Enuresis: Difference between revisions

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{{SI}}
{{SI}}
'''Editor(s)-in-Chief:''' [[C. Michael Gibson]], M.S.,M.D. [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; '''Angela Botts''', M.D., Beth Israel Deaconess Medical Center Geriatric Medicine [mailto:abotts@bidmc.harvard.edu]; {{AE}} {{KS}}
'''Editor(s)-in-Chief:''' [[C. Michael Gibson]], M.S.,M.D. [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; '''Angela Botts''', M.D., Beth Israel Deaconess Medical Center Geriatric Medicine [mailto:abotts@bidmc.harvard.edu]; {{AE}} [[User:Sharma|Vatsala Sharma, M.B.B.S., M.D.]] {{KS}}


==Overview==
==Overview==


Enuresis is the involuntary [[urination]] beyond the age of anticipated control. The two major forms of enuresis are [[daytime wetting|diurnal enuresis]] (or daytime wetting), and [[nocturnal enuresis]] (bedwetting or nighttime wetting). Enuresis impacts the child and is associated with poor scholastic performance. It also has a major psychosocial burden on the family and this results in poorer [[quality of life]] in parents. This condition vastly affects the whole [[family]]. Treatment of enuresis should be holistic by managing enuresis in children, and providing psychotherapeutic support to the parents.
Enuresis is involuntary [[urination]] beyond the age of anticipated control. The two major forms of enuresis are [[daytime wetting|diurnal enuresis]] (or daytime wetting), and [[nocturnal enuresis]] (bedwetting or nighttime wetting). This condition adversely affects the whole [[family]]. Enuresis impacts the child's overall development and is mostly associated with poor scholastic performance. It also has a major psychosocial burden on the parents, resulting in poorer [[quality of life]]. Treatment of enuresis should be holistic, targeting the management of enuresis in [[children]] as well as psychoeducation of the parents.


==Historical Perspective==
==Historical Perspective==
*Enuresis has been a major social problem since ancient times.
*Enuresis has been a major social problem since ancient times.
*Initially enuresis was considered a manifestation of psychiatric disturbance. It has been followed by the clearer theory of maturational delay with the role of [[hereditary]] factors. <ref name="Schulpen1997">{{cite journal|last1=Schulpen|first1=TWJ|title=The burden of nocturnal enuresis|journal=Acta Paediatrica|volume=86|issue=9|year=1997|pages=981–984|issn=0803-5253|doi=10.1111/j.1651-2227.1997.tb15183.x}}</ref>
*The term enuresis is derived from the Greek word 'enourein' that means to void urine.<ref name="SolankiDesai2014">{{cite journal|last1=Solanki|first1=Ashok|last2=Desai|first2=Sarzoo|title=Prevalence and risk factors of nocturnal enuresis among school age children in rural areas|journal=International Journal of Research in Medical Sciences|volume=2|issue=1|year=2014|pages=202|issn=2320-6071|doi=10.5455/2320-6012.ijrms20140239}}</ref>
*Initially, enuresis was considered a psychiatric disturbance. It has been followed by the clearer theory of maturation delay along with the major role of [[hereditary]] factors. <ref name="Schulpen1997">{{cite journal|last1=Schulpen|first1=TWJ|title=The burden of nocturnal enuresis|journal=Acta Paediatrica|volume=86|issue=9|year=1997|pages=981–984|issn=0803-5253|doi=10.1111/j.1651-2227.1997.tb15183.x}}</ref>
*After multiple studies, it has been found that enuresis may be the cause and not the result of a psychiatric disorder.<ref name="LäckgrenHjalmås2007">{{cite journal|last1=Läckgren|first1=G|last2=Hjalmås|first2=K|last3=Gool|first3=J van|last4=Gontard|first4=A von|last5=Gennaro|first5=M de|last6=Lottmann|first6=H|last7=Terho|first7=P|title=COMMITTEE REPORT|journal=Acta Paediatrica|volume=88|issue=6|year=2007|pages=679–690|issn=08035253|doi=10.1111/j.1651-2227.1999.tb00023.x}}</ref>
*After multiple studies, it has been found that enuresis may be the cause and not the result of a psychiatric disorder.<ref name="LäckgrenHjalmås2007">{{cite journal|last1=Läckgren|first1=G|last2=Hjalmås|first2=K|last3=Gool|first3=J van|last4=Gontard|first4=A von|last5=Gennaro|first5=M de|last6=Lottmann|first6=H|last7=Terho|first7=P|title=COMMITTEE REPORT|journal=Acta Paediatrica|volume=88|issue=6|year=2007|pages=679–690|issn=08035253|doi=10.1111/j.1651-2227.1999.tb00023.x}}</ref>
*As early as 1550 BC, the problem of [[childhood]] [[incontinence]] was described in the Ebers papyrus.<ref name="NørgaardDjurhuus2016">{{cite journal|last1=Nørgaard|first1=Jens Peter|last2=Djurhuus|first2=Jens Christian|title=The Pathophysiology of Enuresis in Children and Young Adults|journal=Clinical Pediatrics|volume=32|issue=1_suppl|year=2016|pages=5–9|issn=0009-9228|doi=10.1177/0009922893032001S02}}</ref>
*As early as 1550 BC, the problem of [[childhood]] [[incontinence]] was described in the Ebers papyrus.<ref name="NørgaardDjurhuus2016">{{cite journal|last1=Nørgaard|first1=Jens Peter|last2=Djurhuus|first2=Jens Christian|title=The Pathophysiology of Enuresis in Children and Young Adults|journal=Clinical Pediatrics|volume=32|issue=1_suppl|year=2016|pages=5–9|issn=0009-9228|doi=10.1177/0009922893032001S02}}</ref>
*Prayers became an important supplemental component of the treatment options in the middle ages.
*Prayers were an important component of the treatment options in the middle ages.
*[[Belladonna]], camphor, [[opium]], and [[ergot]] were administered to enhance the bladder muscle tone in the eighteenth century.<ref name="NørgaardDjurhuus2016">{{cite journal|last1=Nørgaard|first1=Jens Peter|last2=Djurhuus|first2=Jens Christian|title=The Pathophysiology of Enuresis in Children and Young Adults|journal=Clinical Pediatrics|volume=32|issue=1_suppl|year=2016|pages=5–9|issn=0009-9228|doi=10.1177/0009922893032001S02}}</ref>
*[[Belladonna]], camphor, [[opium]], and [[ergot]] were administered to enhance the bladder muscle tone in the eighteenth century.<ref name="NørgaardDjurhuus2016">{{cite journal|last1=Nørgaard|first1=Jens Peter|last2=Djurhuus|first2=Jens Christian|title=The Pathophysiology of Enuresis in Children and Young Adults|journal=Clinical Pediatrics|volume=32|issue=1_suppl|year=2016|pages=5–9|issn=0009-9228|doi=10.1177/0009922893032001S02}}</ref>
*In 1948, a direct conditioning based treatment modality called the alarm or bell-and-pad system was introduced.<ref name="NørgaardDjurhuus2016">{{cite journal|last1=Nørgaard|first1=Jens Peter|last2=Djurhuus|first2=Jens Christian|title=The Pathophysiology of Enuresis in Children and Young Adults|journal=Clinical Pediatrics|volume=32|issue=1_suppl|year=2016|pages=5–9|issn=0009-9228|doi=10.1177/0009922893032001S02}}</ref>
*In 1948, a direct conditioning-based treatment modality called the alarm or bell-and-pad system was introduced.<ref name="NørgaardDjurhuus2016">{{cite journal|last1=Nørgaard|first1=Jens Peter|last2=Djurhuus|first2=Jens Christian|title=The Pathophysiology of Enuresis in Children and Young Adults|journal=Clinical Pediatrics|volume=32|issue=1_suppl|year=2016|pages=5–9|issn=0009-9228|doi=10.1177/0009922893032001S02}}</ref>
*Initially, [[psychotherapy]] was accepted as the only possible method to treat enuresis, and there was a lot of skepticism about the conditioning treatment. <ref name="Schulpen1997">{{cite journal|last1=Schulpen|first1=TWJ|title=The burden of nocturnal enuresis|journal=Acta Paediatrica|volume=86|issue=9|year=1997|pages=981–984|issn=0803-5253|doi=10.1111/j.1651-2227.1997.tb15183.x}}</ref>
*Initially, [[psychotherapy]] was accepted as the only possible method to treat enuresis, and there was a lot of skepticism about the conditioning treatment. <ref name="Schulpen1997">{{cite journal|last1=Schulpen|first1=TWJ|title=The burden of nocturnal enuresis|journal=Acta Paediatrica|volume=86|issue=9|year=1997|pages=981–984|issn=0803-5253|doi=10.1111/j.1651-2227.1997.tb15183.x}}</ref>
*Gradually, the alarm system became one of the most efficacious non-pharmacological management options worldwide.


