今日の臨床サポート

夜尿症(小児科)

著者: 片山啓 片山キッズクリニック

監修: 渡辺博 帝京大学老人保健センター

著者校正/監修レビュー済:2017/01/20
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. 夜尿症(nocturnal enuresis)とは、膀胱のコントロールが確立する年齢(通常5歳)を超えても夜間睡眠時の尿漏れがみられる状態をいう。
  1. 日中・夜間を問わず尿漏れがみられる状態は遺尿症(enuresis)、日中のみの場合は尿失禁症(urinary incontinence)という。
  1. 出生から5~6歳に至るまで尿漏れが持続しているものを1次性(primary)、6カ月以上尿漏れのない時期があって再び尿漏れがみられるようになったものを2次性(secondary)という。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
片山啓 : 特に申告事項無し[2021年]
監修:渡辺博 : 特に申告事項無し[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 膀胱のコントロールが確立する年齢(通常5歳)を超えても夜間睡眠時の尿漏れがみられる状態を夜尿症(nocturnal enuresis)という。
  1. 日中・夜間を問わず尿漏れがみられる状態は遺尿症(enuresis)、日中のみの場合は尿失禁症(urinary incontinence)という。
  1. 夜尿症は、夜間の尿産生量の調節障害、器質的あるいは機能的な膀胱容量の不足、睡眠の深度などいくつかの要素が関わってもたらされる症候群である。
  1. 病形について国内・国外でいくつかの分類が試みられているが、まだ確立されたものはない。
  1. 出生から5~6歳に至るまで尿漏れが持続しているものを1次性(primary)、6カ月以上尿漏れのない時期があって再び尿漏れがみられるようになったものを2次性(secondary)という。
  1. 5歳児の15~20%、若年成人の2%にみられ、男性に多い傾向がある。
  1. 無治療の状態で、1年ごとに患者のうち15%が自然軽快するといわれている。
  1. 自然軽快が期待される一方、患者や家族の心理的、物理的負担が大きく、やはり治療は必要と考えられる。
  1. 治療対象となるのは小学校入学後(6歳以上)である。
問診・診察のポイント  
  1. 夜尿症の診断・治療開始に当たっては問診が非常に重要である。以下に列記することを含め、細かく患児の状態、経過を尋ねることによって病像がより明らかになり、より適切と思われる治療から開始できる。

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文献 

著者: C M A Glazener, J H C Evans, R E Peto
雑誌名: Cochrane Database Syst Rev. 2005 Apr 18;(2):CD002911. doi: 10.1002/14651858.CD002911.pub2. Epub 2005 Apr 18.
Abstract/Text 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 STRATEGY: We searched the Cochrane Incontinence Group specialised trials register (searched 22 November 2004) 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 five trials met the inclusion criteria, involving 3152 children of whom 2345 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 45/81 (55%) vs 80/81 (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% 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 appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (4/22 (18%) vs 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69). Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94).
AUTHORS' CONCLUSIONS: Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. 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.

