Urinary incontinence in children: Difference between revisions

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{{SI}}                                                                 
                                                         
{{CMG}} {{AE}}{{Ifeoma Anaya}}
{{CMG}} {{AE}}{{Ifeoma Anaya}}


{{SK}} Urinary incontinence in kids; bedwetting; enuresis; nocturnal enuresis; enuresis nocturna; monosymptomatic enuresis nocturnal (MEN); non-monosymtomatic enuresis nocturnal (non-MEN)  
{{SK}} [[Urinary incontinence]] in [[Children|kids]]; [[Bedwetting]]; [[Enuresis]]; [[Nocturnal enuresis]]; [[Enuresis]] nocturna; Monosymptomatic [[enuresis]] nocturnal (MEN); Non-monosymtomatic [[enuresis]] nocturnal (non-MEN)  


==Overview==
==Overview==
[[Urinary incontinence]] in [[children]] is a very familiar finding and complaint amongst [[patients]] and their caregivers. The earliest documentation of [[urinary incontinence]] dates back to 1550 BC in the [[Ebers papyrus]]. It is broadly classified into [[physiological]] and [[pathological]] with its various subdivisions, and [[nocturnal enuresis]] can be categorized into primary and [[secondary]]. The [[pathophysiology]] of [[urinary incontinence]] in [[children]], particularly [[enuresis]], can be described as increased [[urine]] production at night, reduced [[Urinary bladder|bladder]] capacity at night, and awakening [[disorder]]. The [[causes]] of [[urinary incontinence]] in [[children]] are identified based on the sub-classification of [[pathological]] [[Urinary incontinence|incontinence]]. Differentials include [[diabetes mellitus]], [[diabetes insipidus]], and [[Urinary tract infections|urinary tract infection]]. [[Children]] achieve the ability to [[control]] their [[Urinary bladder|bladder]] between the ages of 3 and 6 [[Year|years]]. This begins initially during the daytime and nighttime control is achieved much later. [[Nocturnal enuresis]] is seen more frequently in boys. There is no documented [[racial]] predisposition for [[enuresis]]. Some [[risk factors]] include, [[age]] less than 5 [[Year|years]], positive [[family history]], [[family]] size, and [[birth]] order. Certain [[complications]] are poor [[self-esteem]] and inability to socialize with [[Peer support|peers]]. [[Prognosis]] is generally good due to the high chances of spontaneous [[resolution]] at the [[rate]] of 15% per [[year]]. The focus is to eliminate any [[potential]] organic [[Causes|cause]] of [[Urinary incontinence|incontinence]] and to classify and identify the type of functional [[Urinary incontinence|incontinence]] using detailed [[History and Physical examination|history]] and [[Non-invasive (medical)|non-invasive]] [[Procedure|procedures]]. Identify any [[comorbidities]] which are mostly [[psychological]] occurring alongside [[Urinary incontinence|incontinence]]. Fundamental [[diagnosis]] includes taking a detailed [[History and Physical examination|history]] using a standardized [[questionnaire]]. The primary aim of a [[physical examination]] is to look for possible organic [[causes]] of [[Urinary incontinence|incontinence]] and [[comorbidities]]. [[Urinalysis]] is essential to rule out [[urinary tract infections]]. [[Ultrasonography]] is a useful tool when further [[diagnostics]] is required especially in situations of a likely organic [[Causes|cause]] or a [[lack of response]] to [[therapy]]. Uroflowmetry and [[Urodynamics|urodynamic]] studies are additional [[diagnostic]] studies that can be employed. Urotherapy encompasses all non-[[pharmacological]] and non-[[surgical]] [[treatment]] methods employed in the [[treatment]] of [[urinary incontinence]] in [[children]]. [[Desmopressin]] and [[oxybutynin]] are common [[drugs]] used for the [[pharmacological]] management of [[urinary incontinence]] in [[children]]. [[Surgery]] is not routinely employed as a form of [[treatment]] but it might be of importance in correcting some organic [[causes]] of [[urinary incontinence]] in [[children]]. There are no documented primary [[Preventive care|preventive]] measures available for [[urinary incontinence]] in [[children]].


==Historical Perspective==
==Historical Perspective==
*Earliest documentation of urinary incontinence dates back to 1550 BC in the Ebers papyrus.  
 
*Pliny the elder, in 77 AD wrote on how incontinence of urine in children is treated by giving boiled mice in their food.  
*The earliest documentation of [[urinary incontinence]] dates back to 1550 BC in the [[Ebers papyrus]].
*Paulus Bagellardus of Padua wrote on the distress experienced by parents due to bedwetting when infants after the age of 3 years 'continue to pass water in the bed' which can sometimes last beyond the period of puberty.
*Pliny the Elder, in 77 AD, wrote about how [[Urinary incontinence|urinary incontinence]] in [[children]] is treated by giving boiled mice in their [[food]].
*In 1891, Jacobi inserted a suppository into the rectum multiple times a day for reinforcement of a supposedly weak bladder to treat enuresis. The suppository was a mixture of old sheep fat and strychnine.<ref name="Salmon2016">{{cite journal|last1=Salmon|first1=Michael A|title=An Historical Account of Nocturnal Enuresis and its Treatment|journal=Proceedings of the Royal Society of Medicine|volume=68|issue=7|year=2016|pages=443–445|issn=0035-9157|doi=10.1177/003591577506800726}}</ref>
*Paulus Bagellardus of Padua wrote about the [[distress]] experienced by parents due to [[bedwetting]] when [[infants]] after the age of 3 years 'continue to pass water in the bed' which can sometimes last beyond the period of [[puberty]].
*Rhazes, the Persian clinician, identified some causes of enuresis in children to be:
*In 1790, the term '[[enuresis]]' was founded, which means 'to [[urinate]] within' and '[[nocturnal]]' which means 'nighttime occurrence'.<ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>
**Bladder outlet muscle relaxation.
*In 1891, Jacobi placed a [[suppository]] into the [[rectum]] several times daily for the [[reinforcement]] of a supposedly weak [[Urinary bladder|bladder]] in order to [[Treatment|treat]] [[enuresis]]. The [[suppository]] was a mixture of old sheep [[fat]] and [[strychnine]].<ref name="Salmon2016">{{cite journal|last1=Salmon|first1=Michael A|title=An Historical Account of Nocturnal Enuresis and its Treatment|journal=Proceedings of the Royal Society of Medicine|volume=68|issue=7|year=2016|pages=443–445|issn=0035-9157|doi=10.1177/003591577506800726}}</ref>
**Deep sleep.
*Rhazes, the Persian [[clinician]], identified some [[causes]] of [[enuresis]] in [[children]] such as:
**Unrestricted fluid intake prior to bedtime, etc.<ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>
**[[Urinary bladder|Bladder]] [[outlet]] [[muscle]] [[relaxation]]
*Some of his treatment protocols included:
**Deep [[sleep]]
**Minimizing fluid intake before bedtime.
**Unrestricted [[fluid intake]] prior to [[bedtime]]<ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>
**Intake of substances producing fluid retention and body fluid losses.
*Some of his [[treatment]] [[protocols]] included:
**Use of both oral and injectable medications to the bladder through the urethra.<ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>
**Minimizing [[fluid intake]] before [[bedtime]]
*The term 'enuresis' was formed in 1790 which means 'to urinate within' and 'nocturnal' which means 'nighttime occurrence'. <ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>
**Intake of [[Substance|substances]] producing [[fluid retention]] and [[body fluid]] losses
**Use of both [[oral]] and [[Injection|injectable]] [[medications]] to the [[bladder]] through the [[urethra]]<ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>