==Classification==
==Classification==
*Enuresis is broadly divided in two types: daytime wetting and nocturnal enuresis.<ref name="Mahony1973">{{cite journal|last1=Mahony|first1=David T.|title=Studies of enuresis|journal=Urology|volume=1|issue=4|year=1973|pages=315–316|issn=00904295|doi=10.1016/0090-4295(73)90278-1}}</ref>
*According to International Children’s Continence Society (ICCS), enuresis consists of wetting by a [[child]] who has passed his or her fifth birthday.<ref name="HaidTekgül2017">{{cite journal|last1=Haid|first1=Bernhard|last2=Tekgül|first2=Serdar|title=Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment|journal=European Urology Focus|volume=3|issue=2-3|year=2017|pages=198–206|issn=24054569|doi=10.1016/j.euf.2017.08.010}}</ref>  
*According to International Children’s Continence Society (ICCS), enuresis consists of wetting by a child who has passed his or her fifth birthday.<ref name="HaidTekgül2017">{{cite journal|last1=Haid|first1=Bernhard|last2=Tekgül|first2=Serdar|title=Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment|journal=European Urology Focus|volume=3|issue=2-3|year=2017|pages=198–206|issn=24054569|doi=10.1016/j.euf.2017.08.010}}</ref>  
*Enuresis is considered significant if it occurs more than once a month and at a frequency of at least three times per three months. Enuresis is termed frequent if there are more than three episodes a week.<ref name="HaidTekgül2017">{{cite journal|last1=Haid|first1=Bernhard|last2=Tekgül|first2=Serdar|title=Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment|journal=European Urology Focus|volume=3|issue=2-3|year=2017|pages=198–206|issn=24054569|doi=10.1016/j.euf.2017.08.010}}</ref>  
*Enuresis is considered significant if it occurs more than once per month and at a frequency of at least three times per three months. Enuresis is termed frequent if there are more than three episodes a week.<ref name="HaidTekgül2017">{{cite journal|last1=Haid|first1=Bernhard|last2=Tekgül|first2=Serdar|title=Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment|journal=European Urology Focus|volume=3|issue=2-3|year=2017|pages=198–206|issn=24054569|doi=10.1016/j.euf.2017.08.010}}</ref>  
*Enuresis is broadly divided into two types: [[daytime wetting]] and nighttime wetting.<ref name="Mahony1973">{{cite journal|last1=Mahony|first1=David T.|title=Studies of enuresis|journal=Urology|volume=1|issue=4|year=1973|pages=315–316|issn=00904295|doi=10.1016/0090-4295(73)90278-1}}</ref>
*If there are concomitant daytime voiding symptoms such as incontinence, frequency, urgency, or low voided volume, the condition is termed nonmonosymptomatic enuresis (NMEN). If bedwetting and nocturia are the only symptoms, the condition is known as monosymptomatic enuresis (MEN).<ref name="HaidTekgül2017">{{cite journal|last1=Haid|first1=Bernhard|last2=Tekgül|first2=Serdar|title=Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment|journal=European Urology Focus|volume=3|issue=2-3|year=2017|pages=198–206|issn=24054569|doi=10.1016/j.euf.2017.08.010}}</ref>
*Primary enuresis is the condition used for a child that was never continent. On the other hand, the term secondary enuresis is used for new-onset symptoms after a dry period of at least six months.<ref name="HaidTekgül2017">{{cite journal|last1=Haid|first1=Bernhard|last2=Tekgül|first2=Serdar|title=Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment|journal=European Urology Focus|volume=3|issue=2-3|year=2017|pages=198–206|issn=24054569|doi=10.1016/j.euf.2017.08.010}}</ref><ref name="ArdaCakiroglu2016">{{cite journal|last1=Arda|first1=Ersan|last2=Cakiroglu|first2=Basri|last3=Thomas|first3=David T.|title=Primary Nocturnal Enuresis: A Review|journal=Nephro-Urology Monthly|volume=8|issue=4|year=2016|issn=2251-7006|doi=10.5812/numonthly.35809}}</ref>
*MEN occurs without any other symptoms of bladder dysfunction whereas NMEN is associated with dysfunction of the lower urinary tract with or without daytime incontinence.<ref name="Kuwertz-Brökingvon Gontard2017">{{cite journal|last1=Kuwertz-Bröking|first1=Eberhard|last2=von Gontard|first2=Alexander|title=Clinical management of nocturnal enuresis|journal=Pediatric Nephrology|volume=33|issue=7|year=2017|pages=1145–1154|issn=0931-041X|doi=10.1007/s00467-017-3778-1}}</ref>
*If [[bedwetting]] and nocturia are the only symptoms, the condition is known as monosymptomatic enuresis (MEN). If there are concomitant daytime voiding symptoms such as [[incontinence]], frequency, urgency, or low voided volume, the condition is termed nonmonosymptomatic enuresis (NMEN).<ref name="HaidTekgül2017">{{cite journal|last1=Haid|first1=Bernhard|last2=Tekgül|first2=Serdar|title=Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment|journal=European Urology Focus|volume=3|issue=2-3|year=2017|pages=198–206|issn=24054569|doi=10.1016/j.euf.2017.08.010}}</ref>
*Primary enuresis is used for a child that was never continent, whereas the term secondary enuresis is used for new-onset symptoms after a dry period of at least six months.<ref name="HaidTekgül2017">{{cite journal|last1=Haid|first1=Bernhard|last2=Tekgül|first2=Serdar|title=Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment|journal=European Urology Focus|volume=3|issue=2-3|year=2017|pages=198–206|issn=24054569|doi=10.1016/j.euf.2017.08.010}}</ref><ref name="ArdaCakiroglu2016">{{cite journal|last1=Arda|first1=Ersan|last2=Cakiroglu|first2=Basri|last3=Thomas|first3=David T.|title=Primary Nocturnal Enuresis: A Review|journal=Nephro-Urology Monthly|volume=8|issue=4|year=2016|issn=2251-7006|doi=10.5812/numonthly.35809}}</ref>
*MEN occurs without any other symptoms of bladder dysfunction whereas NMEN is associated with dysfunction of the lower [[urinary tract]] with or without daytime incontinence.<ref name="Kuwertz-Brökingvon Gontard2017">{{cite journal|last1=Kuwertz-Bröking|first1=Eberhard|last2=von Gontard|first2=Alexander|title=Clinical management of nocturnal enuresis|journal=Pediatric Nephrology|volume=33|issue=7|year=2017|pages=1145–1154|issn=0931-041X|doi=10.1007/s00467-017-3778-1}}</ref>


==Pathophysiology==
==Pathophysiology==
*Some of the underlying pathophysiological mechanisms for enuresis are:<ref name="HaidTekgül2017">{{cite journal|last1=Haid|first1=Bernhard|last2=Tekgül|first2=Serdar|title=Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment|journal=European Urology Focus|volume=3|issue=2-3|year=2017|pages=198–206|issn=24054569|doi=10.1016/j.euf.2017.08.010}}</ref><ref name="PedersenRittig2020">{{cite journal|last1=Pedersen|first1=Malthe J.|last2=Rittig|first2=Søren|last3=Jennum|first3=Poul J.|last4=Kamperis|first4=Konstantinos|title=The role of sleep in the pathophysiology of nocturnal enuresis|journal=Sleep Medicine Reviews|volume=49|year=2020|pages=101228|issn=10870792|doi=10.1016/j.smrv.2019.101228}}</ref><ref name="KanburPinhas2011">{{cite journal|last1=Kanbur|first1=Nuray|last2=Pinhas|first2=Leora|last3=Lorenzo|first3=Armando|last4=Farhat|first4=Walid|last5=Licht|first5=Christoph|last6=Katzman|first6=Debra K.|title=Nocturnal enuresis in adolescents with anorexia nervosa: Prevalence, potential causes, and pathophysiology|journal=International Journal of Eating Disorders|volume=44|issue=4|year=2011|pages=349–355|issn=02763478|doi=10.1002/eat.20822}}</ref>
*Some of the underlying pathophysiological mechanisms for enuresis are:<ref name="HaidTekgül2017">{{cite journal|last1=Haid|first1=Bernhard|last2=Tekgül|first2=Serdar|title=Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment|journal=European Urology Focus|volume=3|issue=2-3|year=2017|pages=198–206|issn=24054569|doi=10.1016/j.euf.2017.08.010}}</ref><ref name="PedersenRittig2020">{{cite journal|last1=Pedersen|first1=Malthe J.|last2=Rittig|first2=Søren|last3=Jennum|first3=Poul J.|last4=Kamperis|first4=Konstantinos|title=The role of sleep in the pathophysiology of nocturnal enuresis|journal=Sleep Medicine Reviews|volume=49|year=2020|pages=101228|issn=10870792|doi=10.1016/j.smrv.2019.101228}}</ref><ref name="KanburPinhas2011">{{cite journal|last1=Kanbur|first1=Nuray|last2=Pinhas|first2=Leora|last3=Lorenzo|first3=Armando|last4=Farhat|first4=Walid|last5=Licht|first5=Christoph|last6=Katzman|first6=Debra K.|title=Nocturnal enuresis in adolescents with anorexia nervosa: Prevalence, potential causes, and pathophysiology|journal=International Journal of Eating Disorders|volume=44|issue=4|year=2011|pages=349–355|issn=02763478|doi=10.1002/eat.20822}}</ref>
**Altered antidiuretic hormone profile
**Altered [[antidiuretic hormone]] profile
**Sleep arousal failure
**Sleep arousal failure
**Delayed bladder maturation
**Delayed bladder maturation
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**Detrusor instability  
**Detrusor instability  
**Excess urine production during sleep  
**Excess urine production during sleep  
*Nocturnal enuresis may be associated with lower urinary tract symptoms such as urgency, frequency, and wetting – with reduced bladder storage, and an overactive bladder. These may be further associated with constipation.<ref name="Harari2013">{{cite journal|last1=Harari|first1=Michael D|title=Nocturnal enuresis|journal=Journal of Paediatrics and Child Health|volume=49|issue=4|year=2013|pages=264–271|issn=10344810|doi=10.1111/j.1440-1754.2012.02506.x}}</ref>
*Nocturnal enuresis may be associated with lower urinary tract symptoms such as [[urgency]], and frequency, with an overactive bladder. These may be further associated with [[constipation]].<ref name="Harari2013">{{cite journal|last1=Harari|first1=Michael D|title=Nocturnal enuresis|journal=Journal of Paediatrics and Child Health|volume=49|issue=4|year=2013|pages=264–271|issn=10344810|doi=10.1111/j.1440-1754.2012.02506.x}}</ref>
*Nocturnal enuresis often occurs early in the night, mainly in sleep stage 2 and deep sleep. Children with nocturnal enuresis and nocturnal polyuria differ in hemodynamics and autonomic activation at night compared to healthy controls.<ref name="PedersenRittig2020">{{cite journal|last1=Pedersen|first1=Malthe J.|last2=Rittig|first2=Søren|last3=Jennum|first3=Poul J.|last4=Kamperis|first4=Konstantinos|title=The role of sleep in the pathophysiology of nocturnal enuresis|journal=Sleep Medicine Reviews|volume=49|year=2020|pages=101228|issn=10870792|doi=10.1016/j.smrv.2019.101228}}</ref>  
*Nocturnal enuresis mostly occurs early in the night, mainly in sleep stage 2 and deep sleep. [[Children]] with [[nocturnal enuresis]] and nocturnal polyuria differ in hemodynamics and autonomic activation at night compared to controls.<ref name="PedersenRittig2020">{{cite journal|last1=Pedersen|first1=Malthe J.|last2=Rittig|first2=Søren|last3=Jennum|first3=Poul J.|last4=Kamperis|first4=Konstantinos|title=The role of sleep in the pathophysiology of nocturnal enuresis|journal=Sleep Medicine Reviews|volume=49|year=2020|pages=101228|issn=10870792|doi=10.1016/j.smrv.2019.101228}}</ref>  
*Children with nocturnal enuresis often have sleep-disordered breathing and disturbed sleep due to awakenings and arousals. Periodic limb movements (PLM) have also been seen in children with refractory enuresis.<ref name="PedersenRittig2020">{{cite journal|last1=Pedersen|first1=Malthe J.|last2=Rittig|first2=Søren|last3=Jennum|first3=Poul J.|last4=Kamperis|first4=Konstantinos|title=The role of sleep in the pathophysiology of nocturnal enuresis|journal=Sleep Medicine Reviews|volume=49|year=2020|pages=101228|issn=10870792|doi=10.1016/j.smrv.2019.101228}}</ref>
*[[Children]] with [[nocturnal enuresis]] often have sleep-disordered breathing and disturbed sleep due to awakenings and arousal.<ref name="PedersenRittig2020">{{cite journal|last1=Pedersen|first1=Malthe J.|last2=Rittig|first2=Søren|last3=Jennum|first3=Poul J.|last4=Kamperis|first4=Konstantinos|title=The role of sleep in the pathophysiology of nocturnal enuresis|journal=Sleep Medicine Reviews|volume=49|year=2020|pages=101228|issn=10870792|doi=10.1016/j.smrv.2019.101228}}</ref>
*Periodic limb movements (PLM) have also been seen in [[children]] with refractory enuresis.<ref name="PedersenRittig2020">{{cite journal|last1=Pedersen|first1=Malthe J.|last2=Rittig|first2=Søren|last3=Jennum|first3=Poul J.|last4=Kamperis|first4=Konstantinos|title=The role of sleep in the pathophysiology of nocturnal enuresis|journal=Sleep Medicine Reviews|volume=49|year=2020|pages=101228|issn=10870792|doi=10.1016/j.smrv.2019.101228}}</ref>


