{"id":40669,"date":"2021-09-30T11:10:25","date_gmt":"2021-09-30T11:10:25","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=40669"},"modified":"2021-10-11T09:24:57","modified_gmt":"2021-10-11T09:24:57","slug":"change-of-urinary-nitrite-excretion-in-primary-enuresis-after-indomethacin-treatment","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol14no3\/change-of-urinary-nitrite-excretion-in-primary-enuresis-after-indomethacin-treatment\/","title":{"rendered":"Change of Urinary Nitrite Excretion in Primary Enuresis after Indomethacin Treatment"},"content":{"rendered":"

Introduction<\/strong><\/p>\n

Nocturnal enuresis affects 15% to 20% of 5-years \u2013 old children Nocturnal enuresis delays early autonomy and socialization by decreasing in self-confidence and self-esteem.\u00a0Classification of nocturnal enuresis is the preliminary step to correct therapy. Enuresis is classified as primary (never acquired nocturnal control) or secondary (at last 6 months of dry nights) 1<\/sup>.<\/p>\n

There are various effects of PGs on the urethral, vesical, renal and sympathetic nervous system, PGs decrease aldosterone secretion, inhibit tubular reabsorption and ADH, so causes\u00a0natriuresis, glomerular vasodilatation and diuresis2<\/sup>. They also relax the urethra, reduce intraurethral pressure and enhance micturition. In addition, they activate capsaicin-sensitive\u00a0afferents in urinary bladder and increase acetylcholine from nerves3<\/sup>.<\/p>\n

PGs are proposed to be important in the pathogenesis of primary enuresis; accordingly, strong inhibitors of PG synthesis (e.g. indomethacin and diclofenac) were used to treat primary\u00a0enuresis 4, 5<\/sup>. We used Carbamazepine to treat PNE and those not responding, responded well to stronger Prostaglandin inhibitors6<\/sup>.<\/p>\n

In enuretic patients urinary and serum PGE2 concentrations are higher than in controls7<\/sup>. There is also evidence of increased production of autacoids in PNE, which\u00a0can cause diuresis and naturesis8<\/sup>.<\/p>\n

Most of the effects of No are similar to those of PGs on the urinary system9<\/sup>. It regulates the paracelluar permeability of proximal tubular cells, Na+\/K+ ATPase and Na+\/H+ exchanger.\u00a0It also inhibits sodium reabsorption, mediating pressure diuresis and natriuresis 10<\/sup>.\u00a0 There are also a relationship between PG production and No biosynthesis, so there might be a link\u00a0between No production in the urinary system and PNE11<\/sup>.<\/p>\n

We used nitrite as a marker for No production in vivo because it is a stable metabolite of No, and it is the major nitric oxide oxidation products in biological fluids. So nitrites can be\u00a0used as a good indicator of both PG and NO levels12, 13<\/sup><\/p>\n

The aim of our study was to assess urinary nitrite excretion in patients with primary nocturnal enuresis (PNE) and to evaluate the effects of indomethacin (a potent PG synthesis inhibitor) on urinary nitrite excretion.<\/p>\n

Patients and Methods<\/strong><\/p>\n

The study comprised forty children (21 girls and 19 boys) recruited from Enuresis clinic of specialized pediatric Hospital of Cairo University and Child Health Clinic, National Research\u00a0Center. They were divided into two groups:<\/p>\n

Group A<\/strong>. Comprised of 20 Children with primary enuresis and were given 50 mg indomethacin suppositories each night for 1 month.<\/p>\n

Group B.<\/strong> Comprised of 20 children with PNE not receiving treatment just fluid restriction by night.<\/p>\n

Inclusion criteria<\/strong><\/p>\n

Age 5-14 years.<\/p>\n

Parents\u2019 consent to participate in the study.<\/p>\n

Bed wetting each night and completely continent during the day.<\/p>\n

No evidence of any other systemic disease, neurological disease or urinary tract abnormalities.<\/p>\n