==Classification==
==Classification==
*Urinary incontinence, also known as 'bedwetting' or 'enuresis' can be classified as follows:
 
*[[Urinary incontinence]], also known as '[[bedwetting]]' or '[[enuresis]]' can be classified as follows:
 
{| class="wikitable"
{| class="wikitable"
|+Classification of Urinary Incontinence in Children
|+Classification of Urinary Incontinence in Children
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Types of urinary incontinence
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Types of urinary incontinence
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Details
! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Details
|-
|-
| style="background:#DCDCDC;" + |'''[[Physiological]]'''
| style="background:#DCDCDC;" + |'''[[Physiological]]<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>'''
|
| colspan="2" |
*It is expected and seen as a norm in the early years.
*It is expected and seen as a norm in the early [[Year|years]].
*Requires a minimum age of 5 years, at least one event in a month, and a minimum period of 3 months.
*Requires a minimum [[age]] of 5 [[Year|years]], at least one [[Event study|event]] in a month, and a minimum [[period]] of 3 months.
*Persisting beyond the age of 5 years is termed pathological.
*Persisting beyond the [[age]] of 5 years is termed [[pathological]].
*However, there are the 'late developers' who continue to experience physiologic urinary incontinence beyond the age of 5 years.
*However, there are the 'late developers' who continue to experience [[physiologic]] [[urinary incontinence]] beyond the [[age]] of 5 [[Year|years]].
*Clinical evaluation of these kids remains normal.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
*[[Clinical]] evaluation of these [[Children|kids]] remains [[normal]].
|-
|-
| rowspan="4"style="background:#DCDCDC;" +|'''[[Pathological]]'''
| rowspan="3" style="background:#DCDCDC;" + |'''[[Pathological]]<ref name="pmid21977217" /><ref name="pmid31844104">{{cite journal| author=Zhu W, Che Y, Wang Y, Jia Z, Wan T, Wen J | display-authors=etal| title=Study on neuropathological mechanisms of primary monosymptomatic nocturnal enuresis in children using cerebral resting-state functional magnetic resonance imaging. | journal=Sci Rep | year= 2019 | volume= 9 | issue= 1 | pages= 19141 | pmid=31844104 | doi=10.1038/s41598-019-55541-9 | pmc=6915704 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31844104  }} </ref><ref name="pmid27703953">{{cite journal| author=Arda E, Cakiroglu B, Thomas DT| title=Primary Nocturnal Enuresis: A Review. | journal=Nephrourol Mon | year= 2016 | volume= 8 | issue= 4 | pages= e35809 | pmid=27703953 | doi=10.5812/numonthly.35809 | pmc=5039962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27703953 }} </ref>'''
|'''Organic''':
| colspan="2" |'''Organic''':
*Usually uncommon.
 
*In-depth investigations needed to be identified more so in cases that have not responded to conventional treatment.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217 }} </ref>
*Usually uncommon.
*In-depth investigations needed to be identified more so in cases that have not responded to conventional [[treatment]].
|-
|-
|'''Functional or psychosomatic''':  
| rowspan="2" |'''Functional or [[psychosomatic]]''':  
*Includes all forms of pathological urinary incontinence without anatomic or neurologic defects.  
 
*Includes all forms of [[pathological]] [[urinary incontinence]] without [[anatomic]] or [[neurologic]] [[Defect|defects]].
*Manifestations of which have been subdivided into two:
*Manifestations of which have been subdivided into two:
|'''''Monosymtomatic [[enuresis]] (MEN)'':'''
*These children have never had a dry period of >6 months and in the absence of any [[bladder]] [[dysfunction]] or [[symptoms]] suggestive of lower [[urinary tract]] issues.
|-
|-
|''Monosymtomatic enuresis(MEN)'':
|'''''Non-monosymptomatic [[enuresis]] Nocturna (Non-MEN)'':'''
*These kids have never had a dry period of >6 months and in the absence of any bladder dysfunction or symptoms suggestive of lower urinary tract issues.<ref name="pmid31844104">{{cite journal| author=Zhu W, Che Y, Wang Y, Jia Z, Wan T, Wen J | display-authors=etal| title=Study on neuropathological mechanisms of primary monosymptomatic nocturnal enuresis in children using cerebral resting-state functional magnetic resonance imaging. | journal=Sci Rep | year= 2019 | volume= 9 | issue= 1 | pages= 19141 | pmid=31844104 | doi=10.1038/s41598-019-55541-9 | pmc=6915704 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31844104  }} </ref>
*[[Diurnal]] presentation with an [[urge]], frequency, and [[enuresis]].
|-
|''Non-monosymptomatic enuresis Nocturna(Non-MEN)'':  
*Diurnal presentation with an urge, frequency, and enuresis.<ref name="pmid27703953">{{cite journal| author=Arda E, Cakiroglu B, Thomas DT| title=Primary Nocturnal Enuresis: A Review. | journal=Nephrourol Mon | year= 2016 | volume= 8 | issue= 4 | pages= e35809 | pmid=27703953 | doi=10.5812/numonthly.35809 | pmc=5039962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27703953  }} </ref>
|}
|}
*Another form of classification is based on the course of nocturnal enuresis is:
 
