outcome: 5 Numbers not achieving 14 dry nights or relapsing
Study or subgroup alarm other behavioural Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 alarm vs waking / lifting
Lovibond 1964b 6/10 5/10 1.20 [ 0.54, 2.67 ]
2 alarm vs star chart + rewards
Ronen 1992 9/15 8/14 1.05 [ 0.57, 1.94 ]
3 alarm vs dry bed training (no alarm)
Bollard 1981b 10/20 17/20 0.59 [ 0.37, 0.95 ]
0.1 0.2 0.5 1 2 5 10
favours alarm favours behaviour
89Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 4.1. Comparison 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 1 Mean
number of wet nights per week.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS
Outcome: 1 Mean number of wet nights per week
Study or subgroup alarm augmented alarmMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 alarm vs alarm + retention control training
Geffken 1986a 10 1.7 (1.2) 10 2.5 (0.9) 49.6 % -0.80 [ -1.73, 0.13 ]
Geffken 1986b 10 2.3 (1) 10 1.6 (1.1) 50.4 % 0.70 [ -0.22, 1.62 ]
Subtotal (95% CI) 20 20 100.0 % -0.04 [ -0.70, 0.61 ]
Heterogeneity: Chi2 = 5.04, df = 1 (P = 0.02); I2 =80%
Test for overall effect: Z = 0.13 (P = 0.90)
2 alarm vs alarm + dry bed training
Bennett 1985 9 1 (1.95) 10 1.4 (1.8) 50.4 % -0.40 [ -2.09, 1.29 ]
Nawaz 2002 12 3.25 (2.67) 12 0.83 (1.4) 49.6 % 2.42 [ 0.71, 4.13 ]
Subtotal (95% CI) 21 22 100.0 % 1.00 [ -0.20, 2.20 ]
Heterogeneity: Chi2 = 5.29, df = 1 (P = 0.02); I2 =81%
Test for overall effect: Z = 1.63 (P = 0.10)
Test for subgroup differences: Chi2 = 2.23, df = 1 (P = 0.14), I2 =55%
-4 -2 0 2 4
favours alarm favours augmentation
Analysis 4.2. Comparison 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 2 Mean
number of wet nights per week (no SDs).
Mean number of wet nights per week (no SDs)
Study Alarm Augmented alarm
unsupervised alarm vs supervised
Bollard 1981a 2.2 wet nights with unsupervised alarm, n=15 0.8 with supervised alarm, n=15
alarm vs alarm + retention control training
Bollard 1982a 0.65 wet nights, n=12 (group B) 0.7 wet nights, n=12 (group E)
Fielding 1980 0.6 wet nights, n=17 1.5 wet nights, n=16
alarm vs alarm + dry bed training
Bollard 1981b 0.6 wet nights, n=20 0 wet nights, n=60
90Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Mean number of wet nights per week (no SDs) (Continued)
Bollard 1982a 0.65 wet nights, n=12 (group B) 0.5 wet nights, n=12 (group F)
Butler 1988 1.81 wet nights, n=20 1.05 wet nights, n=29
Butler 1990b 1.6 wet nights, n=24 1.8 wet nights, n=24
Analysis 4.3. Comparison 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 3 Number
not achieving 14 consecutive dry nights.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS
Outcome: 3 Number not achieving 14 consecutive dry nights
Study or subgroup alarm augmented alarm Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 unsupervised alarm vs supervised
Bollard 1981a 6/15 3/15 2.00 [ 0.61, 6.55 ]
Subtotal (95% CI) 15 15 2.00 [ 0.61, 6.55 ]
Total events: 6 (alarm), 3 (augmented alarm)
Heterogeneity: not applicable
Test for overall effect: Z = 1.14 (P = 0.25)
2 alarm vs alarm + retention control training
Bollard 1982a 0/12 0/12 0.0 [ 0.0, 0.0 ]
Fielding 1980 3/17 5/16 0.56 [ 0.16, 1.99 ]
Geffken 1986a 1/10 1/10 1.00 [ 0.07, 13.87 ]
Geffken 1986b 0/10 1/10 0.33 [ 0.02, 7.32 ]
Houts 1986 3/12 13/13 0.28 [ 0.11, 0.69 ]
Subtotal (95% CI) 61 61 0.39 [ 0.20, 0.77 ]