==Differential Diagnosis==
==Differential Diagnosis==
Enuresis should be differentiated from other causes<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref><ref name="pmid9165606">{{cite journal| author=Lettgen B| title=Differential diagnoses for nocturnal enuresis. | journal=Scand J Urol Nephrol Suppl | year= 1997 | volume= 183 | issue=  | pages= 47-8; discussion 48-9 | pmid=9165606 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9165606  }} </ref><ref name="pmid29217876">{{cite journal| author=Reddy NM, Malve H, Nerli R, Venkatesh P, Agarwal I, Rege V| title=Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? | journal=Indian J Nephrol | year= 2017 | volume= 27 | issue= 6 | pages= 417-426 | pmid=29217876 | doi=10.4103/ijn.IJN_288_16 | pmc=5704404 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29217876  }} </ref><ref name="pmid27458562">{{cite journal| author=Sinha R, Raut S| title=Management of nocturnal enuresis - myths and facts. | journal=World J Nephrol | year= 2016 | volume= 5 | issue= 4 | pages= 328-38 | pmid=27458562 | doi=10.5527/wjn.v5.i4.328 | pmc=4936340 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27458562  }} </ref>
Enuresis should be differentiated from other causes<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref><ref name="pmid9165606">{{cite journal| author=Lettgen B| title=Differential diagnoses for nocturnal enuresis. | journal=Scand J Urol Nephrol Suppl | year= 1997 | volume= 183 | issue=  | pages= 47-8; discussion 48-9 | pmid=9165606 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9165606  }} </ref><ref name="pmid29217876">{{cite journal| author=Reddy NM, Malve H, Nerli R, Venkatesh P, Agarwal I, Rege V| title=Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? | journal=Indian J Nephrol | year= 2017 | volume= 27 | issue= 6 | pages= 417-426 | pmid=29217876 | doi=10.4103/ijn.IJN_288_16 | pmc=5704404 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29217876  }} </ref><ref name="pmid27458562">{{cite journal| author=Sinha R, Raut S| title=Management of nocturnal enuresis - myths and facts. | journal=World J Nephrol | year= 2016 | volume= 5 | issue= 4 | pages= 328-38 | pmid=27458562 | doi=10.5527/wjn.v5.i4.328 | pmc=4936340 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27458562  }} </ref>
*Medication side effects
*[[Medication]] side effects
*[[Neurogenic bladder]]
*[[Neurogenic bladder]]
*Renal diseases
*[[Renal]] diseases
*[[Constipation]]
*[[Constipation]]
*[[Diabetes Mellitus]]
*[[Diabetes Mellitus]]
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*Spinal dysraphism
*Spinal dysraphism
*Nephronopthisis
*Nephronopthisis
*Psychogenic polydipsia
*[[Psychogenic polydipsia]]
*Pinworm infection
*[[Pinworm]] infection
*Upper airway tract obstruction
*Upper airway tract obstruction
*Other urological dysfunction
*Other [[urological]] dysfunction
*Other neurological diseases
*Other [[neurological]] diseases


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Prevalence===
===Prevalence===
*The [[prevalence]] of enuresis is<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*The [[prevalence]] of enuresis is<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
** 5,000-10,000 per 100,000 (5%-10%) among children 5 years of age
** 5,000-10,000 per 100,000 (5%-10%) among [[children]] 5 years of age
** 3,000-5,000 per 100,000 (3%-5%) among children 10 year of age
** 3,000-5,000 per 100,000 (3%-5%) among [[children]] 10 year of age
** 1,000 per 100,000 (1%) among individuals 15 years of age or older
** 1,000 per 100,000 (1%) among individuals 15 years of age or older
===Age===
===Age===
*Enuresis is found to be more prevalent in the first born children.<ref name="AkisIrgil2009">{{cite journal|last1=Akis|first1=N.|last2=Irgil|first2=E.|last3=Aytekin|first3=N.|title=Enuresis and the Effective Factors|journal=Scandinavian Journal of Urology and Nephrology|volume=36|issue=3|year=2009|pages=199–203|issn=0036-5599|doi=10.1080/003655902320131875}}</ref>
*Enuresis is found to be more prevalent in first-born [[children]].<ref name="AkisIrgil2009">{{cite journal|last1=Akis|first1=N.|last2=Irgil|first2=E.|last3=Aytekin|first3=N.|title=Enuresis and the Effective Factors|journal=Scandinavian Journal of Urology and Nephrology|volume=36|issue=3|year=2009|pages=199–203|issn=0036-5599|doi=10.1080/003655902320131875}}</ref>
*If enuretic symptoms persist into adulthood, they are probably less likely to resolve with time.<ref name="YeungSihoe2004">{{cite journal|last1=Yeung|first1=C.K.|last2=Sihoe|first2=J.D.Y.|last3=Sit|first3=F.K.Y.|last4=Bower|first4=W.|last5=Sreedhar|first5=B.|last6=Lau|first6=J.|title=Characteristics of primary nocturnal enuresis in adults: an epidemiological study|journal=BJU International|volume=93|issue=3|year=2004|pages=341–345|issn=1464-4096|doi=10.1111/j.1464-410X.2003.04612.x}}</ref>
*If enuretic symptoms persist into adulthood, they are less likely to resolve with time.<ref name="YeungSihoe2004">{{cite journal|last1=Yeung|first1=C.K.|last2=Sihoe|first2=J.D.Y.|last3=Sit|first3=F.K.Y.|last4=Bower|first4=W.|last5=Sreedhar|first5=B.|last6=Lau|first6=J.|title=Characteristics of primary nocturnal enuresis in adults: an epidemiological study|journal=BJU International|volume=93|issue=3|year=2004|pages=341–345|issn=1464-4096|doi=10.1111/j.1464-410X.2003.04612.x}}</ref>
*Primary Nocturnal Enuresis in adults may represent a more pronounced form and have a more serious social and psychological effect on affected individuals.<ref name="YeungSihoe2004">{{cite journal|last1=Yeung|first1=C.K.|last2=Sihoe|first2=J.D.Y.|last3=Sit|first3=F.K.Y.|last4=Bower|first4=W.|last5=Sreedhar|first5=B.|last6=Lau|first6=J.|title=Characteristics of primary nocturnal enuresis in adults: an epidemiological study|journal=BJU International|volume=93|issue=3|year=2004|pages=341–345|issn=1464-4096|doi=10.1111/j.1464-410X.2003.04612.x}}</ref>
*Primary nocturnal enuresis in adults may represent a more pronounced form and have a more serious social and psychological effect on affected individuals.<ref name="YeungSihoe2004">{{cite journal|last1=Yeung|first1=C.K.|last2=Sihoe|first2=J.D.Y.|last3=Sit|first3=F.K.Y.|last4=Bower|first4=W.|last5=Sreedhar|first5=B.|last6=Lau|first6=J.|title=Characteristics of primary nocturnal enuresis in adults: an epidemiological study|journal=BJU International|volume=93|issue=3|year=2004|pages=341–345|issn=1464-4096|doi=10.1111/j.1464-410X.2003.04612.x}}</ref>
 
