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Original Investigation
September 9, 2021

Evaluation of Nocturnal Enuresis After Adenotonsillectomy in Children With Obstructive Sleep Apnea: A Secondary Analysis of a Randomized Clinical Trial

Author Affiliations
  • 1School of Medicine, Eastern Virginia Medical School, Norfolk, Virginia
  • 2Department of Biostatistics, Children’s Hospital of the King’s Daughters, Norfolk, Virginia
  • 3Department of Otolaryngology–Head and Neck Surgery, Eastern Virginia Medical School, Norfolk
  • 4Department of Pediatric Sleep Medicine, Children’s Hospital of the King’s Daughters, Norfolk, Virginia
JAMA Otolaryngol Head Neck Surg. Published online September 9, 2021. doi:10.1001/jamaoto.2021.2303
Key Points

Question  Do children with nonsevere obstructive sleep apnea experience resolution of nocturnal enuresis after adenotonsillectomy?

Findings  In this econdary analysis of a randomized clinical trial including 393 of the 453 totally enrolled children, those with nonsevere obstructive sleep apnea, those who underwent adenotonsillectomy were more likely to experience resolution of nocturnal enuresis compared with children who did not receive surgery. Nocturnal enuresis was less frequent in girls; other clinical factors, such as age, obesity, and severity of sleep apnea, were not associated with improvement of nocturnal enuresis.

Meaning  The findings of this study suggest that it may be useful for clinicians to inquire about nocturnal enuresis in children with obstructive sleep apnea and counsel caregivers on the potential benefit associated with adenotonsillectomy.


Importance  Children with obstructive sleep apnea (OSA) are at increased risk for nocturnal enuresis (NE). However, randomized clinical trials assessing NE outcomes in children randomized to adenotonsillectomy (AT) vs watchful waiting are lacking.

Objective  To assess the outcomes of AT vs watchful waiting in children with nonsevere OSA who experience NE.

Design, Setting, and Participants  Secondary analysis of data from a multicenter randomized clinical trial conducted at tertiary children’s hospitals was performed. Participants included 453 children aged 5.0 to 9.9 years with nonsevere OSA who were randomized to either watchful waiting or AT as part of the multicenter Childhood Adenotonsillectomy Trial. Caregivers completed the Pediatric Sleep Questionnaire, which includes a binary item on bed-wetting, at baseline and 7-month follow-up. The trial was conducted between October 2007 and June 2012. Evaluation in this secondary analysis involving NE occurred from October 2019 to March 2021.

Interventions  Adenotonsillectomy vs watchful waiting in children with NE.

Main Outcomes and Measures  Prevalence of NE as defined by parental response to the Pediatric Sleep Questionnaire bed-wetting item at baseline and 7-month follow-up.

Results  Of the 453 children enrolled, 393 were included in analysis; of these, 201 were girls (51.1%). Mean (SD) age at baseline was 6.54 (1.40) years. At baseline, the number of children with NE was similar (2.6%; 95% CI, −0.12% to 0.07%) between the AT (59 [30.7%]) and watchful-waiting (67 [33.3%]) groups. The odds of NE in the watchful-waiting group were approximately 2 times higher than the AT group after 7 months (odds ratio, 2.0; 95% CI, 1.3 to 3.1). Following AT, there was a decrease (−11.0%; 95% CI, −16.3% to −5.7%) in the number of children with NE (n = 38). The prevalence of NE did not change significantly (−0.5%; 95% CI, −5.4% to 6.4%) in the watchful-waiting group (n = 66) at follow-up. Although NE was less frequent in girls (adjusted odds ratio, 0.53; 95% CI, 0.33-0.85), other clinical factors, such as age, race and ethnicity, obesity, and apnea-hypopnea index, were not associated with improvement of NE.

Conclusions and Relevance  In this secondary analysis of a randomized clinical trial, AT for the treatment of pediatric OSA appears to result in improvement in NE. Further research is needed to assess whether AT is associated with long-term benefits for NE compared with watchful waiting.

Trial Registration  ClinicalTrials.gov Identifier: NCT00560859

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