**'''Primary nocturnal enuresis''': 6 consecutive months without ever achieving bladder control at night. Most common form.
*Another form of [[classification]] based on the [[Course (medicine)|course]] of [[nocturnal]] [[enuresis]] is:
**'''Secondary nocturnal enuresis''': 6 consecutive months of bladder control attained before a recurrence of incontinence. Could be related to an organic or psychological cause.<ref name="pmid27703953">{{cite journal| author=Arda E, Cakiroglu B, Thomas DT| title=Primary Nocturnal Enuresis: A Review. | journal=Nephrourol Mon | year= 2016 | volume= 8 | issue= 4 | pages= e35809 | pmid=27703953 | doi=10.5812/numonthly.35809 | pmc=5039962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27703953  }} </ref>
**'''Primary [[nocturnal enuresis]]''': 6 consecutive months without ever achieving [[bladder]] control at night. Most common form.
**'''Secondary [[nocturnal enuresis]]''': 6 consecutive months of [[Urinary bladder|bladder]] control attained before a recurrence of [[Urinary incontinence|incontinence]]. Could be related to an organic or [[psychological]] [[Causes|cause]].<ref name="pmid27703953">{{cite journal| author=Arda E, Cakiroglu B, Thomas DT| title=Primary Nocturnal Enuresis: A Review. | journal=Nephrourol Mon | year= 2016 | volume= 8 | issue= 4 | pages= e35809 | pmid=27703953 | doi=10.5812/numonthly.35809 | pmc=5039962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27703953  }} </ref>


==Pathophysiology==
==Pathophysiology==
*The pathophysiology of urinary incontinence in children, particularly enuresis can be described under 3 broad categories:
 
*'''Increased urine production at night'''
*The [[pathophysiology]] of [[urinary incontinence]] in [[children]], particularly [[enuresis]] can be described under three broad [[categories]]:
**The bladder can fill up easily at night as a result of an imbalance between the production of urine at night and the capacity of the bladder. This often leads to frequent awakenings to pass urine for children or incontinence for those with difficulties in waking up.<ref name="pmid11196246">{{cite journal| author=Nevéus T, Läckgren G, Tuvemo T, Hetta J, Hjälmås K, Stenberg A| title=Enuresis--background and treatment. | journal=Scand J Urol Nephrol Suppl | year= 2000 | volume=  | issue= 206 | pages= 1-44 | pmid=11196246 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11196246  }} </ref>
*'''Increased [[urine]] production at night'''
**Nocturnal production of the Antidiuretic hormone, ADH is higher when compared to daytime values.<ref name="pmid24955178">{{cite journal| author=Tas T, Cakiroglu B, Hazar AI, Balci MB, Sinanoglu O, Nas Y | display-authors=etal| title=Monosymptomatic nocturnal enuresis caused by seasonal temperature changes. | journal=Int J Clin Exp Med | year= 2014 | volume= 7 | issue= 4 | pages= 1035-9 | pmid=24955178 | doi= | pmc=4057857 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24955178 }} </ref> Thus, the insufficient production of ADH in these children has been identified with a subsequent rise in urine production, frequency of which is 2 out of 3 children.<ref name="pmid2705537">{{cite journal| author=Rittig S, Knudsen UB, Nørgaard JP, Pedersen EB, Djurhuus JC| title=Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis. | journal=Am J Physiol | year= 1989 | volume= 256 | issue= 4 Pt 2 | pages= F664-71 | pmid=2705537 | doi=10.1152/ajprenal.1989.256.4.F664 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2705537 }} </ref>
**The [[Urinary bladder|bladder]] is able to fill up at night as a [[result]] of an [[imbalance]] between the [[urine]] production at night and the [[Urinary bladder|bladder]] capacity. This often leads to frequent awakenings to pass [[urine]] for [[children]] or [[Urinary incontinence|incontinence]] for those with difficulties in waking up.<ref name="pmid11196246">{{cite journal| author=Nevéus T, Läckgren G, Tuvemo T, Hetta J, Hjälmås K, Stenberg A| title=Enuresis--background and treatment. | journal=Scand J Urol Nephrol Suppl | year= 2000 | volume=  | issue= 206 | pages= 1-44 | pmid=11196246 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11196246  }} </ref>
*'''Reduced bladder capacity at night/Increased contractions of the detrusor muscle'''
**[[Nocturnal]] production of the [[antidiuretic hormone]], [[ADH]] is higher when compared to daytime values. Thus, the insufficient production of [[ADH]] in these [[children]] has been identified with a subsequent rise in [[urine]] production, frequency of which is 2 out of 3 children.<ref name="pmid2705537">{{cite journal| author=Rittig S, Knudsen UB, Nørgaard JP, Pedersen EB, Djurhuus JC| title=Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis. | journal=Am J Physiol | year= 1989 | volume= 256 | issue= 4 Pt 2 | pages= F664-71 | pmid=2705537 | doi=10.1152/ajprenal.1989.256.4.F664 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2705537 }} </ref><ref name="pmid24955178">{{cite journal| author=Tas T, Cakiroglu B, Hazar AI, Balci MB, Sinanoglu O, Nas Y | display-authors=etal| title=Monosymptomatic nocturnal enuresis caused by seasonal temperature changes. | journal=Int J Clin Exp Med | year= 2014 | volume= 7 | issue= 4 | pages= 1035-9 | pmid=24955178 | doi= | pmc=4057857 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24955178 }} </ref>
**Studies have proposed a reduced bladder wall capacity to 70% of the expected values with an increase in the bladder wall thickness on ultrasound in children with majorly nocturnal enuresis. <ref name="pmid15118426">{{cite journal| author=Yeung CK, Sreedhar B, Leung VT, Metreweli C| title=Ultrasound bladder measurements in patients with primary nocturnal enuresis: a urodynamic and treatment outcome correlation. | journal=J Urol | year= 2004 | volume= 171 | issue= 6 Pt 2 | pages= 2589-94 | pmid=15118426 | doi=10.1097/01.ju.0000112978.54300.03 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15118426  }} </ref>
*'''Reduced [[Urinary bladder|bladder]] capacity at night/Increased [[contractions]] of the [[detrusor muscle]]'''
**In addition to this, there is disinhibition in contractions of the bladder wall in about 30% of kids with enuresis.<ref name="pmid8719568">{{cite journal| author=Watanabe H| title=Sleep patterns in children with nocturnal enuresis. | journal=Scand J Urol Nephrol Suppl | year= 1995 | volume= 173 | issue=  | pages= 55-6; discussion 56-7 | pmid=8719568 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8719568  }} </ref>
**Studies have proposed a reduced [[Urinary bladder|bladder]] wall capacity to 70% of the expected values with an increase in the [[Urinary bladder|bladder]] wall thickness on [[ultrasound]] in [[children]] with majorly [[nocturnal enuresis]].<ref name="pmid15118426">{{cite journal| author=Yeung CK, Sreedhar B, Leung VT, Metreweli C| title=Ultrasound bladder measurements in patients with primary nocturnal enuresis: a urodynamic and treatment outcome correlation. | journal=J Urol | year= 2004 | volume= 171 | issue= 6 Pt 2 | pages= 2589-94 | pmid=15118426 | doi=10.1097/01.ju.0000112978.54300.03 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15118426  }} </ref>
*'''Awakening Disorder'''
**In addition to this, there is [[disinhibition]] in [[contractions]] of the [[Urinary bladder|bladder]] wall in about 30% of kids with [[enuresis]].<ref name="pmid8719568">{{cite journal| author=Watanabe H| title=Sleep patterns in children with nocturnal enuresis. | journal=Scand J Urol Nephrol Suppl | year= 1995 | volume= 173 | issue=  | pages= 55-6; discussion 56-7 | pmid=8719568 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8719568  }} </ref>
**The sudden urge to pass urine does not occur adequately in kids that are enuretic.
*'''Awakening [[Disorder]]'''
**Chronic over-stimulation causing a down-regulation of the voiding center has been surmised by researchers.<ref name="pmid18509134">{{cite journal| author=Yeung CK, Diao M, Sreedhar B| title=Cortical arousal in children with severe enuresis. | journal=N Engl J Med | year= 2008 | volume= 358 | issue= 22 | pages= 2414-5 | pmid=18509134 | doi=10.1056/NEJMc0706528 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18509134  }} </ref>
**The sudden [[Urinary urgency|urge]] to pass [[urine]] does not occur adequately in [[Children|kids]] that are enuretic.
**[[Chronic]] over-stimulation [[Causality|causing]] a [[down-regulation]] of the voiding center has been surmised by [[Research|researchers]].<ref name="pmid18509134">{{cite journal| author=Yeung CK, Diao M, Sreedhar B| title=Cortical arousal in children with severe enuresis. | journal=N Engl J Med | year= 2008 | volume= 358 | issue= 22 | pages= 2414-5 | pmid=18509134 | doi=10.1056/NEJMc0706528 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18509134  }} </ref>


