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Nocturnal enuresis in children with adenotonsillar hypertrophy
International Congress Series 1240 (2003) 701 – 705
Nocturnal enuresis in children with adenotonsillar hypertrophy Ahmed Elasfour a,*, Moustafa El-Ayouty b, Alaa Mokhtar c, Nabil Abdel-Mageed d a
Department of Otolaryngology—Head and Neck Surgery, Mansoura University, Mansura, Egypt b Department of Pediatrics, Mansoura University, Mansura, Egypt c Urology Center, Mansoura University, Mansura, Egypt d Department of Anesthesiology, Mansoura University, Mansura, Egypt
Abstract The relationship between upper airway obstruction and nocturnal enuresis (NE) was studied in 25 children with adenotonsillar hypertrophy. There were 11 males and 14 females. Their ages ranged from 4 to 10 years. Most of them received medical therapy for NE with unsatisfactory response. They were classified according to the presence or absence of diurnal voiding into two groups: monosymptomatic NE (16 children) and polysymptomatic NE (9 children). Obvious neurological abnormalities were excluded. All patients had been subjected to adenotonsillectomy and reevaluated 3 – 6 months later for their clinical response. Our results revealed (1) no significant differences between the two groups as far as age, sex, and manifestations of upper airway obstruction were concerned; (2) body mass index was significantly higher in group 2 (polysymptomatic) compared to group 1 ( p < 0.001); (3) detrusor instability was significantly higher in group 2 compared to group 1 ( p < 0.0001); (4) the preoperative apnea/hypopnea index (AHI) and percent oxygen saturation (SaO2%) showed no significant differences between the two groups; however, the postoperative values revealed significant improvement of both AHI and SaO2% in group 1 (monosymptomatic) when compared to group 2 ( p = 0.004 and p < 0.001, respectively). The postoperative follow-up showed a complete response of NE among children of group 1 and inadequate or no response among children of group 2. We concluded that removal of the upper airway obstruction by adenotonsillectomy led to a complete cure of NE in all children with monosymptomatic category. The polysymptomatic category may get more benefit with bladder physiotherapy and/or reduction of body weight. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Nocturnal enuresis; Upper airway obstruction; Adenotonsillar hypertrophy; Detrusor instability
* Corresponding author. Address: 27 Bank Misr Street, Mansoura, Egypt. E-mail addresses: [email protected], [email protected] (A. Elasfour). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00723-4
702
A. Elasfour et al. / International Congress Series 1240 (2003) 701–705
1. Subjects and methods Group 1: children with monosymptomatic enuresis (MSE) (they only had night bed wetting) and included 16 children, 7 males and 9 females. Group 2: Those with polysymptomatic enuresis (They had night bed wetting + diurnal voiding symptoms) and included 9 children, 4 males and 5 females. All children were subjected to the following. (1) History taking and clinical evaluation to exclude those with obvious neurological disorders or mental retardation. (2) Anthropometric measurements, including weight, height, and determination of body mass index. (3) Nose and throat evaluation of tonsils and adenoids grading. (4) Plain X-ray of the nasopharyngeal region (lateral view in the upright position with mouth closed). (5) Sleep study and assessment of apnea/hypopnea index (AHI) and lowest oxygen saturation (SaO2) was done. (6) Urodynamic studies (filling cystometry) were performed using a method described by Ruarte and Quesada [1]. The machine used was Dantic 5500 UD, Denmark. The child was asked to urinate before testing, then catheterized with either a no. 7 or 11 Fr. triple-lumen urodynamic catheter (Cook Urological, Spencer, IN). The residual urine was measured. A small balloon was passed into the rectum to measure the intra-abdominal pressure during the cystometrogram. The bladder was