No medications used within 1 month before the study.<\/p>\n

All patients were subjected to the following<\/strong><\/p>\n

History of frequency of bed wetting episodes, frequency of voiding at daytime and voiding abnormalities.<\/p>\n

Complete clinical examination.<\/p>\n

Laboratory investigations<\/strong><\/p>\n

Complete urine analysis to exclude bacteriuria, proteinuria or glucosuria.<\/p>\n

Urea and creatinine using Kone lab automated analyzer (Kone lab Corporation, Rukintie 18, FIN \u2013 02320, ESPOO, Finland).<\/p>\n

Total nitric oxide: The first urine of the day (mid-stream) was aseptically collected, voided directly into a sterile container. Samples were centrifuged, then diluted 10-folds with reaction buffer and ultra-filtered through a 10.000 molecular weight cut off filter to eliminate proteins.<\/p>\n

Samples were analyzed for nitric oxide by colorimetric method (R & D system, Inc. 614 McKinley place N.E. Minneapolis, USA) according to the following principle\u00a0(R): nitrate is converted to nitrite by nitrate reductase enzyme, nitrite is detected as an azo dye product of the Griess reaction in which acidified nitrite produces a\u00a0nitro sating agent that reacts with sulfanilic acid to produce the diazonium ion. This ion is then coupled to N-(1-naphtly) ethylene diamine to form the\u00a0chromophoric azo-derivative, which absorbs light at 450-570 nm14<\/sup>.<\/p>\n

The previously mentioned tests were assessed at the beginning of the study and at the end after 1 month.<\/p>\n

In addition, 20 normal comparable controls were assessed as regards their urinary nitric acid concentrations to show the difference in its value between enuretics and normal individuals.<\/p>\n

Statistical analysis<\/strong><\/p>\n

All values were expressed as the mean (SD) and student’s t-test used for the statistical analysis and ANOVA test for comparison between three variables, with P<0.05 taken to\u00a0indicate significant differences.<\/p>\n

Results<\/strong><\/p>\n

Our study included 40 children with PNE who were divided into two groups; Group A (11 girls and 9 boys with a mean age of 8.6 \u00b1 2.3) receiving 50 mg Indomethacin\u00a0suppositories each night for 1 month and group B (9 girls and 11 boys with a mean age of 8.9 \u00b1 2.1) not receiving treatment, just fluid intake restriction by night (Table 1).<\/p>\n

Table 1: Data of the studied groups A and B.<\/strong><\/p>\n\n\n\n\n\n\n\n
\u00a0<\/strong><\/td>\nGroup A<\/strong><\/td>\nGroup B<\/strong><\/td>\n<\/tr>\n
Age<\/strong><\/td>\n8.6 \u00b1 2.3<\/td>\n8.9 \u00b1 2.1<\/td>\n<\/tr>\n
Sex<\/strong><\/td>\n11 girls and 9 boys<\/td>\n9 girls and 11 boys<\/td>\n<\/tr>\n
Frequency of bed wetting<\/strong><\/td>\n1-4 \/ night<\/td>\n1-4 \/ night<\/td>\n<\/tr>\n
Frequency of day voiding<\/strong><\/td>\n5-7\/ day<\/td>\n4-6\/ day<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Twenty normal comparable controls were assessed at the beginning of the study as regards only their urinary nitric acid just to show the difference in its levels in normal children from those with PNE (Table 2).<\/p>\n

Table 2: Differences in urinary nitric acid levels between enuretic and normal children before the study. <\/strong><\/p>\n\n\n\n\n\n\n
\u00a0<\/strong><\/td>\nGroup A<\/strong><\/td>\nGroup B<\/strong><\/td>\nControls<\/strong><\/td>\n<\/tr>\n
Urinary nitric acid<\/strong><\/td>\nMean<\/strong><\/td>\nSD<\/strong><\/td>\nMean<\/strong><\/td>\nSD<\/strong><\/td>\nMean<\/strong><\/td>\nSD<\/strong><\/td>\n<\/tr>\n
318.7<\/td>\n66.33<\/td>\n323.8<\/td>\n75.43<\/td>\n33.0<\/td>\n7.6<\/td>\n<\/tr>\n
p-value<\/strong><\/td>\n0.001<\/strong><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