==Causes==
==Causes==
*The causes of urinary incontinence in children are identified based on the subclassification of pathological incontinence.  
 
*Causes of MEN are not fully elucidated but are assumed to be a result of an interplay between the delayed maturation of the neurological bladder and how the production of urine is regulated.  
*The [[causes]] of [[urinary incontinence]] in [[children]] are identified based on the sub-classification of [[pathological]] [[Urinary incontinence|incontinence]].
*Non-MEN is subcategorized based on its symptoms which is predominantly day-time. These symptoms include:
*[[Causes]] of MEN are not fully elucidated but are assumed to be as a [[result]] of an interplay between the delayed [[maturation]] of the [[neurological]] [[Urinary bladder|bladder]] and how the [[urine]] production is regulated.
**Overactive bladder
*Non-MEN is subcategorized based on its [[symptoms]] which is predominantly day-time. These [[symptoms]] include:
**Discoordinated micturition
**[[Overactive bladder]]
**Dis-coordinated [[micturition]]
**Infrequent voiding
**Infrequent voiding
*Causes of organic incontinence which is usually rare include the following;
*[[Causes]] of organic [[Urinary incontinence|incontinence]] (which is usually [[rare]]) include the following;
**Structural renal problems such as:
**[[Structural biology|Structural]] [[renal]] problems such as:
***Ectopic ureter
***[[Ectopic ureter]]
***Malformed urethra
***[[Malformation|Malformed]] [[urethra]]
***Duplex kidney
***Duplex [[kidney]]
**Anatomic neural disorders like:
**[[Anatomic]] [[neural]] [[disorders]] such as:
***Spina bifida
***[[Spina bifida]]
***Neoplasms of the nervous system
***[[Neoplasms]] of the [[nervous system]]
***Tethered cord syndrome
***[[Tethered cord syndrome]]
***Sacral agenesis. <ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
***[[Sacral agenesis]].<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
**[[Obstructive sleep apnea]] ([[Obstructive sleep apnea|OSA]])
**[[Sexual]] [[abuse]]
**[[Pinworm infection|Pinworm infestation]]


==Differentiating [disease name] from other Diseases==
==Differentiating urinary incontinence from other diseases==


For further information about the differential diagnosis, click [[Disease_Name differential diagnosis|here]].
*It must be differentiated from the following:
**[[Diabetes mellitus]]
**[[Diabetes insipidus]]
**[[Urinary tract infections|Urinary tract infection]]
**[[Anxiety disorders|Anxiety disorder]]
**[[Spinal cord]] [[neoplasms]]
**[[Spinal cord]] [[trauma]]
**Small [[Urinary bladder|bladder]]


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Age===
===Age===
*Children achieve the ability to control their bladder between the ages of 3 and 6 years.  
 
*[[Children]] usually achieve the ability to [[control]] their [[Urinary bladder|bladder]] function between the [[Age|ages]] of 3 and 6 [[Year|years]].
*This begins initially during the daytime and nighttime control is achieved a lot later.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
*This begins initially during the daytime and nighttime control is achieved a lot later.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
*Nocturnal enuresis is still seen in 15%-20% of kids at 5 years old with a spontaneous recovery rate of 14% yearly.<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>
*[[Nocturnal enuresis]] is still seen in 15%-20% of five [[Year|year]] old [[Children|kids]] with a spontaneous [[recovery]] [[rate]] of 14% yearly.<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>
*10% of children still have nocturnal enuresis at the age of 7 years with daytime symptoms seen in 2%-9%.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
*10% of [[children]] still have [[nocturnal enuresis]] at the [[age]] of 7 [[Year|years]] with daytime [[symptoms]] seen in 2%-9%.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>


===Gender===
===Gender===
*Nocturnal enuresis is seen more frequently in boys.<ref name="pmid9202545">{{cite journal| author=Nørgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B| title=Experience and current status of research into the pathophysiology of nocturnal enuresis. | journal=Br J Urol | year= 1997 | volume= 79 | issue= 6 | pages= 825-35 | pmid=9202545 | doi=10.1046/j.1464-410x.1997.00207.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9202545  }} </ref>
 
*[[Nocturnal enuresis]] is seen more frequently in boys.<ref name="pmid9202545">{{cite journal| author=Nørgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B| title=Experience and current status of research into the pathophysiology of nocturnal enuresis. | journal=Br J Urol | year= 1997 | volume= 79 | issue= 6 | pages= 825-35 | pmid=9202545 | doi=10.1046/j.1464-410x.1997.00207.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9202545  }} </ref>


===Race===
===Race===


*There is no documented racial predilection for enuresis.
*There is no documented [[racial]] predisposition for [[enuresis]].