===Gender===
===Gender===
*Most studies show a predominance of enuresis in males, whereas some others show no gender predominance.<ref name="McGrathCaldwell2007">{{cite journal|last1=McGrath|first1=Kathleen H|last2=Caldwell|first2=Patrina HY|last3=Jones|first3=Michael P|title=The frequency of constipation in children with nocturnal enuresis: a comparison with parental reporting|journal=Journal of Paediatrics and Child Health|volume=0|issue=0|year=2007|pages=070916021853007–???|issn=1034-4810|doi=10.1111/j.1440-1754.2007.01207.x}}</ref><ref name="ChangYang2011">{{cite journal|last1=Chang|first1=Jei-Wen|last2=Yang|first2=Ling-Yu|last3=Chin|first3=Tai-Wai|last4=Tsai|first4=Hsin-Lin|title=Clinical characteristics, nocturnal antidiuretic hormone levels, and responsiveness to DDAVP of school children with primary nocturnal enuresis|journal=World Journal of Urology|volume=30|issue=4|year=2011|pages=567–571|issn=0724-4983|doi=10.1007/s00345-011-0753-5}}</ref>
*Most studies show a predominance of enuresis in males, whereas some others show no gender predominance.<ref name="McGrathCaldwell2007">{{cite journal|last1=McGrath|first1=Kathleen H|last2=Caldwell|first2=Patrina HY|last3=Jones|first3=Michael P|title=The frequency of constipation in children with nocturnal enuresis: a comparison with parental reporting|journal=Journal of Paediatrics and Child Health|volume=0|issue=0|year=2007|pages=070916021853007–???|issn=1034-4810|doi=10.1111/j.1440-1754.2007.01207.x}}</ref><ref name="ChangYang2011">{{cite journal|last1=Chang|first1=Jei-Wen|last2=Yang|first2=Ling-Yu|last3=Chin|first3=Tai-Wai|last4=Tsai|first4=Hsin-Lin|title=Clinical characteristics, nocturnal antidiuretic hormone levels, and responsiveness to DDAVP of school children with primary nocturnal enuresis|journal=World Journal of Urology|volume=30|issue=4|year=2011|pages=567–571|issn=0724-4983|doi=10.1007/s00345-011-0753-5}}</ref>
===Race===
===Race===
*Sickle-cell anemia (SCA) is the most common inherited hemoglobinopathy in the African population. It has been found that children and adolescents with SCA are at increased risk of nocturnal enuresis.<ref name="EnehOkafor2015">{{cite journal|last1=Eneh|first1=Chizoma I.|last2=Okafor|first2=Henrietta U.|last3=Ikefuna|first3=Anthony N.|last4=Uwaezuoke|first4=Samuel N.|title=Nocturnal enuresis: prevalence and risk factors among school-aged children with sickle-cell anaemia in a South-east Nigerian city|journal=Italian Journal of Pediatrics|volume=41|issue=1|year=2015|issn=1824-7288|doi=10.1186/s13052-015-0176-9}}</ref>
*[[Sickle-cell anemia]] (SCA) is the most common inherited hemoglobinopathy in the African population. It has been found that [[children]] and adolescents with [[SCA]] are at increased risk of [[nocturnal enuresis]].<ref name="EnehOkafor2015">{{cite journal|last1=Eneh|first1=Chizoma I.|last2=Okafor|first2=Henrietta U.|last3=Ikefuna|first3=Anthony N.|last4=Uwaezuoke|first4=Samuel N.|title=Nocturnal enuresis: prevalence and risk factors among school-aged children with sickle-cell anaemia in a South-east Nigerian city|journal=Italian Journal of Pediatrics|volume=41|issue=1|year=2015|issn=1824-7288|doi=10.1186/s13052-015-0176-9}}</ref>


==Risk Factors==
==Risk Factors==
* The risk factors for the development of enuresis are <ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref><ref name="SureshkumarJones2009">{{cite journal|last1=Sureshkumar|first1=Premala|last2=Jones|first2=Mike|last3=Caldwell|first3=Patrina H.Y.|last4=Craig|first4=Jonathan C.|title=Risk Factors for Nocturnal Enuresis in School-Age Children|journal=Journal of Urology|volume=182|issue=6|year=2009|pages=2893–2899|issn=0022-5347|doi=10.1016/j.juro.2009.08.060}}</ref><ref name="SolankiDesai2014">{{cite journal|last1=Solanki|first1=Ashok|last2=Desai|first2=Sarzoo|title=Prevalence and risk factors of nocturnal enuresis among school age children in rural areas|journal=International Journal of Research in Medical Sciences|volume=2|issue=1|year=2014|pages=202|issn=2320-6071|doi=10.5455/2320-6012.ijrms20140239}}</ref><ref name="AdekanmbiOgunlesi2011">{{cite journal|last1=Adekanmbi|first1=AF|last2=Ogunlesi|first2=TA|last3=Fetuga|first3=MB|last4=Oluwole|first4=FA|last5=Alabi|first5=AD|last6=Kehinde|first6=OA|title=Prevalence and Risk Factors for Enuresis in Children|journal=Nigerian Hospital Practice|volume=7|issue=3-4|year=2011|issn=1597-7889|doi=10.4314/nhp.v7i3-4.67123}}</ref><ref name="GurocakMaral2010">{{cite journal|last1=Gurocak|first1=Serhat|last2=Maral|first2=Isil|last3=Bumin|first3=AliM|last4=Ozkan|first4=Secil|last5=Durukan|first5=Elif|last6=Iseri|first6=Elvan|title=Prevalence and risk factors of monosymptomatic nocturnal enuresis in Turkish children|journal=Indian Journal of Urology|volume=26|issue=2|year=2010|pages=200|issn=0970-1591|doi=10.4103/0970-1591.65387}}</ref>
* The risk factors for the development of enuresis are <ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref><ref name="SureshkumarJones2009">{{cite journal|last1=Sureshkumar|first1=Premala|last2=Jones|first2=Mike|last3=Caldwell|first3=Patrina H.Y.|last4=Craig|first4=Jonathan C.|title=Risk Factors for Nocturnal Enuresis in School-Age Children|journal=Journal of Urology|volume=182|issue=6|year=2009|pages=2893–2899|issn=0022-5347|doi=10.1016/j.juro.2009.08.060}}</ref><ref name="SolankiDesai2014">{{cite journal|last1=Solanki|first1=Ashok|last2=Desai|first2=Sarzoo|title=Prevalence and risk factors of nocturnal enuresis among school age children in rural areas|journal=International Journal of Research in Medical Sciences|volume=2|issue=1|year=2014|pages=202|issn=2320-6071|doi=10.5455/2320-6012.ijrms20140239}}</ref><ref name="AdekanmbiOgunlesi2011">{{cite journal|last1=Adekanmbi|first1=AF|last2=Ogunlesi|first2=TA|last3=Fetuga|first3=MB|last4=Oluwole|first4=FA|last5=Alabi|first5=AD|last6=Kehinde|first6=OA|title=Prevalence and Risk Factors for Enuresis in Children|journal=Nigerian Hospital Practice|volume=7|issue=3-4|year=2011|issn=1597-7889|doi=10.4314/nhp.v7i3-4.67123}}</ref><ref name="GurocakMaral2010">{{cite journal|last1=Gurocak|first1=Serhat|last2=Maral|first2=Isil|last3=Bumin|first3=AliM|last4=Ozkan|first4=Secil|last5=Durukan|first5=Elif|last6=Iseri|first6=Elvan|title=Prevalence and risk factors of monosymptomatic nocturnal enuresis in Turkish children|journal=Indian Journal of Urology|volume=26|issue=2|year=2010|pages=200|issn=0970-1591|doi=10.4103/0970-1591.65387}}</ref>
**Delayed or lax toilet training  
**Delayed or lax toilet training  
**Genetic predisposition
**[[Genetic]] predisposition
**Encopresis  
**[[Encopresis]]
**Psychosocial stressors
**Psychosocial stressors
**Family history of enuresis (such as maternal history, and sibling history of bedwetting)  
**[[Family]] history of enuresis (such as maternal history, and sibling history of bedwetting)  
**Low socioeconomic status
**Low socioeconomic status
**Snoring  
**Snoring  
**Heavy and late supper
**Heavy and late supper
**Deep sleeper
**Deep sleeper
**Sleepwalking
**[[Sleepwalking]]
**Being introverted and shy
**Being introverted and shy