Total events: 7 (alarm), 20 (augmented alarm)
Heterogeneity: Chi2 = 1.36, df = 3 (P = 0.71); I2 =0.0%
Test for overall effect: Z = 2.73 (P = 0.0063)
3 alarm vs alarm + overlearning + retention control training
Houts 1986 3/12 4/13 0.81 [ 0.23, 2.91 ]
Subtotal (95% CI) 12 13 0.81 [ 0.23, 2.91 ]
Total events: 3 (alarm), 4 (augmented alarm)
Heterogeneity: not applicable
0.01 0.1 1 10 100
favours alarm favours augmented al
(Continued . . . )
91Alarm interventions for nocturnal enuresis in children (Review)
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(. . . Continued)Study or subgroup alarm augmented alarm Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Test for overall effect: Z = 0.32 (P = 0.75)
4 continuous alarm vs alarm + overlearning
Taylor 1975 8/21 9/22 0.93 [ 0.44, 1.95 ]
Subtotal (95% CI) 21 22 0.93 [ 0.44, 1.95 ]
Total events: 8 (alarm), 9 (augmented alarm)
Heterogeneity: not applicable
Test for overall effect: Z = 0.19 (P = 0.85)
5 intermittent alarm vs alarm + overlearning
Taylor 1975 9/18 9/22 1.22 [ 0.62, 2.42 ]
Subtotal (95% CI) 18 22 1.22 [ 0.62, 2.42 ]
Total events: 9 (alarm), 9 (augmented alarm)
Heterogeneity: not applicable
Test for overall effect: Z = 0.58 (P = 0.56)
6 alarm vs alarm + dry bed training
Bennett 1985 5/9 5/10 1.11 [ 0.47, 2.60 ]
Bollard 1981b 4/20 0/60 26.14 [ 1.47, 465.41 ]
Butler 1988 8/28 10/35 1.00 [ 0.46, 2.19 ]
Butler 1990b 4/24 10/24 0.40 [ 0.15, 1.10 ]
Nawaz 2002 9/12 4/12 2.25 [ 0.95, 5.34 ]
Subtotal (95% CI) 93 141 1.21 [ 0.82, 1.81 ]
Total events: 30 (alarm), 29 (augmented alarm)
Heterogeneity: Chi2 = 11.22, df = 4 (P = 0.02); I2 =64%
Test for overall effect: Z = 0.96 (P = 0.34)
7 alarm vs alarm + dry bed training SENSITIVITY ANALYSIS
Bennett 1985 5/9 5/10 1.11 [ 0.47, 2.60 ]
Bollard 1981b 4/20 0/60 26.14 [ 1.47, 465.41 ]
Butler 1988 8/28 10/35 1.00 [ 0.46, 2.19 ]
Nawaz 2002 9/12 4/12 2.25 [ 0.95, 5.34 ]
Subtotal (95% CI) 69 117 1.67 [ 1.06, 2.62 ]
Total events: 26 (alarm), 19 (augmented alarm)
Heterogeneity: Chi2 = 6.48, df = 3 (P = 0.09); I2 =54%
Test for overall effect: Z = 2.23 (P = 0.026)
8 alarm vs alarm + reward for correct behaviour at time of wetting
van Londen 1993 10/36 1/38 10.56 [ 1.42, 78.34 ]
Subtotal (95% CI) 36 38 10.56 [ 1.42, 78.34 ]
Total events: 10 (alarm), 1 (augmented alarm)
Heterogeneity: not applicable
Test for overall effect: Z = 2.30 (P = 0.021)
9 alarm vs alarm + reward for dry bed, penalty for wet bed
van Londen 1993 10/36 6/39 1.81 [ 0.73, 4.46 ]
0.01 0.1 1 10 100
favours alarm favours augmented al
(Continued . . . )
92Alarm interventions for nocturnal enuresis in children (Review)
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(. . . Continued)Study or subgroup alarm augmented alarm Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Subtotal (95% CI) 36 39 1.81 [ 0.73, 4.46 ]
Total events: 10 (alarm), 6 (augmented alarm)
Heterogeneity: not applicable
Test for overall effect: Z = 1.28 (P = 0.20)
10 alarm + reward for correct behaviour at time of wetting vs alarm + reward for dry bed, penalty for wet bed
van Londen 1993 1/38 6/39 0.17 [ 0.02, 1.35 ]
Subtotal (95% CI) 38 39 0.17 [ 0.02, 1.35 ]
Total events: 1 (alarm), 6 (augmented alarm)
Heterogeneity: not applicable
Test for overall effect: Z = 1.67 (P = 0.094)
0.01 0.1 1 10 100
favours alarm favours augmented al