==Risk Factors==
==Risk Factors==
*Age, before 5 years
 
*Positive family history. Risk is highest when one parent had been a sufferer of enuresis
*Below is a list of [[risk factors]] associated with [[urinary incontinence]] in [[children]]:
*Family size
**[[Age]] less than five [[Year|years]]
*Birth order
**Positive [[family history]] (risk is highest when one parent had been a sufferer of [[enuresis]])
*Male gender
**[[Family]] size
*Low socioeconomic status
**[[Birth]] order
*Constipation
**[[Male]] gender
*History of urinary tract infection, diabetes,
**Low socioeconomic status
*Psychological:
**[[Constipation]]
**Birth of a sibling <ref name="pmid9202545">{{cite journal| author=Nørgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B| title=Experience and current status of research into the pathophysiology of nocturnal enuresis. | journal=Br J Urol | year= 1997 | volume= 79 | issue= 6 | pages= 825-35 | pmid=9202545 | doi=10.1046/j.1464-410x.1997.00207.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9202545  }} </ref>
**History of [[Urinary tract infections|urinary tract infection]]
**ADHD
**History of [[diabetes]]
**Anxiety
**[[Psychological]]:
**Change of school
***[[Birth]] of a sibling <ref name="pmid9202545">{{cite journal| author=Nørgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B| title=Experience and current status of research into the pathophysiology of nocturnal enuresis. | journal=Br J Urol | year= 1997 | volume= 79 | issue= 6 | pages= 825-35 | pmid=9202545 | doi=10.1046/j.1464-410x.1997.00207.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9202545  }} </ref>
**New home
***[[ADHD]]
**Divorce of parents
***[[Anxiety]]
***Change of school
***[[New]] home
***[[Divorcee|Divorce]] of [[Parenting|parents]]


==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
*'''Complications''':
 
**Poor self-esteem
*[[Complications]] include:
**Poor [[self-esteem]]
**Inability to socialize with peers
**Inability to socialize with peers
**Mood disorders
**[[Mood disorders]]
**Stress
**[[Stress]]
**General affectation of child and family's quality of life such as poor academic performance
**General affectation of [[child]] and family's quality of life such as poor academic performance
*'''Prognosis''':
*[[Prognosis]] is generally good due to the high chances of spontaneous resolution at the [[rate]] of 15% per [[year]].
**Generally good due to high chances of spontaneous resolution at the rate of 15% per year.
**As a [[result]] of [[slow]] response to conventional [[treatment]] such as alarm therapy and [[desmopressin]], 20% will remain incontinent by adulthood.<ref name="pmid31424765">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=31424765 | doi= | pmc= | url= }} </ref>
**Due to slow response to conventional treatment like alarm therapy and Desmopressin, 20% will remain incontinent by adulthood.<ref name="pmid31424765">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=31424765 | doi= | pmc= | url= }} </ref>


==Diagnosis==
==Diagnosis==
*The focus is to eliminate any potential organic cause of incontinence and to classify and identify the type of functional incontinence using detailed history and non-invasive procedures.  
 
*Identify any comorbidities which are mostly psychological occurring alongside incontinence. <ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
*The focus is to eliminate any potential organic [[Causes|cause]] of [[Urinary incontinence|incontinence]] and to classify and identify the type of functional [[Urinary incontinence|incontinence]] using detailed history and [[non-invasive]] [[Procedure|procedures]].
*Identify any [[comorbidities]] which are mostly [[psychological]] occurring alongside [[Urinary incontinence|incontinence]].<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>


===Symptoms===
===Symptoms===
*Fundamental diagnosis includes taking a detailed history using a standardized questionnaire. Some of the important questions to ask include:
 
**Time of the day child wets self?
*Fundamental [[diagnosis]] includes taking a detailed history using a standardized [[questionnaire]]. Some of the important questions to ask include:
**Pattern of occurrence (every night or every other night)?
**Time of the day [[child]] wets self?
**[[Pattern]] of occurrence (every night or every other night)?
**Place of occurrence (at home)?
**Place of occurrence (at home)?
**Frequency of restroom visits during the day and any at night?
**[[Frequency]] of restroom visits during the [[Daytime wetting|day]] and any at night?
**How does the child pass urine?
**How does the [[child]] pass [[urine]]?
**Any colored stains on pants during the daytime?
**Any [[Color|colored]] [[Stain|stains]] on pants during the [[Daytime wetting|daytime]]?
**Any holding movements seen?
**See any holding movements?
**Pattern of urine stream?
**[[Pattern]] of [[Urinary Stream (Decrease)|urine stream]]?
**Any straining?
**Any [[Strain|straining]]?
**Child's drinking habits especially in the evenings?
**[[Child|Child's]] [[drinking]] habits especially in the evenings?
**Previous/recurrent urinary tract infections?
**Previous/recurrent [[urinary tract infections]]?
**Constipation?
**[[Constipation]]?
**Encopresis?
**[[Encopresis]]?
**Developmental delays?
**[[Developmental delays]]?
**Psychological issues?
**[[Psychological]] issues?
**Previous surgery?
**Previous [[surgery]]?
**Any stressful circumstances recently either at home or school?
**Any [[Stress|stressful]] circumstances recently either at home or school?
**Method of treatment of incontinence in the past?
**Method of [[treatment]] of [[Urinary incontinence|incontinence]] in the past?
*A symptom or bladder diary is completed over a period of 14 days.
*A [[symptom]] or [[Urinary bladder|bladder]] diary is completed over a [[period]] of 14 days.


===Physical Examination===
===Physical Examination===
*Primary aim of a physical examination is to look for possible organic causes of incontinence and comorbidities.
 
**Spinal malformations in the lumbosacral region:
*Primary aim of a [[physical examination]] is to look for possible organic [[causes]] of [[Urinary incontinence|incontinence]] and [[comorbidities]].
***Lipoma
**[[Weight loss]]
***Hair tufts
**[[Hypertension]] ([[kidney disease]])
***Dimpled sacrum
**Enlarged [[tonsils]]
***Gluteal folds that appear non-symmetric
**[[Slow]] [[growth]]
***Hemangiomas
**[[Breathing]] through the [[mouth]]
**Fecal impaction on palpation of the abdomen
**Spinal [[malformations]] in the [[Lumbosacral trunk|lumbosacral]] [[Region of interest|region]]:
**Genital region:
***[[Lipoma]]
***Phimosis
***[[Hair]] tufts
***Urine leak
***[[Dimple|Dimpled]] [[sacrum]]
***Labial synechiae
***[[Gluteal fold|Gluteal folds]] that [[Appearance|appear]] non-[[Symmetric function|symmetric]]
***Vulval inflammation
***[[Hemangiomas]]
**Anal area:
**[[Mass]] on [[palpation]] of the [[abdomen]] suggesting [[fecal impaction]]
***Soilage
**[[Genital area|Genital region]]:
**Lower extremities:
***[[Phimosis]]
***Asymmetric reflexes
***[[Urine]] leak
***Atrophic muscles
***[[Labial]] synechiae
***Deformities on the foot
***[[Vulva|Vulval]] [[inflammation]]
**Assess developmental milestones attained
***[[Labial]] [[scars]]
**Assess child's behavior and screen for any behavioral abnormalities using appropriate questionnaires.
***[[Cremasteric reflex]]
**[[Anal]] [[area]]:
***[[Soiling|Soilage]]
***[[Scratch]] marks/[[Excoriation|excoriations]]
**[[Lower extremities]]:
***Asymmetric [[reflexes]]
***[[Atrophic]] [[muscles]]
***[[Deformities]] on the [[foot]]
**Assess [[developmental milestones]] attained
**Assess [[Child|child's]] [[behavior]] and [[Screening (medicine)|screen]] for any [[behavioral]] [[abnormalities]] using [[Appropriate Use Criteria|appropriate]] [[questionnaires]].