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
*Most children with enuresis eventually obtain bladder control.
===Natural History===
*It has been found that the prevalence of nocturnal enuresis gradually decreases with increasing age and many may achieve spontaneous resolution.<ref name="KajiwaraInoue2006">{{cite journal|last1=Kajiwara|first1=Mitsuru|last2=Inoue|first2=Katsumi|last3=Kato|first3=Masao|last4=Usui|first4=Akihiro|last5=Kurihara|first5=Makoto|last6=Usui|first6=Tsuguru|title=Nocturnal enuresis and overactive bladder in children: An epidemiological study|journal=International Journal of Urology|volume=13|issue=1|year=2006|pages=36–41|issn=09198172|doi=10.1111/j.1442-2042.2006.01217.x}}</ref>
*Most [[children]] with enuresis eventually attain bladder control.
*The link between childhood enuresis and adult detrusor instability is observed to be stronger for men than women.<ref name="HunskaarArnold2000">{{cite journal|last1=Hunskaar|first1=S.|last2=Arnold|first2=E. P.|last3=Burgio|first3=K.|last4=Diokno|first4=A. C.|last5=Herzog|first5=A. R.|last6=Mallett|first6=V. T.|title=Epidemiology and Natural History of Urinary Incontinence|journal=International Urogynecology Journal and Pelvic Floor Dysfunction|volume=11|issue=5|year=2000|pages=301–319|issn=0937-3462|doi=10.1007/s001920070021}}</ref>
*It has been found that the prevalence of [[nocturnal enuresis]] gradually decreases with increasing age and many may achieve spontaneous resolution.<ref name="KajiwaraInoue2006">{{cite journal|last1=Kajiwara|first1=Mitsuru|last2=Inoue|first2=Katsumi|last3=Kato|first3=Masao|last4=Usui|first4=Akihiro|last5=Kurihara|first5=Makoto|last6=Usui|first6=Tsuguru|title=Nocturnal enuresis and overactive bladder in children: An epidemiological study|journal=International Journal of Urology|volume=13|issue=1|year=2006|pages=36–41|issn=09198172|doi=10.1111/j.1442-2042.2006.01217.x}}</ref>
*If intranasal desmopressin is used in the treatment of enuresis, some patients may develop seizures or altered mental status within 14 days of starting the medication.<ref name="LucchiniSimonetti2013">{{cite journal|last1=Lucchini|first1=Barbara|last2=Simonetti|first2=Giacomo D.|last3=Ceschi|first3=Alessandro|last4=Lava|first4=Sebastiano A.G.|last5=Faré|first5=Pietro B.|last6=Bianchetti|first6=Mario G.|title=Severe signs of hyponatremia secondary to desmopressin treatment for enuresis: A systematic review|journal=Journal of Pediatric Urology|volume=9|issue=6|year=2013|pages=1049–1053|issn=14775131|doi=10.1016/j.jpurol.2013.02.012}}</ref>
*The link between [[childhood]] enuresis and adult detrusor instability is observed to be stronger for men than women.<ref name="HunskaarArnold2000">{{cite journal|last1=Hunskaar|first1=S.|last2=Arnold|first2=E. P.|last3=Burgio|first3=K.|last4=Diokno|first4=A. C.|last5=Herzog|first5=A. R.|last6=Mallett|first6=V. T.|title=Epidemiology and Natural History of Urinary Incontinence|journal=International Urogynecology Journal and Pelvic Floor Dysfunction|volume=11|issue=5|year=2000|pages=301–319|issn=0937-3462|doi=10.1007/s001920070021}}</ref>
*The accidental poisoning of young children by medications (tricyclic antidepressants) prescribed for enuresis have been reported.<ref name="ParkinFrasert2008">{{cite journal|last1=Parkin|first1=J. M.|last2=Frasert|first2=M. S.|title=Poisoning as a Complication of Enuresis|journal=Developmental Medicine & Child Neurology|volume=14|issue=6|year=2008|pages=727–730|issn=00121622|doi=10.1111/j.1469-8749.1972.tb03315.x}}</ref>
===Complications===
* The prognosis of secondary nocturnal enuresis due to cystitis, constipation, diabetes mellitus, seizure disorder, acquired urethral obstruction, and hyperthyroidism, is excellent once the underlying cause has been treated successfully.<ref name="RobsonLeung2016">{{cite journal|last1=Robson|first1=Wm Lane M.|last2=Leung|first2=Alexander K. C.|title=Secondary Nocturnal Enuresis|journal=Clinical Pediatrics|volume=39|issue=7|year=2016|pages=379–385|issn=0009-9228|doi=10.1177/000992280003900701}}</ref>  
*If intranasal [[desmopressin]] is used in the treatment of enuresis, some patients may develop [[seizures]] or altered mental status within 14 days of starting the medication.<ref name="LucchiniSimonetti2013">{{cite journal|last1=Lucchini|first1=Barbara|last2=Simonetti|first2=Giacomo D.|last3=Ceschi|first3=Alessandro|last4=Lava|first4=Sebastiano A.G.|last5=Faré|first5=Pietro B.|last6=Bianchetti|first6=Mario G.|title=Severe signs of hyponatremia secondary to desmopressin treatment for enuresis: A systematic review|journal=Journal of Pediatric Urology|volume=9|issue=6|year=2013|pages=1049–1053|issn=14775131|doi=10.1016/j.jpurol.2013.02.012}}</ref>
*Patients with nocturnal enuresis due to psychological causes generally improve over time with psychosocial alterations or successful psychotherapy.<ref name="RobsonLeung2016">{{cite journal|last1=Robson|first1=Wm Lane M.|last2=Leung|first2=Alexander K. C.|title=Secondary Nocturnal Enuresis|journal=Clinical Pediatrics|volume=39|issue=7|year=2016|pages=379–385|issn=0009-9228|doi=10.1177/000992280003900701}}</ref>
*The accidental poisoning of young children by medications ([[tricyclic antidepressants]]) prescribed for enuresis has been reported.<ref name="ParkinFrasert2008">{{cite journal|last1=Parkin|first1=J. M.|last2=Frasert|first2=M. S.|title=Poisoning as a Complication of Enuresis|journal=Developmental Medicine & Child Neurology|volume=14|issue=6|year=2008|pages=727–730|issn=00121622|doi=10.1111/j.1469-8749.1972.tb03315.x}}</ref>
===Prognosis===
* The prognosis of secondary [[nocturnal enuresis]] due to cystitis, constipation, [[diabetes mellitus]], [[seizure]] disorder, acquired urethral obstruction, and [[hyperthyroidism]], is excellent once the underlying cause has been treated successfully.<ref name="RobsonLeung2016">{{cite journal|last1=Robson|first1=Wm Lane M.|last2=Leung|first2=Alexander K. C.|title=Secondary Nocturnal Enuresis|journal=Clinical Pediatrics|volume=39|issue=7|year=2016|pages=379–385|issn=0009-9228|doi=10.1177/000992280003900701}}</ref>  
*Patients with nocturnal enuresis due to psychological causes generally improve over time with psychosocial alterations or [[psychotherapy]].<ref name="RobsonLeung2016">{{cite journal|last1=Robson|first1=Wm Lane M.|last2=Leung|first2=Alexander K. C.|title=Secondary Nocturnal Enuresis|journal=Clinical Pediatrics|volume=39|issue=7|year=2016|pages=379–385|issn=0009-9228|doi=10.1177/000992280003900701}}</ref>


==Comorbidities==
==Comorbidities==
*Enuresis exists with various comorbid conditions<ref name="RobsonJackson1997">{{cite journal|last1=Robson|first1=Wm Lane M.|last2=Jackson|first2=Harold P.|last3=Blackhurst|first3=Dawn|last4=LEUNG|first4=ALEXANDER k. C.|title=Enuresis in Children With Attention–Deficit Hyperactivity Disorder|journal=Southern Medical Journal|volume=90|issue=5|year=1997|pages=503–505|issn=0038-4348|doi=10.1097/00007611-199705000-00007}}</ref><ref name="KovacevicJurewicz2013">{{cite journal|last1=Kovacevic|first1=Larisa|last2=Jurewicz|first2=Michael|last3=Dabaja|first3=Ali|last4=Thomas|first4=Ronald|last5=Diaz|first5=Mireya|last6=Madgy|first6=David N.|last7=Lakshmanan|first7=Yegappan|title=Enuretic children with obstructive sleep apnea syndrome: Should they see otolaryngology first?|journal=Journal of Pediatric Urology|volume=9|issue=2|year=2013|pages=145–150|issn=14775131|doi=10.1016/j.jpurol.2011.12.013}}</ref><ref name="EnehOkafor2015">{{cite journal|last1=Eneh|first1=Chizoma I.|last2=Okafor|first2=Henrietta U.|last3=Ikefuna|first3=Anthony N.|last4=Uwaezuoke|first4=Samuel N.|title=Nocturnal enuresis: prevalence and risk factors among school-aged children with sickle-cell anaemia in a South-east Nigerian city|journal=Italian Journal of Pediatrics|volume=41|issue=1|year=2015|issn=1824-7288|doi=10.1186/s13052-015-0176-9}}</ref><ref name="WeintraubSinger2012">{{cite journal|last1=Weintraub|first1=Y|last2=Singer|first2=S|last3=Alexander|first3=D|last4=Hacham|first4=S|last5=Menuchin|first5=G|last6=Lubetzky|first6=R|last7=Steinberg|first7=D M|last8=Pinhas-Hamiel|first8=O|title=Enuresis—an unattended comorbidity of childhood obesity|journal=International Journal of Obesity|volume=37|issue=1|year=2012|pages=75–78|issn=0307-0565|doi=10.1038/ijo.2012.108}}</ref><ref>{{cite journal|doi=10.22037/uj.v14i1.3635}}</ref>
*Enuresis exists with various conditions<ref name="RobsonJackson1997">{{cite journal|last1=Robson|first1=Wm Lane M.|last2=Jackson|first2=Harold P.|last3=Blackhurst|first3=Dawn|last4=LEUNG|first4=ALEXANDER k. C.|title=Enuresis in Children With Attention–Deficit Hyperactivity Disorder|journal=Southern Medical Journal|volume=90|issue=5|year=1997|pages=503–505|issn=0038-4348|doi=10.1097/00007611-199705000-00007}}</ref><ref name="KovacevicJurewicz2013">{{cite journal|last1=Kovacevic|first1=Larisa|last2=Jurewicz|first2=Michael|last3=Dabaja|first3=Ali|last4=Thomas|first4=Ronald|last5=Diaz|first5=Mireya|last6=Madgy|first6=David N.|last7=Lakshmanan|first7=Yegappan|title=Enuretic children with obstructive sleep apnea syndrome: Should they see otolaryngology first?|journal=Journal of Pediatric Urology|volume=9|issue=2|year=2013|pages=145–150|issn=14775131|doi=10.1016/j.jpurol.2011.12.013}}</ref><ref name="EnehOkafor2015">{{cite journal|last1=Eneh|first1=Chizoma I.|last2=Okafor|first2=Henrietta U.|last3=Ikefuna|first3=Anthony N.|last4=Uwaezuoke|first4=Samuel N.|title=Nocturnal enuresis: prevalence and risk factors among school-aged children with sickle-cell anaemia in a South-east Nigerian city|journal=Italian Journal of Pediatrics|volume=41|issue=1|year=2015|issn=1824-7288|doi=10.1186/s13052-015-0176-9}}</ref><ref name="WeintraubSinger2012">{{cite journal|last1=Weintraub|first1=Y|last2=Singer|first2=S|last3=Alexander|first3=D|last4=Hacham|first4=S|last5=Menuchin|first5=G|last6=Lubetzky|first6=R|last7=Steinberg|first7=D M|last8=Pinhas-Hamiel|first8=O|title=Enuresis—an unattended comorbidity of childhood obesity|journal=International Journal of Obesity|volume=37|issue=1|year=2012|pages=75–78|issn=0307-0565|doi=10.1038/ijo.2012.108}}</ref><ref>{{cite journal|doi=10.22037/uj.v14i1.3635}}</ref>
**Attention-deficit hyperactivity disorder (ADHD)
**[[Attention-deficit hyperactivity disorder]] (ADHD)
**Obstructive sleep apnea syndrome
**[[Obstructive sleep apnea]] syndrome
**Sickle cell anemia
**[[Sickle cell anemia]]
**Childhood obesity
**Childhood obesity
**Oppositional-defiant disorder (ODD)
**[[Oppositional-defiant disorder]] (ODD)
**Tic disorder
**[[Tic disorder]]
**Conduct disorder
**[[Conduct disorder]]
**Bipolar affective disorder
**[[Bipolar affective disorder]]
**Post-traumatic stress disorder (PTSD)
**[[Post-traumatic stress disorder]] (PTSD)


