Question

• An 8 y.o. girl presents with secondary nocturnal enuresis.  Appropriate physical exam and laboratory testing have ruled out any organic cause.  You don't feel ddAVP, watchful waiting, or the enuresis alarm would be good options.  You are debating between imipramine and the book, Dry All Night, by Alison Mack.

Clinical Bottom Lines

1. Prior studies have indicated that: with imipramine, there is a high rate of relapse with the discontinuation of imipramine, somewhere between 56 and 76%; with no treatment, an estimated 85% of children per year will continue to have nocturnal enuresis without intervention; and with hypnotherapy, the rate of relapse following the teaching of hypnotherapy ranged between 16 and 32%. 
2. In this study, at the 9 month f/u, hypnotherapy was significantly more effective than imipramine (p<0.01).  For various reasons, however, the study was not very valid.  With some adjustments, estimates could be made which include the following: 
• Between 1.6 and 2.8 patients (NNT = 2-3) would need to be treated with hypnotherapy instead of imipramine to relieve sleepwetting in one child 9 months later. 
• Hypnotherapy reduced the risk (RRR) of continued sleepwetting 9 months later by 43 to 73% over imipramine. 
3. Although only one study could be found comparing these 2 treatments, and although the validity of the study is poor, the risks of treatment are low, suggesting that it may be worth a trial. 
4. Because of the benign nature of hypnotherapy in the form of Dry All Night, (no known side effects compared to imipramine, no safety issues for other children in the family, little effort on the part of the parents, low cost, and the nature of the therapy allowing the child to take control of and pride in the therapeutic process), this therapy is a reasonable first line treatment.

Summary of Key Evidence

1. Subjects:  50 children  (30 male, 20 female) from a pediatric outpatient outpatient clinic, all with a history of wetting the bed at least once every night.  44 had primary and 6 had secondary enuresis.  Age range 5 to 16 years.  Subjects assigned alternately to hypnosis or imipramine treatment groups, because it was not felt that randomization was a reasonable alternative in this setting.
2. Methods:

• Hypnotherapy:
• Anatomy explained and the idea that the brain controls the body presented. 
• Taught to relax and then hypnosis induced by using imagery of a favorite place.
• Emphasized the child's capacity to control his or her own body.
• Gave instructions to awaken when the bladder was full, urinate in the toilet, and go back to sleep in bed.
• Two 30 minute sessions, followed by ever other day to once per week visits.
• Imipramine:
• 25 mg po qhs, increased by 25 mg q week until maximum tolerance/effectiveness reached.
• Weekly f/u for 4 weeks, then once per month.
• All intervention d/c'd after 3 months, and follow-up done 6 months later (9 months from the start of treatment).

• Results:

• Lost to follow-up: 4 in the hypnosis group and 5 in the imipramine group.
• Patients responses divided into:
• "Positive response" = all dry beds or a reduction in frequency.
• "No response" = no change in frequency or lost to follow-up
• Treatment response comparable (p>0.05) in both groups at the end of three months.
• At the 9 month f/u, hypnotherapy significantly more effective than imipramine (p<0.01)

Additional Comments

• What is Hypnotherapy, as used in the book, Dry All Night? "A state of mind, usually combining relaxation with concentration or a desired point of focus so that other undesired thoughts or feelings then fade into the background."
• Dry All Night represents multisensory imagery or story-telling techniques. Alternative techniques include movement imagery, ideomotor method, or eye fixation.

Citation

1. Banerjee S, Srivastav A.  Hypnosis and Self-Hypnosis in the Management of Nocturnal Enuresis:  A Comparative Study with Imipramine Therapy.  American Journal of Clinical Hypnosis, 1993; 36:113-119.
2. Edward SD, Van Der Spuy HIJ.  Hypnotherapy as a Treatment for Enuresis.  Journal of Child Psychology and Psychiatry, 1985; 26:161-170.
3. Mack A.  Dry All Night: The Picture Book Technique That Stops Bedwetting.  Little, Brown, and Company.  1989.
4. Olness K.  The Use of Self-Hypnosis in the Treatment of Childhood Nocturnal Enuresis: A Report on Forty Patients.  Clinical Pediatrics, 1975; 14:273-279.
5. Olness K, Kohen D.  Hypnosis and Hypnotherapy with Children.  Guilford Press.  1996.
6. Tietjen DN, Husmann DA.  Nocturnal Enuresis:  A Guide to Evaluation and Treatment.  Mayo Clinic Proceedings, 1996; 71:857-862.

CAT Author: Julie Lumeng, MD

CAT Appraisers: Sheila Gahagan, MD

Date appraised: February 1, 1999