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*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 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>
*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>
*Primary enuresis is the condition preferred 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>
*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>
*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>
*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>
*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>
*Primary enuresis is the condition preferred 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>


==Pathophysiology==
==Pathophysiology==

Revision as of 17:53, 26 February 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: 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). Enuresis affects the child's overall development and is associated with poor scholastic performance. It also has a major psychosocial burden on the parents, resulting in poorer quality of life. This condition adversely affects the whole family. Treatment of enuresis should be holistic, targeting the management of enuresis in children and 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 became an important supplemental 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 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.[5]
  • Enuresis is broadly divided into two types: daytime wetting and nighttime wetting.[6]
  • Primary enuresis is the condition preferred 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, frequency, and wetting – with reduced bladder storage, and an overactive bladder. These may be further associated with constipation.[11]
  • 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.[9]
  • Children with nocturnal enuresis often have sleep-disordered breathing and disturbed sleep due to awakenings and arousal. 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 the first born children.[16]
  • If enuretic symptoms persist into adulthood, they are probably less likely to resolve with time.[17]
  • Primary nocturnal enuresis in adult 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

  • Most children with enuresis eventually obtain 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]
  • 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 have been reported.[27]
  • 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.[28]
  • Patients with nocturnal enuresis due to psychological causes generally improve over time with psychosocial alterations or successful psychotherapy.[28]

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 involuntary or intentional.
    • 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.
    • 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 under the mental age of four years.
  • This category includes urinary incontinence of nonorganic origin or functional enuresis.

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.
  • It is extremely important that the psychosocial consequences of the symptom be recognized and 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, the enuretic alarm device also provided a full response rate in children with primary nocturnal enuresis.[35]
  • Hypnotherapy is found to be an effective alternative or adjunctive form of 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, or arginine vasopressin (AVP), can resolve primary nocturnal enuresis by reducing urine production at the night.[38]
  • 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.[34] [39]
  • Imipramine is useful for enuresis when other treatment options such as desmopressin, alarm, and anticholinergics have failed in older children.[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]
  • 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.[42]
  • Oxybutinin has shown partial response in the management of nocturnal enuresis.[37]

Combined

  • It is effective for resistant cases.[34]
  • The combination of desmopressin and alarm is helpful for severe cases and those with other behavioural problems.[43]
  • Combined therapy (enuresis alarm, bladder training, motivational therapy, and pelvic floor muscle training) is more effective than each component used alone.[38]
  • 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.[38]