==Diagnostic Criteria==
==Diagnostic Criteria==
===DSM-5 Criteria for Enuresis===
===DSM-5 Criteria for Enuresis===
*Enuresis is included under the elimination disorders.
*Enuresis is included under the [[elimination disorders]].
*The diagnostic guidelines are <ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*The diagnostic guidelines are <ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
** Repeated voiding of urine into bed or clothes, either involuntary or intentional.
** Repeated voiding of urine into bed or clothes, either involuntarily or intentionally.
** The behavior is clinically significant as manifested by either a frequency of at least twice a week for at least three consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational) or other areas of functioning
** The behavior is clinically significant manifested as either at least twice a week for a minimum of three consecutive months or with significant impairment of social, occupational, or other areas of functioning.
** Chronological age is a minimum of 5 years.
** Chronological age is a minimum of 5 years.
** The behavior is not attributable to the physiological effects of a substance (such as a [[diuretic]], an [[antipsychotic]] ) or another medical condition (Such as [[diabetes]], [[spina bifida]],or [[seizure disorder]]).
** The behavior is not attributable to the physiological effects of a substance (such as a [[diuretic]], an [[antipsychotic]] ) or another medical condition (such as [[diabetes]], [[spina bifida]], or [[seizure disorder]]).


*Specify if:
*Specify if:
** Nocturnal only: Passage of urine only during nighttime sleep.
** [[Nocturnal]] only: Passage of urine only during nighttime sleep.
** Diurnal only: Passage of urine only during waking hours.
** Diurnal only: Passage of urine only during waking hours.
** Nocturnal and diurnal: A combination of the two subtypes.
** [[Nocturnal]] and diurnal: A combination of the two subtypes.


===ICD-10 Criteria===
===ICD-10 Criteria===
*The criteria for the diagnosis of nonorganic enuresis are described in the section 'F98.0'.
*The criteria for the diagnosis of nonorganic enuresis are described in the section 'F98.0'.
*It emphasizes that enuresis should not be diagnosed in a child under the age of five years or under the mental age of four years.
*It emphasizes that enuresis should not be diagnosed in a [[child]] under the age of five years or mental age of four years.
*This category includes urinary incontinence of nonorganic origin or functional enuresis.
*This category includes urinary [[incontinence]] of nonorganic origin or functional enuresis.


==Treatment==
==Treatment==
*Medications are usually avoided in children under seven years of age.
*Parents should be reassured about the physical and emotional health of their children and counseled about eliminating guilt, and punishment.
*The patients are treated by behavioral modifications, medications, or a combination of both.
*The patients are treated by behavioral modifications, medications, or a combination of both.
*It is extremely important that the psychosocial consequences of the symptom be recognized and addressed with sensitivity during the treatment of enuresis.<ref name="FritzRockney2004">{{cite journal|last1=Fritz|first1=Gregory|last2=Rockney|first2=Randy|title=Practice Parameter for the Assessment and Treatment of Children and Adolescents With Enuresis|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=43|issue=12|year=2004|pages=1540–1550|issn=08908567|doi=10.1097/01.chi.0000142196.41215.cc}}</ref>
*Medications are usually avoided in [[children]] under seven years of age.
*Parents should be reassured about their [[child]]'s health and psychoeducated about eliminating guilt, and punishment.
*It is extremely important that the psychosocial consequences of the symptom be addressed with sensitivity during the treatment of enuresis.<ref name="FritzRockney2004">{{cite journal|last1=Fritz|first1=Gregory|last2=Rockney|first2=Randy|title=Practice Parameter for the Assessment and Treatment of Children and Adolescents With Enuresis|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=43|issue=12|year=2004|pages=1540–1550|issn=08908567|doi=10.1097/01.chi.0000142196.41215.cc}}</ref>


===Non-pharmacological management===
===Non-pharmacological management===
*Enuresis alarms are effective in patients with primary nocturnal enuresis and should be considered for older, highly motivated children from cooperative families.<ref name="pmid18756657">{{cite journal| author=Ramakrishnan K| title=Evaluation and treatment of enuresis. | journal=Am Fam Physician | year= 2008 | volume= 78 | issue= 4 | pages= 489-96 | pmid=18756657 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18756657  }} </ref>
*Enuresis alarms are effective in patients with primary [[nocturnal enuresis]] and should be considered for older, highly motivated [[children]] from cooperative [[families]].<ref name="pmid18756657">{{cite journal| author=Ramakrishnan K| title=Evaluation and treatment of enuresis. | journal=Am Fam Physician | year= 2008 | volume= 78 | issue= 4 | pages= 489-96 | pmid=18756657 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18756657  }} </ref>
*In the long-term follow-up, the enuretic alarm device also provided a full response rate in children with primary nocturnal enuresis.<ref name="TuncelMavituna2009">{{cite journal|last1=Tuncel|first1=Altug|last2=Mavituna|first2=Ilkay|last3=Nalcacioglu|first3=Varol|last4=Tekdogan|first4=Umit|last5=Uzun|first5=Burcin|last6=Atan|first6=Ali|title=Long-term follow-up of enuretic alarm treatment in enuresis nocturna|journal=Scandinavian Journal of Urology and Nephrology|volume=42|issue=5|year=2009|pages=449–454|issn=0036-5599|doi=10.1080/00365590802095678}}</ref>
*In the long-term follow-up, it has been observed that the enuretic alarm device also provide a full response rate in [[children]] with primary [[nocturnal enuresis]].<ref name="TuncelMavituna2009">{{cite journal|last1=Tuncel|first1=Altug|last2=Mavituna|first2=Ilkay|last3=Nalcacioglu|first3=Varol|last4=Tekdogan|first4=Umit|last5=Uzun|first5=Burcin|last6=Atan|first6=Ali|title=Long-term follow-up of enuretic alarm treatment in enuresis nocturna|journal=Scandinavian Journal of Urology and Nephrology|volume=42|issue=5|year=2009|pages=449–454|issn=0036-5599|doi=10.1080/00365590802095678}}</ref>
*Hypnotherapy is found to be an effective alternative or adjunctive form of treatment for enuresis in children.<ref name="EdwardsSpuvy1985">{{cite journal|last1=Edwards|first1=S. D.|last2=Spuvy|first2=H. I. J. Vander|title=HYPNOTHERAPY AS A TREATMENT FOR ENURESIS|journal=Journal of Child Psychology and Psychiatry|volume=26|issue=1|year=1985|pages=161–170|issn=0021-9630|doi=10.1111/j.1469-7610.1985.tb01635.x}}</ref>
*Hypnotherapy is found to be an effective alternative or adjunctive treatment for enuresis in [[children]].<ref name="EdwardsSpuvy1985">{{cite journal|last1=Edwards|first1=S. D.|last2=Spuvy|first2=H. I. J. Vander|title=HYPNOTHERAPY AS A TREATMENT FOR ENURESIS|journal=Journal of Child Psychology and Psychiatry|volume=26|issue=1|year=1985|pages=161–170|issn=0021-9630|doi=10.1111/j.1469-7610.1985.tb01635.x}}</ref>
*Acupressure administered by the parents could be an alternative non-drug treatment. It has the advantages of being non-invasive, cost-effective, and painless.<ref name="YuksekErdem2003">{{cite journal|last1=Yuksek|first1=MS|last2=Erdem|first2=AF|last3=Atalay|first3=C|last4=Demirel|first4=A|title=Acupressure versus Oxybutinin in the Treatment of Enuresis|journal=Journal of International Medical Research|volume=31|issue=6|year=2003|pages=552–556|issn=0300-0605|doi=10.1177/147323000303100611}}</ref>
*Acupressure administered by the parents could be an alternative non-pharmacological treatment. It has the advantages of being non-invasive, cost-effective, and painless.<ref name="YuksekErdem2003">{{cite journal|last1=Yuksek|first1=MS|last2=Erdem|first2=AF|last3=Atalay|first3=C|last4=Demirel|first4=A|title=Acupressure versus Oxybutinin in the Treatment of Enuresis|journal=Journal of International Medical Research|volume=31|issue=6|year=2003|pages=552–556|issn=0300-0605|doi=10.1177/147323000303100611}}</ref>