Analysis 4.4. Comparison 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 4
Numbers not achieving 14 dry nights or relapsing.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS
Outcome: 4 Numbers not achieving 14 dry nights or relapsing
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 unsupervised alarm vs supervised
Bollard 1981a 11/15 7/15 100.0 % 1.57 [ 0.84, 2.92 ]
Subtotal (95% CI) 15 15 100.0 % 1.57 [ 0.84, 2.92 ]
Total events: 11 (Treatment), 7 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.43 (P = 0.15)
2 alarm vs alarm + retention control training
Fielding 1980 11/17 9/16 38.6 % 1.15 [ 0.66, 2.01 ]
Geffken 1986a 4/10 5/10 20.8 % 0.80 [ 0.30, 2.13 ]
Geffken 1986b 6/10 4/10 16.6 % 1.50 [ 0.60, 3.74 ]
Houts 1986 6/12 6/13 24.0 % 1.08 [ 0.48, 2.45 ]
Subtotal (95% CI) 49 49 100.0 % 1.12 [ 0.77, 1.64 ]
Total events: 27 (Treatment), 24 (Control)
0.1 0.2 0.5 1 2 5 10
favours alarm favours augmentation
(Continued . . . )
93Alarm interventions for nocturnal enuresis in children (Review)
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(. . . Continued)Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Heterogeneity: Chi2 = 0.86, df = 3 (P = 0.83); I2 =0.0%
Test for overall effect: Z = 0.58 (P = 0.56)
3 alarm vs alarm + overlearning + retention control training
Houts 1986 6/12 5/13 100.0 % 1.30 [ 0.53, 3.17 ]
Subtotal (95% CI) 12 13 100.0 % 1.30 [ 0.53, 3.17 ]
Total events: 6 (Treatment), 5 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.58 (P = 0.56)
4 continuous alarm vs alarm + overlearning
Taylor 1975 17/21 12/22 64.8 % 1.48 [ 0.96, 2.29 ]
Young 1972 16/46 7/55 35.2 % 2.73 [ 1.23, 6.07 ]
Subtotal (95% CI) 67 77 100.0 % 1.92 [ 1.27, 2.92 ]
Total events: 33 (Treatment), 19 (Control)
Heterogeneity: Chi2 = 2.12, df = 1 (P = 0.15); I2 =53%
Test for overall effect: Z = 3.08 (P = 0.0020)
5 intermittent alarm vs alarm + overlearning
Taylor 1975 13/18 12/22 100.0 % 1.32 [ 0.82, 2.13 ]
Subtotal (95% CI) 18 22 100.0 % 1.32 [ 0.82, 2.13 ]
Total events: 13 (Treatment), 12 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.15 (P = 0.25)
6 alarm vs alarm + dry bed training
Bollard 1981b 10/20 15/60 25.4 % 2.00 [ 1.08, 3.72 ]
Butler 1990b 13/24 17/24 57.6 % 0.76 [ 0.49, 1.20 ]
Nawaz 2002 10/12 5/12 16.9 % 2.00 [ 0.98, 4.09 ]
Subtotal (95% CI) 56 96 100.0 % 1.29 [ 0.94, 1.77 ]
Total events: 33 (Treatment), 37 (Control)
Heterogeneity: Chi2 = 8.58, df = 2 (P = 0.01); I2 =77%
Test for overall effect: Z = 1.56 (P = 0.12)
7 alarm vs alarm + dry bed training SENSITIVITY ANALYSIS
Bollard 1981b 10/20 15/60 60.0 % 2.00 [ 1.08, 3.72 ]
Nawaz 2002 10/12 5/12 40.0 % 2.00 [ 0.98, 4.09 ]
Subtotal (95% CI) 32 72 100.0 % 2.00 [ 1.25, 3.20 ]
Total events: 20 (Treatment), 20 (Control)
Heterogeneity: Chi2 = 0.0, df = 1 (P = 1.00); I2 =0.0%
Test for overall effect: Z = 2.89 (P = 0.0038)
8 alarm vs alarm + reward for correct behaviour at time of wetting
van Londen 1993 10/36 11/38 100.0 % 0.96 [ 0.46, 1.98 ]
Subtotal (95% CI) 36 38 100.0 % 0.96 [ 0.46, 1.98 ]
Total events: 10 (Treatment), 11 (Control)
Heterogeneity: not applicable
0.1 0.2 0.5 1 2 5 10
favours alarm favours augmentation
(Continued . . . )
94Alarm interventions for nocturnal enuresis in children (Review)
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(. . . Continued)Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Test for overall effect: Z = 0.11 (P = 0.91)