There was a much higher levels of urinary nitric acid levels in groups A and B (enuretic children) than found in normal comparable controls which was highly statistically significant (P.0.001).<\/p>\n

After 1 month of treatment by Indomethacin, Group A patients showed a marked decrease in urinary nitric acid and the frequency of bed-wetting is markedly decreased (Table 3).<\/p>\n

Table 3: Urinary nitric acid levels and frequency of bed-wetting in-group A before and after the study.<\/strong><\/p>\n\n\n\n\n\n\n\n
\u00a0<\/strong><\/td>\nNitric acid \u00b5mol\/L<\/strong><\/td>\nFrequency of bed wetting number\/night <\/strong><\/td>\n<\/tr>\n
Mean<\/strong><\/td>\nSD<\/strong><\/td>\nMean<\/strong><\/td>\nSD<\/strong><\/td>\n<\/tr>\n
Before <\/strong><\/td>\n318.7<\/td>\n66.33<\/td>\n2.25<\/td>\n0.35<\/td>\n<\/tr>\n
After<\/strong><\/td>\n146.3<\/td>\n41.58<\/td>\n0.91<\/td>\n0.48<\/td>\n<\/tr>\n
p-value <\/strong><\/td>\n0.001<\/strong><\/td>\n0.04<\/strong><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

While in Group B patients who did not receive Indomethacin; there was an improvement but it was not statistically significant as regards both nitric acid levels and frequency of bed wetting (Table 4).<\/p>\n

Table 4: Urinary nitric acid levels and frequency of bed-wetting in Group B before and after the study.<\/strong><\/p>\n\n\n\n\n\n\n\n
\u00a0<\/strong><\/td>\nNitric acid \u00b5mol\/L<\/strong><\/td>\nFrequency of bed wetting number\/night <\/strong><\/td>\n<\/tr>\n
Mean<\/strong><\/td>\nSD<\/strong><\/td>\nMean<\/strong><\/td>\nSD<\/strong><\/td>\n<\/tr>\n
Before <\/strong><\/td>\n323.8<\/td>\n75.43<\/td>\n2.2<\/td>\n1.45<\/td>\n<\/tr>\n
After<\/strong><\/td>\n275.0<\/td>\n90.68<\/td>\n1.89<\/td>\n0.75<\/td>\n<\/tr>\n
p-value <\/strong><\/td>\n0.487<\/strong><\/td>\n0.366<\/strong><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

On comparing the results of both Groups A and B\u00a0 after the study time, analysis of the results showed a highly statistically significant in the urinary nitric acid and frequency of bed wetting with a much better improvement in group A (Table 5).<\/p>\n

Table 5: Urinary nitric acid levels and frequency of bed-wetting in both groups A and B after the study.<\/strong><\/p>\n\n\n\n\n\n\n\n
\u00a0<\/strong><\/td>\nNitric acid \u00b5mol\/L<\/strong><\/td>\nFrequency of bed wetting number\/night <\/strong><\/td>\n<\/tr>\n
Mean<\/strong><\/td>\nSD<\/strong><\/td>\nMean<\/strong><\/td>\nSD<\/strong><\/td>\n<\/tr>\n
Group A <\/strong><\/td>\n146.3<\/td>\n41.58<\/td>\n0.91<\/td>\n0.48<\/td>\n<\/tr>\n
Group B<\/strong><\/td>\n275.0<\/td>\n90.68<\/td>\n1.89<\/td>\n0.75<\/td>\n<\/tr>\n
p-value <\/strong><\/td>\n0.001<\/strong><\/td>\n0.001<\/strong><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Discussion<\/strong><\/p>\n