===Laboratory Findings===
===Laboratory Findings===
*Urinalysis
**Essential to rule out urinary tract infection.
**Changes in urine specific gravity suggesting Diabetes insipidus
**Glucosuria for Diabetes mellitus
*Lack of response to therapy/interventions and a diagnosis of Non-MEN will warrant further work-up.


===Electrocardiogram===
*[[Urinalysis]]:
There are no ECG findings associated with this condition.
**Essential to rule out [[Urinary tract infections|urinary tract infection]]
**Changes in [[urine]] [[specific gravity]] [[Suggestion|suggesting]] [[diabetes insipidus]]
**[[Glucosuria]] for [[diabetes mellitus]]
*[[Lack of response]] to [[therapy]]/[[interventions]] and a [[diagnosis]] of Non-MEN will warrant further work-up


===X-ray===
===Ultrasound===
There are no x-ray findings associated with urinary incontinence in children.


===Echocardiography or Ultrasound===
*[[Ultrasonography]] is a useful tool when further [[diagnostics]] is required, especially in situations of a likely organic [[Causes|cause]] or a [[lack of response]] to [[therapy]].
*Ultrasonography is a useful tool when further diagnostics is required especially in situations of a likely organic cause or a lack of response to therapy. It can detect anomalies in the renal system such as:
*It can [[Anomaly detection|detect anomalies]] in the [[renal system]] such as:
**Increase in thickness of the bladder wall
**Increase in thickness of the [[Urinary bladder|bladder]] wall
**Dilated ureters
**Dilated [[ureters]]
**Hydronephrosis
**[[Hydronephrosis]]
**Ureterocele
**[[Ureterocele]]
**Duplex kidney
**Duplex [[kidney]]
**Distended rectum. <ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
**[[Distended abdomen|Distended]] [[rectum]]<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>


===CT scan===
===CT scan===
*There are no CT scan findings associated with urinary incontinence in children. However, a CT scan may be helpful in the diagnosis of organic causes where a more detailed observation of anatomical abnormalities is required.
 
*There are no [[CT scan]] findings [[Association (statistics)|associated]] with [[urinary incontinence]] in [[children]]. However, a [[CT scan]] may be helpful in the [[diagnosis]] of organic [[causes]] whenever a more detailed [[observation]] of [[anatomical]] [[abnormalities]] is required.


===MRI===
===MRI===
*There are no MRI findings associated with urinary incontinence in children. However, an MRI may be helpful in the diagnosis of organic causes where a  more detailed observation of anatomical abnormalities is required.


===Other Imaging Findings===
*There are no [[MRI]] findings [[Association (statistics)|associated]] with [[urinary incontinence]] in [[children]]. However, an [[Magnetic resonance imaging|MRI]] may be helpful in the [[diagnosis]] of organic [[causes]] whenever a more detailed [[observation]] of [[anatomical]] [[abnormalities]] is required.
There are no other imaging findings associated with urinary incontinence in children.


===Other Diagnostic Studies===
===Other Diagnostic Studies===
*Uroflowmetry: This shows the bladder's pattern of voiding. If this test comes out suspicious, further testing like the Irofloe-electromyography is required to observe pelvic floor details.<ref name="pmid16753432">{{cite journal| author=Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W | display-authors=etal| title=The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. | journal=J Urol | year= 2006 | volume= 176 | issue= 1 | pages= 314-24 | pmid=16753432 | doi=10.1016/S0022-5347(06)00305-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16753432  }} </ref>
 
*Urodynamic studies: reveals problems associated with the capacity of the bladder, compliance (detrusor muscles).
*'''Uroflowmetry:''' This shows the [[Urinary bladder|bladder's]] [[pattern]] of voiding. If this [[test]] comes out suspicious, further [[testing]] like the uroflow-[[electromyography]] is required to [[Observation|observe]] [[pelvic floor]] details.<ref name="pmid16753432">{{cite journal| author=Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W | display-authors=etal| title=The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. | journal=J Urol | year= 2006 | volume= 176 | issue= 1 | pages= 314-24 | pmid=16753432 | doi=10.1016/S0022-5347(06)00305-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16753432  }} </ref>
**Valuable for illustrating neurogenic bladder or issues related to obstruction of the bladder outlet. <ref name="pmid15118427">{{cite journal| author=Yeung CK, Sihoe JD, Sit FK, Diao M, Yew SY| title=Urodynamic findings in adults with primary nocturnal enuresis. | journal=J Urol | year= 2004 | volume= 171 | issue= 6 Pt 2 | pages= 2595-8 | pmid=15118427 | doi=10.1097/01.ju.0000112790.72612.0a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15118427  }} </ref>
*'''[[Urodynamics|Urodynamic studies]]:''' Reveal problems [[Association (statistics)|associated]] with the [[Urinary bladder|bladder]] capacity, and [[compliance]] ([[Detrusor muscle|detrusor muscles]]).
**Valuable for illustrating [[neurogenic]] [[Urinary bladder|bladder]] or issues related to the [[bladder outlet obstruction]].<ref name="pmid15118427">{{cite journal| author=Yeung CK, Sihoe JD, Sit FK, Diao M, Yew SY| title=Urodynamic findings in adults with primary nocturnal enuresis. | journal=J Urol | year= 2004 | volume= 171 | issue= 6 Pt 2 | pages= 2595-8 | pmid=15118427 | doi=10.1097/01.ju.0000112790.72612.0a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15118427  }} </ref>


==Treatment==
==Treatment==
*Treatment modality is based on the following fundamental principles:
 