PMID 15846643  Cochrane Database Syst Rev. 2005 Apr 18;(2):CD002911. d・・・
著者: National Clinical Guideline Centre (UK)
Abstract/Text This guideline aims to provide advice on the assessment and management of children and young people with bedwetting. The guidance is applicable to children and young people up to 19 years with the symptom of bedwetting. It has been common practice to define enuresis as abnormal from 5 years and only to consider children for treatment when they are 7 years. While the prevalence of symptoms decreases with age the guideline scope did not specify a younger age limit in order to consider whether there were useful interventions that might be of benefit to children previously excluded from advice and services.
PMID 22031959  
著者: C M Glazener, J H Evans
雑誌名: Cochrane Database Syst Rev. 2002;(3):CD002112. doi: 10.1002/14651858.CD002112.
Abstract/Text BACKGROUND: Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults.
OBJECTIVES: To assess the effects of desmopressin on nocturnal enuresis in children, and to compare desmopressin with other interventions.
SEARCH STRATEGY: We searched the Cochrane Incontinence Group trials register. Date of the most recent search: March 2002. The reference list of a previous version of this review was also searched.
SELECTION CRITERIA: All randomised trials of desmopressin for nocturnal enuresis in children were included in the review. Comparison interventions included placebo, other drugs, alarms or behavioural methods. Trials focused solely on daytime wetting were excluded.
DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the quality of the eligible trials, and extracted data.
MAIN RESULTS: Forty one randomised trials involving 2760 children (of whom 1813 received desmopressin) met the inclusion criteria. The quality of many of the trials was poor. Desmopressin was compared with another drug in four trials, and with alarms in seven. Desmopressin was effective in reducing bedwetting in a variety of doses and forms. Each dose of desmopressin reduced bedwetting by at least one night per week during treatment compared with placebo (e.g. 20 microg: 1.34 fewer wet nights per week, 95% CI 1.11 to 1.57). Children on desmopressin were more likely to become dry (e.g. RR for failure to achieve 14 dry nights with 20 mcg 0.84, 95% CI 0.79 to 0.91). However, there was no difference after treatment was finished. There was no clear dose-related effect of desmopressin, but the evidence was limited. Data which compared oral and nasal administration were too few to be conclusive. While desmopressin was better than diclofenac or indomethacin, and comparison with tricyclic drugs (amitriptyline and imipramine) suggested that they might be as effective as desmopressin, the data were inconclusive due to small numbers. There were more side effects with the tricyclics. In one small trial, desmopressin resulted in more wet nights than alarms towards the end of treatment (WMD 1.4, 95% CI: 0.14 to 2.66) and the chance of failure or relapse after alarms was less (RR 9.17, 95% CI 1.28 to 65.90). Although there were fewer wet nights during alarm treatment supplemented by desmopressin compared with alarms alone (WMD -1.35, 95% CI -2.32 to -0.38), the data are inconclusive about whether this is reflected in lower failure (RR 0.88, 95%CI 0.52 to 1.50) or subsequent relapse rates (RR 0.58, 95% CI 0.31 to 1.10).
REVIEWER'S CONCLUSIONS: Desmopressin rapidly reduced the number of wet nights per week, but there was some evidence that this was not sustained after treatment stopped. Comparison with alternative treatments suggested that desmopressin and tricyclics had similar clinical effects, but that alarms may produce more sustained benefits. However, based on the available limited evidence, these conclusions can only be tentative. Children should be advised not to drink more than 240 ml (8 oz) fluid during desmopressin treatment in order to avoid the possible risk of water intoxication.

PMID 12137645  Cochrane Database Syst Rev. 2002;(3):CD002112. doi: 10.・・・
著者: Kazunari Kaneko
雑誌名: Pediatr Int. 2012 Feb;54(1):8-13. doi: 10.1111/j.1442-200X.2011.03554.x.
Abstract/Text Nocturnal enuresis is common problem in children with a prevalence as high as 20% among children aged 5. Though nocturnal enuresis does not directly impose imminent danger to a patient's life, children with enuresis and their parents can be psychologically suffering in day-to-day life, including in school activities. Therefore, it is important to provide an explanation regarding the cause of nocturnal enuresis, how to approach the disorder, the course, and the outlook leading to the planned treatment. The cause of enuresis is considered to be a mismatch between nocturnal diuresis and nocturnal bladder capacity, nocturnal polyuria due to a lack of circadian change in antidiuretic hormones, and a developmental delay in the voiding mechanisms. Therefore, patients can be classified as the type associated with a large amount of urine at night (polyuria type), the type that is associated with a functionally small bladder capacity (bladder type), the type associated with both the aforementioned (mixed type), or the type that does not fall under any of these (normal type). Based on this logic, although the International Children's Continence Society has issued the standardization document, in which the enuresis alarm and desmopressin therapy are recommended as the first line treatment, a different tack has been taken in Japan, where the therapeutic strategy is plotted depending on the type of enuresis; pharmacotherapy for enuretic children aged 6 years or older includes desmopressin acetate for polyuria type, anticholinergic agents for bladder type, and a combination of these agents for mixed type.

© 2011 The Author. Pediatrics International © 2011 Japan Pediatric Society.
PMID 22222057  Pediatr Int. 2012 Feb;54(1):8-13. doi: 10.1111/j.1442-2・・・
著者: Tryggve Neveus, Paul Eggert, Jonathan Evans, Antonio Macedo, Søren Rittig, Serdar Tekgül, Johan Vande Walle, C K Yeung, Lane Robson, International Children's Continence Society
雑誌名: J Urol. 2010 Feb;183(2):441-7. doi: 10.1016/j.juro.2009.10.043. Epub 2009 Dec 14.
Abstract/Text PURPOSE: We provide updated, clinically useful recommendations for treating children with monosymptomatic nocturnal enuresis.
MATERIALS AND METHODS: Evidence was gathered from the literature and experience was gathered from the authors with priority given to evidence when present. The draft document was circulated among all members of the International Children's Continence Society as well as other relevant expert associations before completion.
RESULTS: Available evidence suggests that children with monosymptomatic nocturnal enuresis could primarily be treated by a primary care physician or an adequately educated nurse. The mainstays of primary evaluation are a proper history and a voiding chart. The mainstays of primary therapy are bladder advice, the enuresis alarm and/or desmopressin. Therapy resistant cases should be handled by a specialist doctor. Among the recommended second line therapies are anticholinergics and in select cases imipramine.
CONCLUSIONS: Enuresis in a child older than 5 years is not a trivial condition, and needs proper evaluation and treatment. This requires time but usually does not demand costly or invasive procedures.