Our study showed that patients with PNE have high nitrite concentration that markedly decreased after indomethacin treatment and this was associated with a significant decrease in\u00a0the frequency of bed-wetting.<\/p>\n

The means of nitric acid excretion in the normal control was 33 \u00b1 7.6 while it was 318.7\u00a0 \u00b1 66.3 in group A (Patients with PNE receiving indomethacin) and 323.8 \u00b1 75.4 in group B<\/p>\n

(enuretics not receiving treatment) at the beginning of the study which is a highly significant difference. While comparing the nitric acid excretion by the end of the study in both of group A\u00a0and B; their means were 146.3 \u00b1 41.58 and 275 \u00b1 90.68 respectively with a p-value of 0.001, which is a highly statistically significant difference. The decrease in the nitrite\u00a0excretion was associated with a great improvement in the frequency of bed-wetting in-group A receiving indomethacin, while in-group B (not receiving indomethacin, just fluid\u00a0restriction) there was an improvement in bed wetting, but was not of statistically significant difference.<\/p>\n

So the percentage of improvement in bed wetting and the decrease in the nitric acid excretion in group A after taking indomethacin was 95% white it was only 35% in group B.<\/p>\n

It was suggested that there is a major interaction between PG and No in mediating the renal response to various situations. Rajapakse et al., (2004) reported that over production of No\u00a0increases urine production, decrease urethral pressure and solute excretion allowing passage of little urine in urethra and initiating contraction of the bladder, which is exaggerated by\u00a0high PG production, encountered to enuresis 15<\/sup>.<\/p>\n

Our findings agree with a study done by Jabbour et al., (2019) who stated that urinary excretion of nitrite, nitrate and No production were inhibited by indomethacin treatment and so\u00a0enuresis is improved by inhibiting No and PG production in urinary system 16<\/sup>.<\/p>\n

In addition, a study done by Al-Waili et al., (2005) reported that high urinary nitrite excretion in UTIs and cystitis cause enuresis, and this provide an evidence of the possible role\u00a0of No in the pathogenesis of enuresis 17<\/sup>.<\/p>\n

A report done by Kawauchi et al., (2000) stated that decrease in nocturnal bladder capacity was related to nocturnal voiding frequency in elderly patients, as volumes did not change\u00a0significantly18<\/sup>. Another study done by Al-Waili (2002) showed that indomethacin decreased the nocturnal voiding frequency 19<\/sup>.<\/p>\n

Kamperis et al., (2017) stated that inhibiting PGs with indomethacin could increase the bladder capacity and decrease voiding frequency in patients with a small bladder capacity, as\u00a0PGs prompt bladder contractions and responsible for an unstable bladder20<\/sup>.<\/p>\n

Conclusion<\/strong><\/p>\n

In patients with PNE, there is a significant increase in urinary nitrite excretion, indomethacin markedly reduced bed-wetting and decreased the frequency of voiding in enuretics,\u00a0which was associated with significant decrease in urinary nitrite excretion. Drugs reducing urinary nitrite excretion should be considered as successful therapies in primary nocturnal enuresis.<\/p>\n

Conflict of interest<\/strong><\/p>\n

The authors declare that they have no conflict of interest.<\/p>\n

Acknowledgment<\/strong><\/p>\n

The authors thank all participants and their parents.<\/p>\n

References<\/strong><\/p>\n

    \n
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    Introduction Nocturnal enuresis affects 15% to 20% of 5-years \u2013 […]<\/p>\n","protected":false},"author":15,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[93],"tags":[],"class_list":["post-40669","post","type-post","status-publish","format-standard","hentry","category-vol14no3"],"_links":{"self":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/40669","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/users\/15"}],"replies":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/comments?post=40669"}],"version-history":[{"count":5,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/40669\/revisions"}],"predecessor-version":[{"id":41166,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/40669\/revisions\/41166"}],"wp:attachment":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/media?parent=40669"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/categories?post=40669"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/tags?post=40669"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}