**Encourage both patient and caregiver to undergo therapy.
*[[Treatment]] [[modality]] is based on the following [[Fundamental science|fundamental]] [[Principle (chemistry)|principles]]:
**Treat day-time symptoms prior to night-time in non-MEN.
**Encourage both [[patient]] and caregiver to undergo [[therapy]].
**Fecal incontinence where present should be treated first.
**[[Treatment|Treat]] [[Daytime wetting|day-time]] [[symptoms]] prior to night-time in non-MEN.
**Psychiatric comorbidities should be treated concurrently.
**[[Fecal]] [[Urinary incontinence|incontinence]] where present should be [[Treatment|treated]] first.
**Higher success rates documented with combined treatment modalities.
**[[Psychiatric]] [[comorbidities]] should be [[Treatment|treated]] [[Concurrent overlap|concurrently]].
**Continuous monitoring of treatment is highly necessary.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
**Higher success [[rates]] documented with combined [[treatment]] [[Modality|modalities]].
**Continuous [[Monitoring competence|monitoring]] of [[treatment]] is highly essential.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
 
===Medical Therapy===
===Medical Therapy===


*'''Urotherapy:'''
**This encompasses all the [[treatment]] methods employed in the [[treatment]] of [[urinary incontinence]] in [[children]].
**They are non-[[pharmacological]] and non-[[surgical]] and usually first-line approach.
**It has been proven [[Effective method|effective]] in the management of functional [[urinary incontinence]] and supplementary to [[treatment]] methods of [[Organic Chemistry|organic]] [[urinary incontinence]].
**The components of urotherapy are divided into [[standard]] urotherapy and specific [[interventions]] which may or may not be needed.
**'''[[Standard]] urotherapy''' which is the primary [[treatment]] for the functional type of [[urinary incontinence]] involves the following:
***Extensive [[family]] [[education]] regarding the [[disorder]] and its management.
***[[Suggestions]] on voiding [[behavior]] such as schedules for [[urination]].
***[[Fluid intake]] [[Restriction|restrictions]] and [[nutrition]] in the setting of [[constipation]].
***[[Tracking changes|Tracking]] of the progress of [[treatment]].
**'''Specific [[interventions]]''' that can be occasionally added to [[treatment]] include:
***'''Alarm [[therapy]]:'''
****Most useful for [[disorders]] with awakening.
****It is intended to increase the [[Urinary bladder|bladder]] capacity at night.
****The [[child]] is groomed to awaken prior to [[bedwetting]].
****The [[Ideal solution|ideal]] [[treatment]] for [[children]] < 8 [[Year|years]] with MEN and with good [[support]] from caregivers.<ref name="pmid7962877">{{cite journal| author=Houts AC, Berman JS, Abramson H| title=Effectiveness of psychological and pharmacological treatments for nocturnal enuresis. | journal=J Consult Clin Psychol | year= 1994 | volume= 62 | issue= 4 | pages= 737-45 | pmid=7962877 | doi=10.1037//0022-006x.62.4.737 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7962877  }} </ref>
***'''[[Neuromodulation]]:''' [[Transcutaneous electric nerve stimulation|Transcutaneous]] parasacral neurostimulation for [[overactive bladder]] cases.
***'''[[Biofeedback]]:''' Using [[optical]] and [[auditory]] cues to help [[children]] to [[Relaxation|relax]] and empty their [[Urinary bladder|bladder]] in cases of [[micturition]] that are uncoordinated:<ref name="EbilogluErgin2016">{{cite journal|last1=Ebiloglu|first1=Turgay|last2=Ergin|first2=Giray|last3=Irkilata|first3=Hasan Cem|last4=Kibar|first4=Yusuf|title=The biofeedback treatment for non-monosymptomatic enuresis nocturna|journal=Neurourology and Urodynamics|volume=35|issue=1|year=2016|pages=58–61|issn=07332467|doi=10.1002/nau.22678}}</ref>
****Anti-[[stress]] program
****[[Pelvic floor]] [[exercise]]
****Self-[[catheterization]]<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
**'''[[Pharmacological]] [[treatment]]:'''
***'''[[ADH]] analogs''' such as [[desmopressin|'''desmopressin''']] are helpful in the setting of high [[urine output]] at night. Effective in 70% of cases with complete [[remission]] seen in 25%. [[Relapse]] is however a concern but the [[Coordination|coordinated]] stepwise [[withdrawal]] of [[therapy]] is promising.
***'''[[Anticholinergics]]''' such as '''[[oxybutynin]], and [[propiverine]]''' (preferred due to lower side-effects) are sometimes used in cases of [[overactive bladder]] with [[failure]] to achieve dryness from urotherapy. 65%-87% [[Response rate|response rates]] are [[Reporting results|reported]] with [[Chance|chances]] of [[relapse]] also documented.
***'''[[Botulinum toxin]] A:''' [[Rare|rarely]] indicated.
***'''[[Alpha-blockers]]'''
***'''[[Tricyclic antidepressants]]:'''  Have [[lethal]] [[heart]] [[side effects]] and not usually used.<ref name="pmid27703953">{{cite journal| author=Arda E, Cakiroglu B, Thomas DT| title=Primary Nocturnal Enuresis: A Review. | journal=Nephrourol Mon | year= 2016 | volume= 8 | issue= 4 | pages= e35809 | pmid=27703953 | doi=10.5812/numonthly.35809 | pmc=5039962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27703953  }} </ref>


===Surgery===
===Surgery===


*Surgery is the mainstay of therapy for [disease name].
*[[Surgery]] is not routinely employed as a form of [[treatment]]. Might be of importance in [[Corrective|correcting]] some organic [[causes]] of [[urinary incontinence]] in [[children]].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
 
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].
===Prevention===
===Prevention===


*There are no primary preventive measures available for [disease name].
*There are no documented [[Primary prevention|primary preventive]] [[Measure (mathematics)|measures]] available for [[urinary incontinence]] in [[children]].
*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
 
*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].


==References==
==References==
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[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Primary care]]
[[Category:Up-To-Date]]

Latest revision as of 14:24, 9 April 2021

Urinary incontinence in children Microchapters

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differential Diagnosis

Epidemiology and Demographics

Risk factors

Natural History, Complications and Prognosis

Diagnosis

Treatment

Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ifeoma Anaya, M.D.[2]

Synonyms and keywords: Urinary incontinence in kids; Bedwetting; Enuresis; Nocturnal enuresis; Enuresis nocturna; Monosymptomatic enuresis nocturnal (MEN); Non-monosymtomatic enuresis nocturnal (non-MEN)