===Pharmacological management===
===Pharmacological management===
*Desmopressin, an antidiuretic hormone (ADH) analog, or arginine vasopressin (AVP), can resolve primary nocturnal enuresis by reducing urine production at the night.<ref name="pmid17571056">{{cite journal| author=Zaffanello M, Giacomello L, Brugnara M, Fanos V| title=Therapeutic options in childhood nocturnal enuresis. | journal=Minerva Urol Nefrol | year= 2007 | volume= 59 | issue= 2 | pages= 199-205 | pmid=17571056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17571056  }} </ref>
*[[Desmopressin]], an [[antidiuretic hormone]] (ADH) analog, is also called as arginine vasopressin (AVP). It can resolve primary nocturnal enuresis by reducing urine production at the night.<ref name="pmid17571056">{{cite journal| author=Zaffanello M, Giacomello L, Brugnara M, Fanos V| title=Therapeutic options in childhood nocturnal enuresis. | journal=Minerva Urol Nefrol | year= 2007 | volume= 59 | issue= 2 | pages= 199-205 | pmid=17571056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17571056  }} </ref>
*Patients respond to desmopressin more quickly than to alarm systems. However, it has been observed that more children improve from psychological (urine alarm) than from pharmacological interventions.<ref name="pmid18756657">{{cite journal| author=Ramakrishnan K| title=Evaluation and treatment of enuresis. | journal=Am Fam Physician | year= 2008 | volume= 78 | issue= 4 | pages= 489-96 | pmid=18756657 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18756657  }} </ref> <ref name="HoutsBerman1994">{{cite journal|last1=Houts|first1=Arthur C.|last2=Berman|first2=Jeffrey S.|last3=Abramson|first3=Hillel|title=Effectiveness of psychological and pharmacological treatments for nocturnal enuresis.|journal=Journal of Consulting and Clinical Psychology|volume=62|issue=4|year=1994|pages=737–745|issn=1939-2117|doi=10.1037/0022-006X.62.4.737}}</ref>
*It has been found that a structured withdrawal program from sublingual formulation of fast-melting oral desmopressin lyophilisate (MELT) therapy doesn't offer advantages compared to abrupt discontinuation.<ref name="FerraraRomano2014">{{cite journal|last1=Ferrara|first1=Pietro|last2=Romano|first2=Valerio|last3=Cortina|first3=Ivana|last4=Ianniello|first4=Francesca|last5=Fabrizio|first5=Giovanna Carmela|last6=Chiaretti|first6=Antonio|title=Oral desmopressin lyophilisate (MELT) for monosymptomatic enuresis: Structured versus abrupt withdrawal|journal=Journal of Pediatric Urology|volume=10|issue=1|year=2014|pages=52–55|issn=14775131|doi=10.1016/j.jpurol.2013.05.021}}</ref>
*Imipramine is useful for enuresis when other treatment options such as desmopressin, alarm, and anticholinergics have failed in older children.<ref name="GepertzNevéus2004">{{cite journal|last1=Gepertz|first1=Simon|last2=Nevéus|first2=Tryggve|title=IMIPRAMINE FOR THERAPY RESISTANT ENURESIS: A RETROSPECTIVE EVALUATION|journal=Journal of Urology|volume=171|issue=6 Part 2|year=2004|pages=2607–2610|issn=0022-5347|doi=10.1097/01.ju.0000110613.51078.93}}</ref>
*Patients respond rapidly to [[desmopressin]] as compared to alarm systems. However, it has been observed that more [[children]] improve from psychological (urine alarm) than from pharmacological interventions.<ref name="pmid18756657">{{cite journal| author=Ramakrishnan K| title=Evaluation and treatment of enuresis. | journal=Am Fam Physician | year= 2008 | volume= 78 | issue= 4 | pages= 489-96 | pmid=18756657 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18756657  }} </ref> <ref name="HoutsBerman1994">{{cite journal|last1=Houts|first1=Arthur C.|last2=Berman|first2=Jeffrey S.|last3=Abramson|first3=Hillel|title=Effectiveness of psychological and pharmacological treatments for nocturnal enuresis.|journal=Journal of Consulting and Clinical Psychology|volume=62|issue=4|year=1994|pages=737–745|issn=1939-2117|doi=10.1037/0022-006X.62.4.737}}</ref>
*Tricyclics and desmopressin are effective in reducing the number of wet nights while taking the drugs, but most children relapse after stopping active treatment. On the contrary, relapse rates are lower after alarm treatment.<ref name="GlazenerEvans2003">{{cite journal|last1=Glazener|first1=Cathryn MA|last2=Evans|first2=Jonathan HC|last3=Peto|first3=Rachel E|last4=Glazener|first4=Cathryn MA|title=Tricyclic and related drugs for nocturnal enuresis in children|year=2003|doi=10.1002/14651858.CD002117}}</ref>
*[[Tricyclics]] and [[desmopressin]] are effective in reducing the number of wet nights while taking the drugs, but most [[children]] relapse after stopping active treatment. On the contrary, relapse rates are lower after alarm treatment.<ref name="GlazenerEvans2003">{{cite journal|last1=Glazener|first1=Cathryn MA|last2=Evans|first2=Jonathan HC|last3=Peto|first3=Rachel E|last4=Glazener|first4=Cathryn MA|title=Tricyclic and related drugs for nocturnal enuresis in children|year=2003|doi=10.1002/14651858.CD002117}}</ref>
*It has been found that structured withdrawal program from sublingual formulation of fast-melting oral desmopressin lyophilisate (MELT) therapy doesn't offer advantages compared to abrupt discontinuation in patients with nocturnal enuresis.<ref name="FerraraRomano2014">{{cite journal|last1=Ferrara|first1=Pietro|last2=Romano|first2=Valerio|last3=Cortina|first3=Ivana|last4=Ianniello|first4=Francesca|last5=Fabrizio|first5=Giovanna Carmela|last6=Chiaretti|first6=Antonio|title=Oral desmopressin lyophilisate (MELT) for monosymptomatic enuresis: Structured versus abrupt withdrawal|journal=Journal of Pediatric Urology|volume=10|issue=1|year=2014|pages=52–55|issn=14775131|doi=10.1016/j.jpurol.2013.05.021}}</ref>
*[[Imipramine]] is useful for enuresis when other treatment options such as [[desmopressin]], alarm, and [[anticholinergics]] have failed in older [[children]].<ref name="GepertzNevéus2004">{{cite journal|last1=Gepertz|first1=Simon|last2=Nevéus|first2=Tryggve|title=IMIPRAMINE FOR THERAPY RESISTANT ENURESIS: A RETROSPECTIVE EVALUATION|journal=Journal of Urology|volume=171|issue=6 Part 2|year=2004|pages=2607–2610|issn=0022-5347|doi=10.1097/01.ju.0000110613.51078.93}}</ref>
*Oxybutinin has shown partial response in the management of nocturnal enuresis.<ref name="YuksekErdem2003">{{cite journal|last1=Yuksek|first1=MS|last2=Erdem|first2=AF|last3=Atalay|first3=C|last4=Demirel|first4=A|title=Acupressure versus Oxybutinin in the Treatment of Enuresis|journal=Journal of International Medical Research|volume=31|issue=6|year=2003|pages=552–556|issn=0300-0605|doi=10.1177/147323000303100611}}</ref>
*[[Oxybutynin]] has shown partial response in the management of [[nocturnal enuresis]].<ref name="YuksekErdem2003">{{cite journal|last1=Yuksek|first1=MS|last2=Erdem|first2=AF|last3=Atalay|first3=C|last4=Demirel|first4=A|title=Acupressure versus Oxybutinin in the Treatment of Enuresis|journal=Journal of International Medical Research|volume=31|issue=6|year=2003|pages=552–556|issn=0300-0605|doi=10.1177/147323000303100611}}</ref>


===Combined===
===Combined therapy===
*It is effective for resistant cases.<ref name="pmid18756657">{{cite journal| author=Ramakrishnan K| title=Evaluation and treatment of enuresis. | journal=Am Fam Physician | year= 2008 | volume= 78 | issue= 4 | pages= 489-96 | pmid=18756657 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18756657  }} </ref>
*Combined pharmacological and non-pharmacological interventions are effective for resistant cases.<ref name="pmid18756657">{{cite journal| author=Ramakrishnan K| title=Evaluation and treatment of enuresis. | journal=Am Fam Physician | year= 2008 | volume= 78 | issue= 4 | pages= 489-96 | pmid=18756657 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18756657  }} </ref>
*The combination of desmopressin and alarm is helpful for severe cases and those with other behavioural problems.<ref name="BradburyMeadow2008">{{cite journal|last1=Bradbury|first1=MG|last2=Meadow|first2=SR|title=Combined treatment with enuresis alarm and desmopressin for nocturnal enuresis|journal=Acta Paediatrica|volume=84|issue=9|year=2008|pages=1014–1018|issn=08035253|doi=10.1111/j.1651-2227.1995.tb13818.x}}</ref>
*Many studies have found that the combined therapy (enuresis alarm, bladder training, motivational therapy, and pelvic floor muscle training) is more effective than each component used alone.<ref name="pmid17571056">{{cite journal| author=Zaffanello M, Giacomello L, Brugnara M, Fanos V| title=Therapeutic options in childhood nocturnal enuresis. | journal=Minerva Urol Nefrol | year= 2007 | volume= 59 | issue= 2 | pages= 199-205 | pmid=17571056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17571056  }} </ref>
*Combined therapy (enuresis alarm, bladder training, motivational therapy, and pelvic floor muscle training) is more effective than each component used alone.<ref name="pmid17571056">{{cite journal| author=Zaffanello M, Giacomello L, Brugnara M, Fanos V| title=Therapeutic options in childhood nocturnal enuresis. | journal=Minerva Urol Nefrol | year= 2007 | volume= 59 | issue= 2 | pages= 199-205 | pmid=17571056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17571056  }} </ref>
*The combination of [[desmopressin]] and alarm is also helpful for severe cases with other behavioral problems.<ref name="BradburyMeadow2008">{{cite journal|last1=Bradbury|first1=MG|last2=Meadow|first2=SR|title=Combined treatment with enuresis alarm and desmopressin for nocturnal enuresis|journal=Acta Paediatrica|volume=84|issue=9|year=2008|pages=1014–1018|issn=08035253|doi=10.1111/j.1651-2227.1995.tb13818.x}}</ref>
*Pharmacotherapy can provide early relief, while behavioral intervention may lead to more long-term benefits. Utilizing this, the positive effect of achieving dry nights with pharmacotherapy can encourage the patient to sustain behavioral therapy.<ref name="pmid17571056">{{cite journal| author=Zaffanello M, Giacomello L, Brugnara M, Fanos V| title=Therapeutic options in childhood nocturnal enuresis. | journal=Minerva Urol Nefrol | year= 2007 | volume= 59 | issue= 2 | pages= 199-205 | pmid=17571056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17571056  }} </ref>
*Pharmacotherapy can provide early relief, while behavioral intervention may lead to more long-term benefits. Therefore, the positive effect of achieving dry nights with pharmacotherapy can encourage the patient to sustain behavioral therapy.<ref name="pmid17571056">{{cite journal| author=Zaffanello M, Giacomello L, Brugnara M, Fanos V| title=Therapeutic options in childhood nocturnal enuresis. | journal=Minerva Urol Nefrol | year= 2007 | volume= 59 | issue= 2 | pages= 199-205 | pmid=17571056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17571056  }} </ref>


