Editing Enuresis (section)

== Management ==
{{See also|Urinary incontinence#Treatment|Nocturnal enuresis#Treatment}}There are a number of management options for enuresis. Management of enuresis, both nocturnal and daytime, can include behavioral therapy, drug therapy, [[traditional Chinese medicine]] (TCM), and other alternative medicine therapies. Treatment of enuresis for children under 5 years old is not recommended.<ref name=":2" /> In adults with nocturnal enuresis, use of a bedwetting diary, which keeps track of when enuresis occurs, may be helpful for healthcare providers to figure out the causes of a person's enuresis and their best route for treatment.<ref>{{Cite web|title=What Causes Adult Bedwetting (Sleep Enuresis) And How To Make It Stop|url=https://www.nafc.org/adult-bedwetting|access-date=2020-08-05|website=URINARY INCONTINENCE EDUCATION {{!}} BLADDER HEALTH {{!}} NATIONAL ASSOCIATION FOR CONTINENCE|language=en-US}}</ref>
[[File:DRIsleeper-Wireless-Alarm.gif|thumb|308x308px|Enuresis Alarm]]

=== Behavioral therapy ===
Simple behavioral interventions may prove to be superior in comparison to no ongoing form of treatment and are recommended as initial treatment.<ref name="Simple behavioural interventions fo">{{cite journal | vauthors = Caldwell PH, Nankivell G, Sureshkumar P | title = Simple behavioural interventions for nocturnal enuresis in children | journal = The Cochrane Database of Systematic Reviews | issue = 7 | pages = CD003637 | date = July 2013 | pmid = 23881652 | doi = 10.1002/14651858.CD003637.pub3 | doi-access = free }}</ref>
* Nighttime fluid limitation
* Enuresis alarm – includes sleeping mats with electrical circuits; alarms with sensors placed in child's underwear; alarms that are wired or wireless and produce noise, vibration, or light; and alarm clocks or mobile phones for older individuals
* Motivational therapy
* [[Bladder training]] – training the bladder to hold more urine
* Reward systems – give star charts for dry nights
* Lifting – carrying the child, who is still asleep, away from the bed to an appropriate place to urinate
Waking a child up at night is not a medically supported long-term cure or solution for nocturnal enuresis, and may just be a one-time solution even if it appears to resolve enuresis.<ref name=":3" />

==== Neurostimulation ====
Evidence suggests that neurostimulation therapy may be an efficacious and safe form of treatment of pediatric primary enuresis, also known as [[Nocturnal enuresis|bedwetting]].<ref>{{cite journal | vauthors = Chua ME, Fernandez N, Ming JM, Silangcruz JM, Dos Santos J, Lorenzo AJ, Koyle MA, Lopes RI | display-authors = 6 | title = Neurostimulation Therapy for Pediatric Primary Enuresis: A Meta-analysis | journal = Urology | volume = 106 | pages = 183–187 | date = August 2017 | pmid = 28476683 | doi = 10.1016/j.urology.2017.04.035 }}</ref> Neurostimulation of the sacral nerve is an option for children in which all other therapies have failed.<ref>{{cite journal | vauthors = Sulkowski JP, Nacion KM, Deans KJ, Minneci PC, Levitt MA, Mousa HM, Alpert SA, Teich S | display-authors = 6 | title = Sacral nerve stimulation: a promising therapy for fecal and urinary incontinence and constipation in children | journal = Journal of Pediatric Surgery | volume = 50 | issue = 10 | pages = 1644–7 | date = October 2015 | pmid = 25858097 | doi = 10.1016/j.jpedsurg.2015.03.043 }}</ref> Neurostimulation treatment of adult enuresis may be considered prior to pursuing surgical methods. For adult enuresis, [[sacral nerve stimulation]] can be administered to decrease bladder muscle activity so that the bladder muscles are not constantly in a contracted state to help improve enuresis symptoms.<ref>{{cite journal | vauthors = Marshall CJ | title = Persistent adult bedwetting treated by sacral neurotomy | journal = British Medical Journal | volume = 1 | issue = 4857 | pages = 308–11 | date = February 1954 | pmid = 13115705 | pmc = 2093347 | doi = 10.1136/bmj.1.4857.308 }}</ref><ref name="Nocturnal enuresis: non-pharmacolog">{{cite journal | vauthors = Kiddoo D | title = Nocturnal enuresis: non-pharmacological treatments | journal = BMJ Clinical Evidence | volume = 2015 | date = January 2015 | pmid = 25585036 | pmc = 4292411 }}</ref>