9 alarm vs alarm + reward for dry bed, penalty for wet bed
van Londen 1993 10/36 21/39 100.0 % 0.52 [ 0.28, 0.94 ]
Subtotal (95% CI) 36 39 100.0 % 0.52 [ 0.28, 0.94 ]
Total events: 10 (Treatment), 21 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 2.16 (P = 0.031)
10 alarm + reward for correct behaviour at time of wetting vs alarm + reward for dry bed, penalty for wet bed
van Londen 1993 11/38 21/39 100.0 % 0.54 [ 0.30, 0.96 ]
Subtotal (95% CI) 38 39 100.0 % 0.54 [ 0.30, 0.96 ]
Total events: 11 (Treatment), 21 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 2.11 (P = 0.035)
0.1 0.2 0.5 1 2 5 10
favours alarm favours augmentation
Analysis 4.5. Comparison 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS, Outcome 5 Mean
number of wet nights at follow-up.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 4 ALARM vs ALARM + BEHAVIOURAL INTERVENTIONS
Outcome: 5 Mean number of wet nights at follow-up
Study or subgroup alarm augmented alarmMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 alarm vs alarm + dry bed training
Bennett 1985 9 0.85 (1.55) 10 2.35 (2.65) -1.50 [ -3.43, 0.43 ]
-4 -2 0 2 4
favours alarm favours augmentation
95Alarm interventions for nocturnal enuresis in children (Review)
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Analysis 5.1. Comparison 5 ALARM vs DRUGS, Outcome 1 Mean number of wet nights per week.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 5 ALARM vs DRUGS
Outcome: 1 Mean number of wet nights per week
Study or subgroup Alarm DrugMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 alarm vs imipramine
Motavalli 1994 10 1.4 (2.15) 10 2.05 (1.3) 100.0 % -0.65 [ -2.21, 0.91 ]
Subtotal (95% CI) 10 10 100.0 % -0.65 [ -2.21, 0.91 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.82 (P = 0.41)
2 alarm vs clomipramine
Motavalli 1994 10 1.4 (2.15) 9 3.3 (2.75) 100.0 % -1.90 [ -4.14, 0.34 ]
Subtotal (95% CI) 10 9 100.0 % -1.90 [ -4.14, 0.34 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.66 (P = 0.096)
3 alarm vs desmopressin (first week)
Wille 1986 22 4.6 (1.88) 24 2.5 (1.96) 100.0 % 2.10 [ 0.99, 3.21 ]
Subtotal (95% CI) 22 24 100.0 % 2.10 [ 0.99, 3.21 ]
Heterogeneity: not applicable
Test for overall effect: Z = 3.71 (P = 0.00021)
4 alarm vs desmopressin (last week)
Ng 2005 28 2.8 (2.2) 36 2.6 (2.4) 49.1 % 0.20 [ -0.93, 1.33 ]
Wille 1986 22 1.1 (1.88) 24 2.1 (1.96) 50.9 % -1.00 [ -2.11, 0.11 ]
Subtotal (95% CI) 50 60 100.0 % -0.41 [ -1.20, 0.38 ]
Heterogeneity: Chi2 = 2.20, df = 1 (P = 0.14); I2 =55%
Test for overall effect: Z = 1.02 (P = 0.31)
5 alarm vs alarm + desmopressin
Bradbury 1995 27 2.2 (2.12) 33 0.85 (1.61) 11.3 % 1.35 [ 0.38, 2.32 ]
Gibb 2004 106 2.4 (1.53) 101 1.8 (1.13) 79.5 % 0.60 [ 0.23, 0.97 ]
Ng 2005 28 2.8 (2.2) 29 1.3 (1.9) 9.3 % 1.50 [ 0.43, 2.57 ]
Subtotal (95% CI) 161 163 100.0 % 0.77 [ 0.44, 1.09 ]
Heterogeneity: Chi2 = 4.00, df = 2 (P = 0.14); I2 =50%
Test for overall effect: Z = 4.62 (P < 0.00001)
Test for subgroup differences: Chi2 = 21.56, df = 4 (P = 0.00), I2 =81%
-10 -5 0 5 10
favours alarm favours drug
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Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 5.2. Comparison 5 ALARM vs DRUGS, Outcome 2 Mean number of wet nights per week (no SDs
or crossover trials).