filled with a rate ranging from 5 to 10 ml/min depending on the age of the child. At capacity, the child urinates, and the voiding pressures were measured. Bladder capacity refers to the cystometric maximum capacity recorded with the patient standing (boys) or sitting (girls) and is expressed as a percentage of the mean normal value. The child’s predicted bladder capacity=[(age in years + 2) 30 and divided by 10. Bladder instability was defined as the presence of detrusor contractions that the patient could not suppress, recorded during provocative cystometry [2]. (7) Adenotonsillectomy was carried out for all children. Postoperative evaluation of AHI and SaO2 was done after 3
Table 1 Some clinical and urodynamic data and postoperative response in the studied groups (chi-square) Studied parameter
Monosymptomatic (N = 16)
Male/female
7:9
Number
Snoring At night only All time Daytime somnolence Detrusor Stable Unstable Response Adequate Incomplete No response
%
Polysymptomatic (N = 9) Number
Test used v2
P
0.001
0.97
%
4:5
8 8 9
50 50 56
4 5 5
44 56 56
0.07
0.78
0.001
< 0.0001
14 2
88 12
1 8
11 89
11.0
< 0.0001
16 0 0
100 0 0
0 7 2
0 78 22
25
< 0.001
A. Elasfour et al. / International Congress Series 1240 (2003) 701–705
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Table 2 Body mass index (BMI) and sleep studies in the 2 studied groups Parameter
Monosymptomatic
Polysymptomatic
T-test
P
Age BMI Pre AHI Post AHI % of imp. AHI Pre SaO2 Post SaO2 % of imp. SaO2
05.75 F 02.11 19.40 F 01.10 31.12 F 11.70 05.62 F 02.52 81.10 F 09.70 80.62 F 06.90 91.69 F 02.84 14.40 F 08.50
05.78 F 02.11 26.00 F 03.35 41.89 F 13.70 17.56 F 09.20 61.10 F 13.60 75.56 F 05.80 82.44 F 04.72 09.30 F 03.50
0.03 5.70 1.90 3.81 3.89 1.90 5.35 2.10
0.97 < 0.001 0.08 0.004 0.002 0.06 < 0.001 0.04
Pre AHI = preoperative apnea/hypopnea index; Post AHI = postoperative apnea/hypopnea index; % of imp. AHI = percentage of AHI improvement after adenotonsillectomy = Pre AHI Post AHI/Pre AHI (%); Pre and Post SaO2 = preoperative and postoperative values of lowest oxygen saturation; % of imp. SaO2 = percentage of improvement of the lowest oxygen saturation after surgery.
months. Clinical response of nocturnal enuresis (NE) within 3 –6 months was also assessed.
2. Results All patients had grade 3 tonsillar enlargement (Table 1). Body mass index was significantly higher in children with group 2 (polysymptomatic NE) compared to those of group 1 ( p < 0.001). The preoperative AHI and the lowest SaO2 showed no significant differences between the two groups ( p = 0.08 and 0.06, respectively). However, the postoperative AHI was significantly decreased, and SaO2 was significantly improved in group 1 when compared with group 2 ( p = 0.004 and p < 0.001, respectively) (Table 2). Urodynamic studies revealed the presence of detrusor instability in 12% of children of group 1 and in 89% of group 2. Decreased bladder compliance was not found among group 1 children and detected in 11% of children of group 2. The difference was statistically significant ( p < 0.0001) (Table 3, Fig. 1). Response to adenotonsillectomy led to a complete cure of NE in children of group 1. However, in group 2, 7 out of 9 children had incomplete response (presence of night bed wetting), and the other 2 children showed no response at all (Table 1). Significant positive correlation was found between the
Table 3 The incidence of detrusor instability and the distribution of bladder stability with maximum detrusor capacity Type of enuresis
Monosymptomatic
Polysymptomatic
Maximum/normal capacity (%)
Bladder Stable
Unstable
< 80 80 – 120 >120 < 80 80 – 120 >120
1 10 3 0 1 0
0 1 1 1 5 2
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A. Elasfour et al. / International Congress Series 1240 (2003) 701–705
Fig. 1. Clinical and urodynamic parameters in both groups.
clinical cure and the percentage of improvement of AHI ( p = 0.002). However, there was a significant negative correlation between the response and the presence of diurnal voiding symptoms ( p < 0.001, Table 4).