References

  1. ↑ 1.0 1.1 Solanki, Ashok; Desai, Sarzoo (2014). "Prevalence and risk factors of nocturnal enuresis among school age children in rural areas". International Journal of Research in Medical Sciences. 2 (1): 202. doi:10.5455/2320-6012.ijrms20140239. ISSN 2320-6071.
  2. ↑ 2.0 2.1 Schulpen, TWJ (1997). "The burden of nocturnal enuresis". Acta Paediatrica. 86 (9): 981–984. doi:10.1111/j.1651-2227.1997.tb15183.x. ISSN 0803-5253.
  3. ↑ Läckgren, G; Hjalmås, K; Gool, J van; Gontard, A von; Gennaro, M de; Lottmann, H; Terho, P (2007). "COMMITTEE REPORT". Acta Paediatrica. 88 (6): 679–690. doi:10.1111/j.1651-2227.1999.tb00023.x. ISSN 0803-5253.
  4. ↑ 4.0 4.1 4.2 Nørgaard, Jens Peter; Djurhuus, Jens Christian (2016). "The Pathophysiology of Enuresis in Children and Young Adults". Clinical Pediatrics. 32 (1_suppl): 5–9. doi:10.1177/0009922893032001S02. ISSN 0009-9228.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Haid, Bernhard; Tekgül, Serdar (2017). "Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment". European Urology Focus. 3 (2–3): 198–206. doi:10.1016/j.euf.2017.08.010. ISSN 2405-4569.
  6. ↑ Mahony, David T. (1973). "Studies of enuresis". Urology. 1 (4): 315–316. doi:10.1016/0090-4295(73)90278-1. ISSN 0090-4295.
  7. ↑ 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.
  8. ↑ Kuwertz-Bröking, Eberhard; von Gontard, Alexander (2017). "Clinical management of nocturnal enuresis". Pediatric Nephrology. 33 (7): 1145–1154. doi:10.1007/s00467-017-3778-1. ISSN 0931-041X.
  9. ↑ 9.0 9.1 9.2 Pedersen, Malthe J.; Rittig, Søren; Jennum, Poul J.; Kamperis, Konstantinos (2020). "The role of sleep in the pathophysiology of nocturnal enuresis". Sleep Medicine Reviews. 49: 101228. doi:10.1016/j.smrv.2019.101228. ISSN 1087-0792.
  10. ↑ Kanbur, Nuray; Pinhas, Leora; Lorenzo, Armando; Farhat, Walid; Licht, Christoph; Katzman, Debra K. (2011). "Nocturnal enuresis in adolescents with anorexia nervosa: Prevalence, potential causes, and pathophysiology". International Journal of Eating Disorders. 44 (4): 349–355. doi:10.1002/eat.20822. ISSN 0276-3478.
  11. ↑ Harari, Michael D (2013). "Nocturnal enuresis". Journal of Paediatrics and Child Health. 49 (4): 264–271. doi:10.1111/j.1440-1754.2012.02506.x. ISSN 1034-4810.
  12. ↑ 12.0 12.1 12.2 12.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  13. ↑ Lettgen B (1997). "Differential diagnoses for nocturnal enuresis". Scand J Urol Nephrol Suppl. 183: 47–8, discussion 48-9. PMID 9165606.
  14. ↑ Reddy NM, Malve H, Nerli R, Venkatesh P, Agarwal I, Rege V (2017). "Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly?". Indian J Nephrol. 27 (6): 417–426. doi:10.4103/ijn.IJN_288_16. PMC 5704404. PMID 29217876.
  15. ↑ Sinha R, Raut S (2016). "Management of nocturnal enuresis - myths and facts". World J Nephrol. 5 (4): 328–38. doi:10.5527/wjn.v5.i4.328. PMC 4936340. PMID 27458562.
  16. ↑ Akis, N.; Irgil, E.; Aytekin, N. (2009). "Enuresis and the Effective Factors". Scandinavian Journal of Urology and Nephrology. 36 (3): 199–203. doi:10.1080/003655902320131875. ISSN 0036-5599.
  17. ↑ 17.0 17.1 Yeung, C.K.; Sihoe, J.D.Y.; Sit, F.K.Y.; Bower, W.; Sreedhar, B.; Lau, J. (2004). "Characteristics of primary nocturnal enuresis in adults: an epidemiological study". BJU International. 93 (3): 341–345. doi:10.1111/j.1464-410X.2003.04612.x. ISSN 1464-4096.