Mean number of wet nights per week (no SDs or crossover trials)
Study Alarm Control / drug
alarm vs placebo
Fournier 1987 2.5 wet nights, n=8 5 wet nights, n=8
Kolvin 1972 2.3 wet nights, n=32 2.7 wet nights, n=27
Wright 1974 1.7 wet nights, n=10 3.5 wet nights, n=5
alarm vs desmopressin
Faraj 1999 0.7 wet nights, n=73 1.05 wet nights, n=62
alarm vs alarm + desmopressin
Leebeek 2001 3.9 wet nights, n=45 2.9 wet nights, n=47
Sukhai 1989 # 2.9 wet nights (SD 1.06) n=28 1.9 wet nights (SD 1.06) n=28
alarm vs imipramine
Fournier 1987 2.5 wet nights, n=8 1.9 wet nights, n=8
Kolvin 1972 2.3 wet nights, n=32 2.3 wet nights, n=35
Wagner 1982 0.58 wet nights, n=12 2.75 wet nights, n=12
alarm vs alarm + imipramine
Fournier 1987 2.5 wet nights, n=8 1 wet night, n=8
alarm vs amphetamine sulphate\Enetrol (ephedrine + atropine)
Wright 1974 1.7 wet nights, n=10 4.1 wet nights, n=8
97Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 5.3. Comparison 5 ALARM vs DRUGS, Outcome 3 Numbers not achieving 14 dry nights during
treatment.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 5 ALARM vs DRUGS
Outcome: 3 Numbers not achieving 14 dry nights during treatment
Study or subgroup Alarm Drug Risk Ratio Weight Risk Ratio
n/N n/N
M-H,Random,95%
CI
M-H,Random,95%
CI
1 alarm vs placebo
Longstaffe 2000 26/61 38/61 100.0 % 0.68 [ 0.48, 0.97 ]
Subtotal (95% CI) 61 61 100.0 % 0.68 [ 0.48, 0.97 ]
Total events: 26 (Alarm), 38 (Drug)
Heterogeneity: not applicable
Test for overall effect: Z = 2.12 (P = 0.034)
2 alarm vs desmopressin
Faraj 1999 6/37 12/39 16.0 % 0.53 [ 0.22, 1.26 ]
Longstaffe 2000 26/61 31/60 35.7 % 0.82 [ 0.56, 1.21 ]
Ng 2005 27/35 22/38 38.6 % 1.33 [ 0.96, 1.85 ]
Wille 1986 3/22 7/24 9.7 % 0.47 [ 0.14, 1.59 ]
Subtotal (95% CI) 155 161 100.0 % 0.85 [ 0.53, 1.37 ]
Total events: 62 (Alarm), 72 (Drug)
Heterogeneity: Tau2 = 0.13; Chi2 = 8.45, df = 3 (P = 0.04); I2 =64%
Test for overall effect: Z = 0.66 (P = 0.51)
3 alarm vs alarm + desmopressin
Bradbury 1995 11/27 6/33 15.2 % 2.24 [ 0.95, 5.27 ]
Gibb 2004 55/106 49/101 38.4 % 1.07 [ 0.81, 1.40 ]
Ng 2005 27/35 12/32 28.0 % 2.06 [ 1.27, 3.33 ]
Rodriguez 2001 8/30 12/29 18.4 % 0.64 [ 0.31, 1.34 ]
Subtotal (95% CI) 198 195 100.0 % 1.32 [ 0.80, 2.16 ]
Total events: 101 (Alarm), 79 (Drug)
Heterogeneity: Tau2 = 0.17; Chi2 = 10.25, df = 3 (P = 0.02); I2 =71%
Test for overall effect: Z = 1.09 (P = 0.27)
4 alarm vs imipramine
McKendry 1975 52/75 61/74 58.9 % 0.84 [ 0.70, 1.01 ]
Netley 1984 7/18 13/17 30.2 % 0.51 [ 0.27, 0.96 ]
Wagner 1982 2/12 8/12 10.9 % 0.25 [ 0.07, 0.94 ]
Subtotal (95% CI) 105 103 100.0 % 0.59 [ 0.32, 1.09 ]
Total events: 61 (Alarm), 82 (Drug)
0.01 0.1 1 10 100
favours alarm alone favours alarm + drug
(Continued . . . )
98Alarm interventions for nocturnal enuresis in children (Review)
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(. . . Continued)Study or subgroup Alarm Drug Risk Ratio Weight Risk Ratio
n/N n/N
M-H,Random,95%
CI
M-H,Random,95%
CI
Heterogeneity: Tau2 = 0.19; Chi2 = 6.02, df = 2 (P = 0.05); I2 =67%
Test for overall effect: Z = 1.68 (P = 0.092)