3. Discussion Welder et al. [3] found a relation between NE and disturbed sleep patterns. In this study, our children had NE with manifestations of upper airway obstruction due to adenotonsillar hypertrophy. Sleep studies of AHI and SaO2 revealed the presence of pathological events ranging from mild to severe obstructive sleep apnea. Preoperative AHI was higher, and SaO2 was lower in group 2 compared to group 1, but the differences were not statistically significant ( p = 0.08 and 0.06, respectively). The higher value of AHI in group 2 may be affected by the significantly high value of BMI in this group compared to group 1 ( p < 0.001), thus, obesity may be an adding factor to OSAS. The above findings were clarified by Kudoh and Sanai [4], who observed that obese children with adenotonsillar Table 4 Correlation studies between the response and % of improvement of AHI, % of improvement of SaO2, and presence of diurnal voiding symptoms (Kendall Tau-b) Parameter % of improvement of AHI % of improvement of SaO2 Diurnal voiding symptoms
r
P 0.51 0.25 0.95
0.002 0.13 < 0.001
A. Elasfour et al. / International Congress Series 1240 (2003) 701–705
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hypertrophy have more severe apnea than subjects suffering from only one condition. In agreement to the above, we found that the postoperative AHI and SaO2 were significantly improved in children with group 1 (who were not obese and had no diurnal voiding symptoms) compared to group 2 children ( p = 0.004 and 0.001, respectively). Urodynamic studies revealed that 2 out of 16 patients in group 1 showed unstable detrusor contraction. The remaining children had normal filling cystometry, and micturition was normal in all subjects. In group 2, 8 out of 9 children had detrusor instability, and 1 of them also had decreased bladder compliance. The remaining one had a stable bladder. The micturition was also normal in the whole group. Thus, group 2 children who had diurnal voiding symptoms and higher BMI showed significantly more urodynamic abnormalities than children of group 1 ( p < 0.0001). Adenotonsillectomy led to a complete cure of NE in children of group 1. However, no one among group 2 was cured completely (78% of them had some night bed wetting, and 22% were still having frequent night bed wetting). On the other hand, the absence of clinical response was due to the presence of abnormal urodynamic, singly or in association of with obesity. In conclusion, removal of upper airway obstruction by adenotonsillectomy led to a complete cure of NE in all children with monosymptomatic category. The response was inadequate or absent in the presence of urodynamic abnormalities. Obesity also may affect the response either singly through the persistence of obstructive sleep apnea or in combination with abnormal urodynamics. Therefore, these children may benefit from bladder physiotherapy and/or reduction of body weight.
References [1] A. Ruarte, E.M. Quesada, Urodynamic evaluation in children, in: A.B. Retik, J. Cukier (Eds.), Pediatric Urology, Williams & Wilkins, 1987, pp. 114 – 132. Chap. 6. [2] R. Turner-Warwick, Observations on the function and dysfunction of the sphincter and detrusor mechanisms, Urol. Clin. North Am. 6 (1979) 13 – 30. [3] D.J. Welder, M.J. Sateia, R.P. West, Nocturnal enuresis in children with upper airway obstruction, Otolaryngol.-Head Neck Surg. 103 (3) (1991) 427 – 432. [4] F. Kudoh, A. Sanai, Effect of tonsillectomy and adenoidectomy on obese children with sleep-associated breathing disorder, Acta Otolaryngol. (Stockh.) (Suppl. 523) (1996) 216 – 218.
Nocturnal enuresis in children with adenotonsillar hypertrophy Ahmed Elasfour a,*, Moustafa El-Ayouty b, Alaa Mokhtar c, Nabil Abdel-Mageed d a
Department of Otolaryngology—Head and Neck Surgery, Mansoura University, Mansura, Egypt b Department of Pediatrics, Mansoura University, Mansura, Egypt c Urology Center, Mansoura University, Mansura, Egypt d Department of Anesthesiology, Mansoura University, Mansura, Egypt
Abstract The relationship between upper airway obstruction and nocturnal enuresis (NE) was studied in 25 children with adenotonsillar hypertrophy. There were 11 males and 14 females. Their ages ranged from 4 to 10 years. Most of them received medical therapy for NE with unsatisfactory response. They were classified according to the presence or absence of diurnal voiding into two groups: monosymptomatic NE (16 children) and polysymptomatic NE (9 children). Obvious neurological abnormalities were excluded. All patients had been subjected to adenotonsillectomy and reevaluated 3 – 6 months later for their clinical response. Our results revealed (1) no significant differences between the two groups as far as age, sex, and manifestations of upper airway obstruction were concerned; (2) body mass index was significantly