  18. ↑ McGrath, Kathleen H; Caldwell, Patrina HY; Jones, Michael P (2007). "The frequency of constipation in children with nocturnal enuresis: a comparison with parental reporting". Journal of Paediatrics and Child Health. 0 (0): 070916021853007–???. doi:10.1111/j.1440-1754.2007.01207.x. ISSN 1034-4810.
  19. ↑ Chang, Jei-Wen; Yang, Ling-Yu; Chin, Tai-Wai; Tsai, Hsin-Lin (2011). "Clinical characteristics, nocturnal antidiuretic hormone levels, and responsiveness to DDAVP of school children with primary nocturnal enuresis". World Journal of Urology. 30 (4): 567–571. doi:10.1007/s00345-011-0753-5. ISSN 0724-4983.
  20. ↑ 20.0 20.1 Eneh, Chizoma I.; Okafor, Henrietta U.; Ikefuna, Anthony N.; Uwaezuoke, Samuel N. (2015). "Nocturnal enuresis: prevalence and risk factors among school-aged children with sickle-cell anaemia in a South-east Nigerian city". Italian Journal of Pediatrics. 41 (1). doi:10.1186/s13052-015-0176-9. ISSN 1824-7288.
  21. ↑ Sureshkumar, Premala; Jones, Mike; Caldwell, Patrina H.Y.; Craig, Jonathan C. (2009). "Risk Factors for Nocturnal Enuresis in School-Age Children". Journal of Urology. 182 (6): 2893–2899. doi:10.1016/j.juro.2009.08.060. ISSN 0022-5347.
  22. ↑ Adekanmbi, AF; Ogunlesi, TA; Fetuga, MB; Oluwole, FA; Alabi, AD; Kehinde, OA (2011). "Prevalence and Risk Factors for Enuresis in Children". Nigerian Hospital Practice. 7 (3–4). doi:10.4314/nhp.v7i3-4.67123. ISSN 1597-7889.
  23. ↑ Gurocak, Serhat; Maral, Isil; Bumin, AliM; Ozkan, Secil; Durukan, Elif; Iseri, Elvan (2010). "Prevalence and risk factors of monosymptomatic nocturnal enuresis in Turkish children". Indian Journal of Urology. 26 (2): 200. doi:10.4103/0970-1591.65387. ISSN 0970-1591.
  24. ↑ Kajiwara, Mitsuru; Inoue, Katsumi; Kato, Masao; Usui, Akihiro; Kurihara, Makoto; Usui, Tsuguru (2006). "Nocturnal enuresis and overactive bladder in children: An epidemiological study". International Journal of Urology. 13 (1): 36–41. doi:10.1111/j.1442-2042.2006.01217.x. ISSN 0919-8172.
  25. ↑ Hunskaar, S.; Arnold, E. P.; Burgio, K.; Diokno, A. C.; Herzog, A. R.; Mallett, V. T. (2000). "Epidemiology and Natural History of Urinary Incontinence". International Urogynecology Journal and Pelvic Floor Dysfunction. 11 (5): 301–319. doi:10.1007/s001920070021. ISSN 0937-3462.
  26. ↑ Lucchini, Barbara; Simonetti, Giacomo D.; Ceschi, Alessandro; Lava, Sebastiano A.G.; Faré, Pietro B.; Bianchetti, Mario G. (2013). "Severe signs of hyponatremia secondary to desmopressin treatment for enuresis: A systematic review". Journal of Pediatric Urology. 9 (6): 1049–1053. doi:10.1016/j.jpurol.2013.02.012. ISSN 1477-5131.
  27. ↑ Parkin, J. M.; Frasert, M. S. (2008). "Poisoning as a Complication of Enuresis". Developmental Medicine & Child Neurology. 14 (6): 727–730. doi:10.1111/j.1469-8749.1972.tb03315.x. ISSN 0012-1622.
  28. ↑ 28.0 28.1 Robson, Wm Lane M.; Leung, Alexander K. C. (2016). "Secondary Nocturnal Enuresis". Clinical Pediatrics. 39 (7): 379–385. doi:10.1177/000992280003900701. ISSN 0009-9228.
  29. ↑ Robson, Wm Lane M.; Jackson, Harold P.; Blackhurst, Dawn; LEUNG, ALEXANDER k. C. (1997). "Enuresis in Children With Attention–Deficit Hyperactivity Disorder". Southern Medical Journal. 90 (5): 503–505. doi:10.1097/00007611-199705000-00007. ISSN 0038-4348.