6 alarm + placebo vs alarm + nortriptyline
Scholander 1968 12/15 15/15 100.0 % 0.81 [ 0.61, 1.06 ]
Subtotal (95% CI) 15 15 100.0 % 0.81 [ 0.61, 1.06 ]
Total events: 12 (Alarm), 15 (Drug)
Heterogeneity: not applicable
Test for overall effect: Z = 1.54 (P = 0.12)
7 alarm vs alarm + methedrine
Kennedy 1968 4/10 0/8 100.0 % 7.36 [ 0.45, 119.38 ]
Subtotal (95% CI) 10 8 100.0 % 7.36 [ 0.45, 119.38 ]
Total events: 4 (Alarm), 0 (Drug)
Heterogeneity: not applicable
Test for overall effect: Z = 1.40 (P = 0.16)
8 alarm vs amphetamine
Forrester 1964 6/16 14/17 100.0 % 0.46 [ 0.23, 0.89 ]
Subtotal (95% CI) 16 17 100.0 % 0.46 [ 0.23, 0.89 ]
Total events: 6 (Alarm), 14 (Drug)
Heterogeneity: not applicable
Test for overall effect: Z = 2.30 (P = 0.021)
0.01 0.1 1 10 100
favours alarm alone favours alarm + drug
Analysis 5.4. Comparison 5 ALARM vs DRUGS, Outcome 4 Number of wet nights at follow-up (no SDs).
Number of wet nights at follow-up (no SDs)
Study Alarm Control / drug
alarm vs placebo
Kolvin 1972 2.33 wet nights, n=32 2.83 wet nights, n=27
alarm vs alarm + desmopressin
Leebeek 2001 1.9 wet nights, n=37 2.7 wet nights, n=41
alarm vs imipramine
Kolvin 1972 2.3 wet nights, n=32 3.4 wet nights, n=35
alarm vs amitriptyline
99Alarm interventions for nocturnal enuresis in children (Review)
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Number of wet nights at follow-up (no SDs) (Continued)
Danquah 1975 3.2 wet nights, n=10 4 wet nights, n=10
Analysis 5.5. Comparison 5 ALARM vs DRUGS, Outcome 5 Number not achieving 14 dry nights or
relapsing.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 5 ALARM vs DRUGS
Outcome: 5 Number not achieving 14 dry nights or relapsing
Study or subgroup Alarm Drug Risk Ratio Weight Risk Ratio
n/N n/N
M-H,Random,95%
CI
M-H,Random,95%
CI
1 alarm vs desmopressin
Ng 2005 25/35 30/38 77.9 % 0.90 [ 0.69, 1.18 ]
Wille 1986 4/22 16/24 22.1 % 0.27 [ 0.11, 0.69 ]
Subtotal (95% CI) 57 62 100.0 % 0.53 [ 0.14, 2.06 ]
Total events: 29 (Alarm), 46 (Drug)
Heterogeneity: Tau2 = 0.85; Chi2 = 7.95, df = 1 (P = 0.005); I2 =87%
Test for overall effect: Z = 0.92 (P = 0.36)
2 alarm vs alarm + desmopressin
Bradbury 1995 14/27 10/33 16.0 % 1.71 [ 0.91, 3.22 ]
Gibb 2004 58/106 56/101 33.7 % 0.99 [ 0.77, 1.26 ]
Leebeek 2001 21/46 20/47 22.6 % 1.07 [ 0.68, 1.70 ]
Ng 2005 25/35 19/32 27.7 % 1.20 [ 0.84, 1.72 ]
Subtotal (95% CI) 214 213 100.0 % 1.10 [ 0.92, 1.31 ]
Total events: 118 (Alarm), 105 (Drug)
Heterogeneity: Tau2 = 0.0; Chi2 = 2.88, df = 3 (P = 0.41); I2 =0.0%
Test for overall effect: Z = 1.02 (P = 0.31)
3 alarm vs imipramine
Wagner 1982 7/12 12/12 100.0 % 0.60 [ 0.37, 0.97 ]
Subtotal (95% CI) 12 12 100.0 % 0.60 [ 0.37, 0.97 ]
Total events: 7 (Alarm), 12 (Drug)
Heterogeneity: not applicable
Test for overall effect: Z = 2.09 (P = 0.036)
4 alarm + placebo vs alarm + nortriptyline
Scholander 1968 9/15 6/15 100.0 % 1.50 [ 0.71, 3.16 ]
0.001 0.01 0.1 1 10 100 1000
favours alarm favours drug
(Continued . . . )
100Alarm interventions for nocturnal enuresis in children (Review)