==== Hypnotherapy ====
[[Hypnotherapy]] is often performed under the guidance of a licensed clinician or hypnotherapist. It is a guided state of relaxation, concentration and focused attention, and is often where the individual is in a guided trance-like state to treat conditions such as pediatric enuresis.<ref>{{Cite web|title=Hypnosis and Mental Health|url=https://www.webmd.com/mental-health/mental-health-hypnotherapy|access-date=2020-08-05|website=WebMD|language=en}}</ref> However, some studies have shown that the utilization of enuresis alarm may be more effective than hypnotherapy.<ref>{{cite journal | vauthors = Seabrook JA, Gorodzinsky F, Freedman S | title = Treatment of primary nocturnal enuresis: A randomized clinical trial comparing hypnotherapy and alarm therapy | journal = Paediatrics & Child Health | volume = 10 | issue = 10 | pages = 609–10 | date = December 2005 | pmid = 19668674 | pmc = 2722618 | doi = 10.1093/pch/10.10.609 }}</ref> On the other hand, certain types of hypnotherapy may be more effective compared to no treatment of enuresis, but evidence is insufficient.<ref name="Nocturnal enuresis: non-pharmacolog" />

=== Medications ===
Nighttime incontinence may be treated by increasing antidiuretic hormone levels. The hormone can be boosted by a synthetic version known as [[desmopressin]], or DDAVP.<ref name="LMCC" />  Desmopressin is approved by the [[Food and Drug Administration|United States Food & Drug Administration (FDA)]] for use in children 6 years and older with primary [[nocturnal enuresis]] and is available in both spray and tablet formulations.<ref>{{Cite web|title=DailyMed – DDAVP- desmopressin acetate spray|url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d9d8442a-4722-4b41-9faa-1ee853a4cc3b|access-date=2020-07-30|website=dailymed.nlm.nih.gov}}</ref><ref>{{Cite web|title=DailyMed – DDAVP- desmopressin acetate tablet|url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=6d55baa9-2b62-469c-93ae-3909ab249332|access-date=2020-07-30|website=dailymed.nlm.nih.gov}}</ref> There is good short-term success rate; however, there is difficulty in keeping the bed dry after medication is stopped.<ref name="LMCC" />

In children whose enuresis symptoms do not resolve with desmopressin, [[anticholinergic]] drugs may be effective as a second-line therapy or as an add-on drug with desmopressin.<ref name=":3" /> However currently only [[oxybutynin]] has an FDA-approved labeled indication in children aged 6 and older.<ref name=":3" /><ref>{{Cite web|title=DailyMed – OXYBUTYNIN CHLORIDE EXTENDED RELEASE- oxybutynin chloride tablet, extended release|url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c5950dba-d92b-46a0-993f-af9f9ddb52bf|access-date=2020-07-30|website=dailymed.nlm.nih.gov}}</ref> An additional third-line alternative shown to be effective is the [[tricyclic antidepressant]] [[imipramine]], however the use of tricyclic antidepressants carries the risk of [[cardiotoxicity]] and is not recommended to be given without evaluating a person's risk factors for certain [[Cardiovascular disease|heart diseases]].<ref name=":3" /><ref>{{Cite web|title=DailyMed – IMIPRAMINE HYDROCHLORIDE tablet|url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=92ca69d4-cdba-4789-91a9-922664d52498|access-date=2020-07-30|website=dailymed.nlm.nih.gov}}</ref>

=== Acupuncture ===
There are multiple studies examining the efficacy of acupuncture in treating nocturnal enuresis in children, but the evidence is generally of low quality and has multiple limitations.<ref>{{cite journal | vauthors = Lv ZT, Song W, Wu J, Yang J, Wang T, Wu CH, Gao F, Yuan XC, Liu JH, Li M | display-authors = 6 | title = Efficacy of Acupuncture in Children with Nocturnal Enuresis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials | journal = Evidence-Based Complementary and Alternative Medicine | volume = 2015 | pages = 320701 | date = 2015 | pmid = 26167190 | pmc = 4488007 | doi = 10.1155/2015/320701 | doi-access = free }}</ref> Therefore, there is not strong evidence to suggest that acupuncture is useful for treating enuresis.<ref name="Mayo Bed-wetting">{{cite web |title=Bed-wetting – Diagnosis and treatment – Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/bed-wetting/diagnosis-treatment/drc-20366711 |website=www.mayoclinic.org |publisher=Mayo Foundation for Medical Education and Research |access-date=13 August 2020}}</ref>