  30. ↑ Kovacevic, Larisa; Jurewicz, Michael; Dabaja, Ali; Thomas, Ronald; Diaz, Mireya; Madgy, David N.; Lakshmanan, Yegappan (2013). "Enuretic children with obstructive sleep apnea syndrome: Should they see otolaryngology first?". Journal of Pediatric Urology. 9 (2): 145–150. doi:10.1016/j.jpurol.2011.12.013. ISSN 1477-5131.
  31. ↑ Weintraub, Y; Singer, S; Alexander, D; Hacham, S; Menuchin, G; Lubetzky, R; Steinberg, D M; Pinhas-Hamiel, O (2012). "Enuresis—an unattended comorbidity of childhood obesity". International Journal of Obesity. 37 (1): 75–78. doi:10.1038/ijo.2012.108. ISSN 0307-0565.
  32. ↑ . doi:10.22037/uj.v14i1.3635. Missing or empty |title= (help)
  33. ↑ Fritz, Gregory; Rockney, Randy (2004). "Practice Parameter for the Assessment and Treatment of Children and Adolescents With Enuresis". Journal of the American Academy of Child & Adolescent Psychiatry. 43 (12): 1540–1550. doi:10.1097/01.chi.0000142196.41215.cc. ISSN 0890-8567.
  34. ↑ 34.0 34.1 34.2 Ramakrishnan K (2008). "Evaluation and treatment of enuresis". Am Fam Physician. 78 (4): 489–96. PMID 18756657.
  35. ↑ Tuncel, Altug; Mavituna, Ilkay; Nalcacioglu, Varol; Tekdogan, Umit; Uzun, Burcin; Atan, Ali (2009). "Long-term follow-up of enuretic alarm treatment in enuresis nocturna". Scandinavian Journal of Urology and Nephrology. 42 (5): 449–454. doi:10.1080/00365590802095678. ISSN 0036-5599.
  36. ↑ Edwards, S. D.; Spuvy, H. I. J. Vander (1985). "HYPNOTHERAPY AS A TREATMENT FOR ENURESIS". Journal of Child Psychology and Psychiatry. 26 (1): 161–170. doi:10.1111/j.1469-7610.1985.tb01635.x. ISSN 0021-9630.
  37. ↑ 37.0 37.1 Yuksek, MS; Erdem, AF; Atalay, C; Demirel, A (2003). "Acupressure versus Oxybutinin in the Treatment of Enuresis". Journal of International Medical Research. 31 (6): 552–556. doi:10.1177/147323000303100611. ISSN 0300-0605.
  38. ↑ 38.0 38.1 38.2 Zaffanello M, Giacomello L, Brugnara M, Fanos V (2007). "Therapeutic options in childhood nocturnal enuresis". Minerva Urol Nefrol. 59 (2): 199–205. PMID 17571056.
  39. ↑ Houts, Arthur C.; Berman, Jeffrey S.; Abramson, Hillel (1994). "Effectiveness of psychological and pharmacological treatments for nocturnal enuresis". Journal of Consulting and Clinical Psychology. 62 (4): 737–745. doi:10.1037/0022-006X.62.4.737. ISSN 1939-2117.
  40. ↑ Gepertz, Simon; Nevéus, Tryggve (2004). "IMIPRAMINE FOR THERAPY RESISTANT ENURESIS: A RETROSPECTIVE EVALUATION". Journal of Urology. 171 (6 Part 2): 2607–2610. doi:10.1097/01.ju.0000110613.51078.93. ISSN 0022-5347.
  41. ↑ Glazener, Cathryn MA; Evans, Jonathan HC; Peto, Rachel E; Glazener, Cathryn MA (2003). "Tricyclic and related drugs for nocturnal enuresis in children". doi:10.1002/14651858.CD002117.
  42. ↑ Ferrara, Pietro; Romano, Valerio; Cortina, Ivana; Ianniello, Francesca; Fabrizio, Giovanna Carmela; Chiaretti, Antonio (2014). "Oral desmopressin lyophilisate (MELT) for monosymptomatic enuresis: Structured versus abrupt withdrawal". Journal of Pediatric Urology. 10 (1): 52–55. doi:10.1016/j.jpurol.2013.05.021. ISSN 1477-5131.
  43. ↑ Bradbury, MG; Meadow, SR (2008). "Combined treatment with enuresis alarm and desmopressin for nocturnal enuresis". Acta Paediatrica. 84 (9): 1014–1018. doi:10.1111/j.1651-2227.1995.tb13818.x. ISSN 0803-5253.


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