higher in group 2 (polysymptomatic) compared to group 1 ( p < 0.001); (3) detrusor instability was significantly higher in group 2 compared to group 1 ( p < 0.0001); (4) the preoperative apnea/hypopnea index (AHI) and percent oxygen saturation (SaO2%) showed no significant differences between the two groups; however, the postoperative values revealed significant improvement of both AHI and SaO2% in group 1 (monosymptomatic) when compared to group 2 ( p = 0.004 and p < 0.001, respectively). The postoperative follow-up showed a complete response of NE among children of group 1 and inadequate or no response among children of group 2. We concluded that removal of the upper airway obstruction by adenotonsillectomy led to a complete cure of NE in all children with monosymptomatic category. The polysymptomatic category may get more benefit with bladder physiotherapy and/or reduction of body weight. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Nocturnal enuresis; Upper airway obstruction; Adenotonsillar hypertrophy; Detrusor instability
* Corresponding author. Address: 27 Bank Misr Street, Mansoura, Egypt. E-mail addresses: [email protected], [email protected] (A. Elasfour). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00723-4
702
A. Elasfour et al. / International Congress Series 1240 (2003) 701–705
1. Subjects and methods Group 1: children with monosymptomatic enuresis (MSE) (they only had night bed wetting) and included 16 children, 7 males and 9 females. Group 2: Those with polysymptomatic enuresis (They had night bed wetting + diurnal voiding symptoms) and included 9 children, 4 males and 5 females. All children were subjected to the following. (1) History taking and clinical evaluation to exclude those with obvious neurological disorders or mental retardation. (2) Anthropometric measurements, including weight, height, and determination of body mass index. (3) Nose and throat evaluation of tonsils and adenoids grading. (4) Plain X-ray of the nasopharyngeal region (lateral view in the upright position with mouth closed). (5) Sleep study and assessment of apnea/hypopnea index (AHI) and lowest oxygen saturation (SaO2) was done. (6) Urodynamic studies (filling cystometry) were performed using a method described by Ruarte and Quesada [1]. The machine used was Dantic 5500 UD, Denmark. The child was asked to urinate before testing, then catheterized with either a no. 7 or 11 Fr. triple-lumen urodynamic catheter (Cook Urological, Spencer, IN). The residual urine was measured. A small balloon was passed into the rectum to measure the intra-abdominal pressure during the cystometrogram. The bladder was filled with a rate ranging from 5 to 10 ml/min depending on the age of the child. At capacity, the child urinates, and the voiding pressures were measured. Bladder capacity refers to the cystometric maximum capacity recorded with the patient standing (boys) or sitting (girls) and is expressed as a percentage of the mean normal value. The child’s predicted bladder capacity=[(age in years + 2) 30 and divided by 10. Bladder instability was defined as the presence of detrusor contractions that the patient could not suppress, recorded during provocative cystometry [2]. (7) Adenotonsillectomy was carried out for all children. Postoperative evaluation of AHI and SaO2 was done after 3
Table 1 Some clinical and urodynamic data and postoperative response in the studied groups (chi-square) Studied parameter
Monosymptomatic (N = 16)
Male/female
7:9
Number
Snoring At night only All time Daytime somnolence Detrusor Stable Unstable Response Adequate Incomplete No response
%
Polysymptomatic (N = 9) Number
Test used v2
P
0.001
0.97
%
4:5
8 8 9
50 50 56
4 5 5
44 56 56
0.07
0.78
0.001
< 0.0001
14 2
88 12
1 8
11 89
11.0
< 0.0001
16 0 0
100 0 0
0 7 2
0 78 22
25
< 0.001
A. Elasfour et al. / International Congress Series 1240 (2003) 701–705
703
Table 2 Body mass index (BMI) and sleep studies in the 2 studied groups Parameter
Monosymptomatic
Polysymptomatic
T-test
P
Age BMI Pre AHI Post AHI % of imp. AHI Pre SaO2 Post SaO2 % of imp. SaO2
05.75 F 02.11 19.40 F 01.10 31.12 F 11.70 05.62 F 02.52 81.10 F 09.70 80.62 F 06.90 91.69 F 02.84 14.40 F 08.50
05.78 F 02.11 26.00 F 03.35 41.89 F 13.70 17.56 F 09.20 61.10 F 13.60 75.56 F 05.80 82.44 F 04.72 09.30 F 03.50
0.03 5.70 1.90 3.81 3.89 1.90 5.35 2.10
0.97 < 0.001 0.08 0.004 0.002 0.06 < 0.001 0.04
Pre AHI = preoperative apnea/hypopnea index; Post AHI = postoperative apnea/hypopnea index; % of imp. AHI = percentage of AHI improvement after adenotonsillectomy = Pre AHI Post AHI/Pre AHI (%); Pre and Post SaO2 = preoperative and postoperative values of lowest oxygen saturation; % of imp. SaO2 = percentage of improvement of the lowest oxygen saturation after surgery.
months. Clinical response of nocturnal enuresis (NE) within 3 –6 months was also assessed.