==References==
==References==

Latest revision as of 22:26, 2 March 2021

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Editor(s)-in-Chief: C. Michael Gibson, M.S.,M.D. [1] Phone:617-632-7753; Angela Botts, M.D., Beth Israel Deaconess Medical Center Geriatric Medicine [2]; Associate Editor(s)-in-Chief: Vatsala Sharma, M.B.B.S., M.D. Kiran Singh, M.D. [3]

Overview

Enuresis is involuntary urination beyond the age of anticipated control. The two major forms of enuresis are diurnal enuresis (or daytime wetting), and nocturnal enuresis (bedwetting or nighttime wetting). This condition adversely affects the whole family. Enuresis impacts the child's overall development and is mostly associated with poor scholastic performance. It also has a major psychosocial burden on the parents, resulting in poorer quality of life. Treatment of enuresis should be holistic, targeting the management of enuresis in children as well as psychoeducation of the parents.

Historical Perspective

  • Enuresis has been a major social problem since ancient times.
  • The term enuresis is derived from the Greek word 'enourein' that means to void urine.[1]
  • Initially, enuresis was considered a psychiatric disturbance. It has been followed by the clearer theory of maturation delay along with the major role of hereditary factors. [2]
  • After multiple studies, it has been found that enuresis may be the cause and not the result of a psychiatric disorder.[3]
  • As early as 1550 BC, the problem of childhood incontinence was described in the Ebers papyrus.[4]
  • Prayers were an important component of the treatment options in the middle ages.
  • Belladonna, camphor, opium, and ergot were administered to enhance the bladder muscle tone in the eighteenth century.[4]
  • In 1948, a direct conditioning-based treatment modality called the alarm or bell-and-pad system was introduced.[4]
  • Initially, psychotherapy was accepted as the only possible method to treat enuresis, and there was a lot of skepticism about the conditioning treatment. [2]
  • Gradually, the alarm system became one of the most efficacious non-pharmacological management options worldwide.

Classification

  • According to International Children’s Continence Society (ICCS), enuresis consists of wetting by a child who has passed his or her fifth birthday.[5]
  • Enuresis is considered significant if it occurs more than once a month and at a frequency of at least three times per three months. Enuresis is termed frequent if there are more than three episodes a week.[5]
  • Enuresis is broadly divided into two types: daytime wetting and nighttime wetting.[6]
  • Primary enuresis is the condition used for a child that was never continent. On the other hand, the term secondary enuresis is used for new-onset symptoms after a dry period of at least six months.[5][7]
  • If bedwetting and nocturia are the only symptoms, the condition is known as monosymptomatic enuresis (MEN). If there are concomitant daytime voiding symptoms such as incontinence, frequency, urgency, or low voided volume, the condition is termed nonmonosymptomatic enuresis (NMEN).[5]
  • MEN occurs without any other symptoms of bladder dysfunction whereas NMEN is associated with dysfunction of the lower urinary tract with or without daytime incontinence.[8]

Pathophysiology

  • Some of the underlying pathophysiological mechanisms for enuresis are:[5][9][10]
    • Altered antidiuretic hormone profile
    • Sleep arousal failure
    • Delayed bladder maturation
    • Abnormal bladder function
    • Detrusor instability
    • Excess urine production during sleep
  • Nocturnal enuresis may be associated with lower urinary tract symptoms such as urgency, and frequency, with an overactive bladder. These may be further associated with constipation.[11]
  • Nocturnal enuresis mostly occurs early in the night, mainly in sleep stage 2 and deep sleep. Children with nocturnal enuresis and nocturnal polyuria differ in hemodynamics and autonomic activation at night compared to controls.[9]
  • Children with nocturnal enuresis often have sleep-disordered breathing and disturbed sleep due to awakenings and arousal.[9]
  • Periodic limb movements (PLM) have also been seen in children with refractory enuresis.[9]

Differential Diagnosis

Enuresis should be differentiated from other causes[12][13][14][15]

Epidemiology and Demographics

Prevalence

  • The prevalence of enuresis is[12]
    • 5,000-10,000 per 100,000 (5%-10%) among children 5 years of age
    • 3,000-5,000 per 100,000 (3%-5%) among children 10 year of age
    • 1,000 per 100,000 (1%) among individuals 15 years of age or older

Age

  • Enuresis is found to be more prevalent in first-born children.[16]
  • If enuretic symptoms persist into adulthood, they are less likely to resolve with time.[17]
  • Primary nocturnal enuresis in adults may represent a more pronounced form and have a more serious social and psychological effect on affected individuals.[17]

Gender

  • Most studies show a predominance of enuresis in males, whereas some others show no gender predominance.[18][19]

Race

Risk Factors

  • The risk factors for the development of enuresis are [12][21][1][22][23]
    • Delayed or lax toilet training
    • Genetic predisposition
    • Encopresis
    • Psychosocial stressors
    • Family history of enuresis (such as maternal history, and sibling history of bedwetting)
    • Low socioeconomic status
    • Snoring
    • Heavy and late supper
    • Deep sleeper
    • Sleepwalking
    • Being introverted and shy

Natural History, Complications, and Prognosis

Natural History

  • Most children with enuresis eventually attain bladder control.
  • It has been found that the prevalence of nocturnal enuresis gradually decreases with increasing age and many may achieve spontaneous resolution.[24]
  • The link between childhood enuresis and adult detrusor instability is observed to be stronger for men than women.[25]

Complications

  • If intranasal desmopressin is used in the treatment of enuresis, some patients may develop seizures or altered mental status within 14 days of starting the medication.[26]
  • The accidental poisoning of young children by medications (tricyclic antidepressants) prescribed for enuresis has been reported.[27]

Prognosis

Comorbidities

Diagnostic Criteria

DSM-5 Criteria for Enuresis

  • Enuresis is included under the elimination disorders.
  • The diagnostic guidelines are [12]
    • Repeated voiding of urine into bed or clothes, either involuntarily or intentionally.
    • The behavior is clinically significant manifested as either at least twice a week for a minimum of three consecutive months or with significant impairment of social, occupational, or other areas of functioning.
    • Chronological age is a minimum of 5 years.
    • The behavior is not attributable to the physiological effects of a substance (such as a diuretic, an antipsychotic ) or another medical condition (such as diabetes, spina bifida, or seizure disorder).
  • Specify if:
    • Nocturnal only: Passage of urine only during nighttime sleep.
    • Diurnal only: Passage of urine only during waking hours.
    • Nocturnal and diurnal: A combination of the two subtypes.

ICD-10 Criteria

  • The criteria for the diagnosis of nonorganic enuresis are described in the section 'F98.0'.
  • It emphasizes that enuresis should not be diagnosed in a child under the age of five years or mental age of four years.
  • This category includes urinary incontinence of nonorganic origin or functional enuresis.

Treatment

  • The patients are treated by behavioral modifications, medications, or a combination of both.
  • Medications are usually avoided in children under seven years of age.
  • Parents should be reassured about their child's health and psychoeducated about eliminating guilt, and punishment.
  • It is extremely important that the psychosocial consequences of the symptom be addressed with sensitivity during the treatment of enuresis.[33]

Non-pharmacological management

  • Enuresis alarms are effective in patients with primary nocturnal enuresis and should be considered for older, highly motivated children from cooperative families.[34]
  • In the long-term follow-up, it has been observed that the enuretic alarm device also provide a full response rate in children with primary nocturnal enuresis.[35]
  • Hypnotherapy is found to be an effective alternative or adjunctive treatment for enuresis in children.[36]
  • Acupressure administered by the parents could be an alternative non-pharmacological treatment. It has the advantages of being non-invasive, cost-effective, and painless.[37]

Pharmacological management

  • Desmopressin, an antidiuretic hormone (ADH) analog, is also called as arginine vasopressin (AVP). It can resolve primary nocturnal enuresis by reducing urine production at the night.[38]
  • It has been found that a structured withdrawal program from sublingual formulation of fast-melting oral desmopressin lyophilisate (MELT) therapy doesn't offer advantages compared to abrupt discontinuation.[39]
  • Patients respond rapidly to desmopressin as compared to alarm systems. However, it has been observed that more children improve from psychological (urine alarm) than from pharmacological interventions.[34] [40]
  • Tricyclics and desmopressin are effective in reducing the number of wet nights while taking the drugs, but most children relapse after stopping active treatment. On the contrary, relapse rates are lower after alarm treatment.[41]
  • Imipramine is useful for enuresis when other treatment options such as desmopressin, alarm, and anticholinergics have failed in older children.[42]
  • Oxybutynin has shown partial response in the management of nocturnal enuresis.[37]

Combined therapy

  • Combined pharmacological and non-pharmacological interventions are effective for resistant cases.[34]
  • Many studies have found that the combined therapy (enuresis alarm, bladder training, motivational therapy, and pelvic floor muscle training) is more effective than each component used alone.[38]
  • The combination of desmopressin and alarm is also helpful for severe cases with other behavioral problems.[43]
  • Pharmacotherapy can provide early relief, while behavioral intervention may lead to more long-term benefits. Therefore, the positive effect of achieving dry nights with pharmacotherapy can encourage the patient to sustain behavioral therapy.[38]

References

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  32. . doi:10.22037/uj.v14i1.3635. Missing or empty |title= (help)
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