Copyright 2010 American Urological Association. Published by Elsevier Inc. All rights reserved.
PMID 20006865  J Urol. 2010 Feb;183(2):441-7. doi: 10.1016/j.juro.2009・・・
著者: C M A Glazener, J H C Evans, R E Peto
雑誌名: Cochrane Database Syst Rev. 2003;(3):CD002117. doi: 10.1002/14651858.CD002117.
Abstract/Text BACKGROUND: Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults.
OBJECTIVES: To assess the effects of tricyclic and related drugs on nocturnal enuresis in children, and to compare them with other interventions.
SEARCH STRATEGY: We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles including two previously published versions of this review. Date of the most recent searches: December 2002.
SELECTION CRITERIA: All randomised and quasi-randomised trials of tricyclics or related drugs for nocturnal enuresis in children were included in the review. Comparison interventions included placebo, other drugs, alarms, behavioural methods or complementary/miscellaneous interventions. Trials focused solely on daytime wetting were excluded.
DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the quality of the eligible trials, and extracted data.
MAIN RESULTS: Fifty four randomised trials met the inclusion criteria, involving 3379 children. The quality of many of the trials was poor. Most comparisons or outcomes were addressed only by single trials. Treatment with most tricyclic drugs (such as imipramine, amitriptyline, viloxazine, nortriptyline, clomipramine and desipramine) was associated with a reduction of about one wet night per week while on treatment (eg imipramine compared with placebo, weighted mean difference (WMD) -1.19, 95% CI -1.56 to -0.82). The exception was mianserin, where results from one small trial did not reach statistical significance. About a fifth of the children became dry while on treatment (relative risk for failure (RR) 0.77, 95% CI 0.72 to 0.83), but this effect was not sustained after treatment stopped (eg imipramine versus placebo, RR 0.98, 95% CI 0.95 to 1.03). There was not enough information to assess the relative performance of one tricyclic against another, except that imipramine was better than mianserin. The evidence comparing desmopressin with tricyclics was unreliable or conflicting, but in one small trial all the children failed or relapsed after stopping active treatment with either drug.The evidence comparing tricyclics with alarms was also unreliable or conflicting during treatment. In one small trial all the children failed or relapsed after tricyclics stopped, compared with about half after alarms. This result was compatible with the results in the Cochrane review of alarm treatment, which found that about half the children remained dry after alarm treatment was finished. There was a little evidence from single trials to suggest that imipramine might be better than a simple reward system with star charts during treatment; worse than a complex intervention involving education, counseling, waking and retention control training; better than a restricted diet; and worse than hypnosis. However, these results need to be confirmed by further research.
REVIEWER'S CONCLUSIONS: Although tricyclics and desmopressin are effective in reducing the number of wet nights while taking the drugs, most children relapse after stopping active treatment. In contrast, only half the children relapse after alarm treatment. Parents should be warned of the potentially serious adverse effects of tricyclic overdose when choosing treatment. Further research is needed into comparisons between drug and behavioural or complementary treatments, and should include relapse rates after treatment is finished.

PMID 12917922  Cochrane Database Syst Rev. 2003;(3):CD002117. doi: 10.・・・
著者: C Persson-Jünemann, O Seemann, K U Köhrmann, K P Jünemann, P Alken
雑誌名: Eur Urol. 1993;24(1):92-6.
Abstract/Text Sixty-three children with persistent nocturnal enuresis were urodynamically assessed and subsequently treated with oxybutynin chloride. Urodynamic evaluation, including graduation of detrusor instability and comparison of maximum bladder capacity with the age-predicted norm, confirmed an inadequate storage function in 84% of the children. Treatment benefit totaling 70% was dependent upon urodynamic findings, with best relation to the determined bladder capacity. The value attributed to graduation of uninhibited contractions was prognostic in accordance with further subdivision of the maximum bladder capacity. Treatment benefit was limited in children with normal urodynamic findings.

PMID 8365449  Eur Urol. 1993;24(1):92-6.

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