2. Results All patients had grade 3 tonsillar enlargement (Table 1). Body mass index was significantly higher in children with group 2 (polysymptomatic NE) compared to those of group 1 ( p < 0.001). The preoperative AHI and the lowest SaO2 showed no significant differences between the two groups ( p = 0.08 and 0.06, respectively). However, the postoperative AHI was significantly decreased, and SaO2 was significantly improved in group 1 when compared with group 2 ( p = 0.004 and p < 0.001, respectively) (Table 2). Urodynamic studies revealed the presence of detrusor instability in 12% of children of group 1 and in 89% of group 2. Decreased bladder compliance was not found among group 1 children and detected in 11% of children of group 2. The difference was statistically significant ( p < 0.0001) (Table 3, Fig. 1). Response to adenotonsillectomy led to a complete cure of NE in children of group 1. However, in group 2, 7 out of 9 children had incomplete response (presence of night bed wetting), and the other 2 children showed no response at all (Table 1). Significant positive correlation was found between the
Table 3 The incidence of detrusor instability and the distribution of bladder stability with maximum detrusor capacity Type of enuresis
Monosymptomatic
Polysymptomatic
Maximum/normal capacity (%)
Bladder Stable
Unstable
< 80 80 – 120 >120 < 80 80 – 120 >120
1 10 3 0 1 0
0 1 1 1 5 2
704
A. Elasfour et al. / International Congress Series 1240 (2003) 701–705
Fig. 1. Clinical and urodynamic parameters in both groups.
clinical cure and the percentage of improvement of AHI ( p = 0.002). However, there was a significant negative correlation between the response and the presence of diurnal voiding symptoms ( p < 0.001, Table 4).
3. Discussion Welder et al. [3] found a relation between NE and disturbed sleep patterns. In this study, our children had NE with manifestations of upper airway obstruction due to adenotonsillar hypertrophy. Sleep studies of AHI and SaO2 revealed the presence of pathological events ranging from mild to severe obstructive sleep apnea. Preoperative AHI was higher, and SaO2 was lower in group 2 compared to group 1, but the differences were not statistically significant ( p = 0.08 and 0.06, respectively). The higher value of AHI in group 2 may be affected by the significantly high value of BMI in this group compared to group 1 ( p < 0.001), thus, obesity may be an adding factor to OSAS. The above findings were clarified by Kudoh and Sanai [4], who observed that obese children with adenotonsillar Table 4 Correlation studies between the response and % of improvement of AHI, % of improvement of SaO2, and presence of diurnal voiding symptoms (Kendall Tau-b) Parameter % of improvement of AHI % of improvement of SaO2 Diurnal voiding symptoms
r
P 0.51 0.25 0.95
0.002 0.13 < 0.001
A. Elasfour et al. / International Congress Series 1240 (2003) 701–705
705
hypertrophy have more severe apnea than subjects suffering from only one condition. In agreement to the above, we found that the postoperative AHI and SaO2 were significantly improved in children with group 1 (who were not obese and had no diurnal voiding symptoms) compared to group 2 children ( p = 0.004 and 0.001, respectively). Urodynamic studies revealed that 2 out of 16 patients in group 1 showed unstable detrusor contraction. The remaining children had normal filling cystometry, and micturition was normal in all subjects. In group 2, 8 out of 9 children had detrusor instability, and 1 of them also had decreased bladder compliance. The remaining one had a stable bladder. The micturition was also normal in the whole group. Thus, group 2 children who had diurnal voiding symptoms and higher BMI showed significantly more urodynamic abnormalities than children of group 1 ( p < 0.0001). Adenotonsillectomy led to a complete cure of NE in children of group 1. However, no one among group 2 was cured completely (78% of them had some night bed wetting, and 22% were still having frequent night bed wetting). On the other hand, the absence of clinical response was due to the presence of abnormal urodynamic, singly or in association of with obesity. In conclusion, removal of upper airway obstruction by adenotonsillectomy led to a complete cure of NE in all children with monosymptomatic category. The response was inadequate or absent in the presence of urodynamic abnormalities. Obesity also may affect the response either singly through the persistence of obstructive sleep apnea or in combination with abnormal urodynamics. Therefore, these children may benefit from bladder physiotherapy and/or reduction of body weight.
References [1] A. Ruarte, E.M. Quesada, Urodynamic evaluation in children, in: A.B. Retik, J. Cukier (Eds.), Pediatric Urology, Williams & Wilkins, 1987, pp. 114 – 132. Chap. 6. [2] R. Turner-Warwick, Observations on the function and dysfunction of the sphincter and detrusor mechanisms, Urol. Clin. North Am. 6 (1979) 13 – 30. [3] D.J. Welder, M.J. Sateia, R.P. West, Nocturnal enuresis in children with upper airway obstruction, Otolaryngol.-Head Neck Surg. 103 (3) (1991) 427 – 432. [4] F. Kudoh, A. Sanai, Effect of tonsillectomy and adenoidectomy on obese children with sleep-associated breathing disorder, Acta Otolaryngol. (Stockh.) (Suppl. 523) (1996) 216 – 218.