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(. . . Continued)Study or subgroup Alarm Drug Risk Ratio Weight Risk Ratio
n/N n/N
M-H,Random,95%
CI
M-H,Random,95%
CI
Subtotal (95% CI) 15 15 100.0 % 1.50 [ 0.71, 3.16 ]
Total events: 9 (Alarm), 6 (Drug)
Heterogeneity: not applicable
Test for overall effect: Z = 1.07 (P = 0.29)
0.001 0.01 0.1 1 10 100 1000
favours alarm favours drug
Analysis 5.6. Comparison 5 ALARM vs DRUGS, Outcome 6 Mean number of wet nights at follow-up.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 5 ALARM vs DRUGS
Outcome: 6 Mean number of wet nights at follow-up
Study or subgroup Alarm DrugMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
1 alarm vs desmopressin
Ng 2005 24 2.5 (2.4) 34 3.4 (2.5) 47.7 % -0.90 [ -2.18, 0.38 ]
Wille 1986 22 1.3 (1.88) 24 3.5 (1.96) 52.3 % -2.20 [ -3.31, -1.09 ]
Subtotal (95% CI) 46 58 100.0 % -1.59 [ -2.86, -0.32 ]
Heterogeneity: Tau2 = 0.47; Chi2 = 2.27, df = 1 (P = 0.13); I2 =56%
Test for overall effect: Z = 2.45 (P = 0.014)
2 alarm vs alarm + desmopressin
Ng 2005 24 2.5 (2.4) 24 2.6 (2.7) 100.0 % -0.10 [ -1.55, 1.35 ]
Subtotal (95% CI) 24 24 100.0 % -0.10 [ -1.55, 1.35 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.14 (P = 0.89)
-10 -5 0 5 10
favours alarm favours drug
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Analysis 6.1. Comparison 6 ALARM vs OTHER / MISCELLANEOUS TREATMENTS, Outcome 1 Mean
number of wet nights per week.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 6 ALARM vs OTHER / MISCELLANEOUS TREATMENTS
Outcome: 1 Mean number of wet nights per week
Study or subgroup Alarm OtherMean
DifferenceMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 alarm vs cognitive therapy
Ronen 1992 15 0.41 (1.76) 18 0.34 (0.72) 0.07 [ -0.88, 1.02 ]
-4 -2 0 2 4
Favours alarm Favours other
Analysis 6.3. Comparison 6 ALARM vs OTHER / MISCELLANEOUS TREATMENTS, Outcome 3 Numbers
not achieving 14 dry nights.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 6 ALARM vs OTHER / MISCELLANEOUS TREATMENTS
Outcome: 3 Numbers not achieving 14 dry nights
Study or subgroup Alarm Other Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 alarm vs restricted diet
McKendry 1975 52/75 74/75 100.0 % 0.70 [ 0.60, 0.82 ]
Subtotal (95% CI) 75 75 100.0 % 0.70 [ 0.60, 0.82 ]
Total events: 52 (Alarm), 74 (Other)
Heterogeneity: not applicable
Test for overall effect: Z = 4.53 (P < 0.00001)
2 alarm vs cognitive therapy / psychotherapy
Ronen 1992 7/19 5/20 12.9 % 1.47 [ 0.56, 3.85 ]
Sacks 1974 13/64 8/10 36.7 % 0.25 [ 0.14, 0.45 ]
Werry 1965 15/21 19/21 50.4 % 0.79 [ 0.58, 1.07 ]
Subtotal (95% CI) 104 51 100.0 % 0.68 [ 0.52, 0.90 ]
Total events: 35 (Alarm), 32 (Other)
Heterogeneity: Chi2 = 14.67, df = 2 (P = 0.00065); I2 =86%
Test for overall effect: Z = 2.71 (P = 0.0068)
0.1 0.2 0.5 1 2 5 10
favours alarm favours other
102Alarm interventions for nocturnal enuresis in children (Review)
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Analysis 6.4. Comparison 6 ALARM vs OTHER / MISCELLANEOUS TREATMENTS, Outcome 4 Number
not achieving 14 dry nights or relapsing.