Overview

Urinary incontinence in children is a very familiar finding and complaint amongst patients and their caregivers. The earliest documentation of urinary incontinence dates back to 1550 BC in the Ebers papyrus. It is broadly classified into physiological and pathological with its various subdivisions, and nocturnal enuresis can be categorized into primary and secondary. The pathophysiology of urinary incontinence in children, particularly enuresis, can be described as increased urine production at night, reduced bladder capacity at night, and awakening disorder. The causes of urinary incontinence in children are identified based on the sub-classification of pathological incontinence. Differentials include diabetes mellitus, diabetes insipidus, and urinary tract infection. Children achieve the ability to control their bladder between the ages of 3 and 6 years. This begins initially during the daytime and nighttime control is achieved much later. Nocturnal enuresis is seen more frequently in boys. There is no documented racial predisposition for enuresis. Some risk factors include, age less than 5 years, positive family history, family size, and birth order. Certain complications are poor self-esteem and inability to socialize with peers. Prognosis is generally good due to the high chances of spontaneous resolution at the rate of 15% per year. The focus is to eliminate any potential organic cause of incontinence and to classify and identify the type of functional incontinence using detailed history and non-invasive procedures. Identify any comorbidities which are mostly psychological occurring alongside incontinence. Fundamental diagnosis includes taking a detailed history using a standardized questionnaire. The primary aim of a physical examination is to look for possible organic causes of incontinence and comorbidities. Urinalysis is essential to rule out urinary tract infections. Ultrasonography is a useful tool when further diagnostics is required especially in situations of a likely organic cause or a lack of response to therapy. Uroflowmetry and urodynamic studies are additional diagnostic studies that can be employed. Urotherapy encompasses all non-pharmacological and non-surgical treatment methods employed in the treatment of urinary incontinence in children. Desmopressin and oxybutynin are common drugs used for the pharmacological management of urinary incontinence in children. Surgery is not routinely employed as a form of treatment but it might be of importance in correcting some organic causes of urinary incontinence in children. There are no documented primary preventive measures available for urinary incontinence in children.

Historical Perspective

Classification

Classification of Urinary Incontinence in Children
Types of urinary incontinence Details
Physiological[3]
Pathological[3][4][5] Organic:
  • Usually uncommon.
  • In-depth investigations needed to be identified more so in cases that have not responded to conventional treatment.
Functional or psychosomatic: Monosymtomatic enuresis (MEN):
Non-monosymptomatic enuresis Nocturna (Non-MEN):

Pathophysiology

Causes

Differentiating urinary incontinence from other diseases

Epidemiology and Demographics

Age

Gender

Race

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Symptoms

Physical Examination

Laboratory Findings

Ultrasound

CT scan

MRI

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Prevention

References

  1. 1.0 1.1 1.2 Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM (2013). "Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history". Iran Red Crescent Med J. 15 (8): 633–8. doi:10.5812/ircmj.5017. PMC 3918184. PMID 24578827.
  2. Salmon, Michael A (2016). "An Historical Account of Nocturnal Enuresis and its Treatment". Proceedings of the Royal Society of Medicine. 68 (7): 443–445. doi:10.1177/003591577506800726. ISSN 0035-9157.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H (2011). "Urinary incontinence in children". Dtsch Arztebl Int. 108 (37): 613–20. doi:10.3238/arztebl.2011.0613. PMC 3187617. PMID 21977217.
  4. Zhu W, Che Y, Wang Y, Jia Z, Wan T, Wen J; et al. (2019). "Study on neuropathological mechanisms of primary monosymptomatic nocturnal enuresis in children using cerebral resting-state functional magnetic resonance imaging". Sci Rep. 9 (1): 19141. doi:10.1038/s41598-019-55541-9. PMC 6915704 Check |pmc= value (help). PMID 31844104.
  5. 5.0 5.1 5.2 Arda E, Cakiroglu B, Thomas DT (2016). "Primary Nocturnal Enuresis: A Review". Nephrourol Mon. 8 (4): e35809. doi:10.5812/numonthly.35809. PMC 5039962. PMID 27703953.
  6. Nevéus T, Läckgren G, Tuvemo T, Hetta J, Hjälmås K, Stenberg A (2000). "Enuresis--background and treatment". Scand J Urol Nephrol Suppl (206): 1–44. PMID 11196246.
  7. Rittig S, Knudsen UB, Nørgaard JP, Pedersen EB, Djurhuus JC (1989). "Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis". Am J Physiol. 256 (4 Pt 2): F664–71. doi:10.1152/ajprenal.1989.256.4.F664. PMID 2705537.
  8. Tas T, Cakiroglu B, Hazar AI, Balci MB, Sinanoglu O, Nas Y; et al. (2014). "Monosymptomatic nocturnal enuresis caused by seasonal temperature changes". Int J Clin Exp Med. 7 (4): 1035–9. PMC 4057857. PMID 24955178.
  9. Yeung CK, Sreedhar B, Leung VT, Metreweli C (2004). "Ultrasound bladder measurements in patients with primary nocturnal enuresis: a urodynamic and treatment outcome correlation". J Urol. 171 (6 Pt 2): 2589–94. doi:10.1097/01.ju.0000112978.54300.03. PMID 15118426.
  10. Watanabe H (1995). "Sleep patterns in children with nocturnal enuresis". Scand J Urol Nephrol Suppl. 173: 55–6, discussion 56-7. PMID 8719568.
  11. Yeung CK, Diao M, Sreedhar B (2008). "Cortical arousal in children with severe enuresis". N Engl J Med. 358 (22): 2414–5. doi:10.1056/NEJMc0706528. PMID 18509134.
  12. Arda, Ersan; Cakiroglu, Basri; Thomas, David T. (2016). "Primary Nocturnal Enuresis: A Review". Nephro-Urology Monthly. 8 (4). doi:10.5812/numonthly.35809. ISSN 2251-7006.
  13. 13.0 13.1 Nørgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B (1997). "Experience and current status of research into the pathophysiology of nocturnal enuresis". Br J Urol. 79 (6): 825–35. doi:10.1046/j.1464-410x.1997.00207.x. PMID 9202545.
  14. "StatPearls". 2020. PMID 31424765.
  15. Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W; et al. (2006). "The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society". J Urol. 176 (1): 314–24. doi:10.1016/S0022-5347(06)00305-3. PMID 16753432.
  16. Yeung CK, Sihoe JD, Sit FK, Diao M, Yew SY (2004). "Urodynamic findings in adults with primary nocturnal enuresis". J Urol. 171 (6 Pt 2): 2595–8. doi:10.1097/01.ju.0000112790.72612.0a. PMID 15118427.
  17. Houts AC, Berman JS, Abramson H (1994). "Effectiveness of psychological and pharmacological treatments for nocturnal enuresis". J Consult Clin Psychol. 62 (4): 737–45. doi:10.1037//0022-006x.62.4.737. PMID 7962877.
  18. Ebiloglu, Turgay; Ergin, Giray; Irkilata, Hasan Cem; Kibar, Yusuf (2016). "The biofeedback treatment for non-monosymptomatic enuresis nocturna". Neurourology and Urodynamics. 35 (1): 58–61. doi:10.1002/nau.22678. ISSN 0733-2467.