Review: Alarm interventions for nocturnal enuresis in children
Comparison: 6 ALARM vs OTHER / MISCELLANEOUS TREATMENTS
Outcome: 4 Number not achieving 14 dry nights or relapsing
Study or subgroup Alarm Other Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 alarm vs cognitive therapy
Ronen 1992 9/15 3/18 3.60 [ 1.18, 10.95 ]
0.1 0.2 0.5 1 2 5 10
favours alarm favours other
Analysis 6.5. Comparison 6 ALARM vs OTHER / MISCELLANEOUS TREATMENTS, Outcome 5 Mean
number of wet nights per week at follow up (no SDs).
Mean number of wet nights per week at follow up (no SDs)
Study Alarm Other
alarm vs shaming
Danquah 1975 3.2 wet nights, n=10 5.6 wet nights, n=10
W H A T ’ S N E W
Last assessed as up-to-date: 27 February 2007.
Date Event Description
20 August 2008 Amended Converted to new review format.
H I S T O R Y
Protocol first published: Issue 1, 2001
Review first published: Issue 1, 2001
103Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Date Event Description
28 February 2007 New search has been performed Third (minor) update (Issue 3 2007), one new trial com-
paring desmopressin and alarms (Ng 2005) was added:
the review conclusion that children are less likely to re-
lapse after alarm treatment than after desmopressin were
not altered
22 February 2005 New citation required and conclusions have changed Substantive amendment. Second update Issue 2 2005.
Three new trials (Gibb 2004, Nawaz 2002 and Tobias
2001) were added. There was some evidence that dry
bed training may reduce the relapse rate
26 February 2003 New citation required and conclusions have changed Substantive amendment. First update Issue 2 2003.
Twelve trials which were previously included only in
a sensitivity analysis and 20 new trials were added.
Two previously included trials were excluded. Com-
pared to the previous version, there was more evidence
that alarms were better than no treatment, desmopressin
or tricyclics. Overlearning may reduce the relapse rate
C O N T R I B U T I O N S O F A U T H O R S
CMAG (the contact reviewer) originally based this review on work done at the NHS Centre for Reviews and Dissemination, University
of York, UK (see acknowledgements). CMAG used the data extracted by the York reviewers, converted them into Cochrane Review
format, and separated them into seven component intervention reviews (of which this is one).
This update includes 32 new trials. REP and CMAG performed double data abstraction for the new trials. All three reviewers edited
the text and JHCE also provided a clinical perspective and interpretation.
D E C L A R A T I O N S O F I N T E R E S T
JHCE has received reimbursement for attending a conference, fees for lecturing and a consultancy fee which was paid into a research
fund from Ferring Pharmaceuticals, manufacturers of desmopressin.
S O U R C E S O F S U P P O R T
104Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Internal sources
• Chief Scientist Office, Scottish Executive Health Department, UK.
External sources
• National Health Service Research and Development Programme, UK.
I N D E X T E R M S
Medical Subject Headings (MeSH)
Absorbent Pads; Case-Control Studies; Deamino Arginine Vasopressin [therapeutic use]; Electrodes; Enuresis [drug therapy; ∗ prevention
& control]; Nephrology [methods]; Randomized Controlled Trials as Topic; Renal Agents [therapeutic use]
MeSH check words
Child; Child, Preschool; Humans
105Alarm interventions for nocturnal enuresis in children (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.