Editing Enuresis (section)

== Causes ==
Bedwetting children are often normal emotionally and physically, although enuresis can be caused by other health conditions.<ref name=":6" /> Primary [[nocturnal enuresis]] can have multiple causes, which can make approaching a course of treatment more difficult.<ref>{{Cite journal|last=Cendron|first=Marc|date=1999-03-01|title=Primary Nocturnal Enuresis: Current|url=https://www.aafp.org/afp/1999/0301/p1205.html|journal=American Family Physician|language=en|volume=59|issue=5|pages=1205–14, 1219–20|pmid=10088876|issn=0002-838X}}</ref>

Enuresis can be caused by one or more of the following:<ref name=":7">{{cite journal | vauthors = Jalkut MW, Lerman SE, Churchill BM | title = Enuresis | journal = Pediatric Clinics of North America | volume = 48 | issue = 6 | pages = 1461–88 | date = December 2001 | pmid = 11732125 | doi = 10.1016/S0031-3955(05)70386-2 }}</ref>

=== Caffeine consumption ===
[[Caffeine]] is a [[diuretic]], which means that it increases urine production.<ref>{{cite journal | vauthors = Zhang Y, Coca A, Casa DJ, Antonio J, Green JM, Bishop PA | title = Caffeine and diuresis during rest and exercise: A meta-analysis | journal = Journal of Science and Medicine in Sport | volume = 18 | issue = 5 | pages = 569–74 | date = September 2015 | pmid = 25154702 | pmc = 4725310 | doi = 10.1016/j.jsams.2014.07.017 }}</ref> Reports from those who have failed enuresis treatment say that they were not recommended to limit caffeine and that they mostly consume 2 to 4&nbsp;mg/kg/day.<ref name=":7" />

=== Pattern and volume of fluid intake ===
A pediatric day can be categorized into 3 periods: 7 AM to 12 PM, 12 PM to 5 PM, and after 5 PM.<ref name=":7" /> Children with enuresis are usually dehydrated and drink the most after 5 PM.<ref name=":7" /> This can be remedied by having the child drink 40% of daily fluid requirement before noon, 40% from noon to 4:30 PM, and 20% in the evening.<ref name=":7" />

=== Lower functional bladder capacity ===

Children with enuresis have lower functional bladder capacity than healthy children.<ref name=":7" /> This means that their bladders hold less urine, often over 50% less.<ref name=":7" />

=== Dysfunctional voiding ===
Both bladder [[voiding]] and storage problems may be present with dysfunctional voiding and may be present at any age.<ref>{{cite journal | vauthors = Sinha S | title = Dysfunctional voiding: A review of the terminology, presentation, evaluation and management in children and adults | journal = Indian Journal of Urology | volume = 27 | issue = 4 | pages = 437–47 | date = October 2011 | pmid = 22279306 | pmc = 3263208 | doi = 10.4103/0970-1591.91429 | doi-access = free }}</ref> It is characterized by an obstruction of the bladder as a result of a non-neurogenic cause, which is due to the muscles controlling urine flow that do not completely relax. Symptoms may include daytime wetting, night wetting, urgency, a feeling that the bladder is always full, and straining to urinate.<ref>{{cite journal | vauthors = Stoffel JT | title = Detrusor sphincter dyssynergia: a review of physiology, diagnosis, and treatment strategies | journal = Translational Andrology and Urology | volume = 5 | issue = 1 | pages = 127–35 | date = February 2016 | pmid = 26904418 | pmc = 4739973 | doi = 10.3978/j.issn.2223-4683.2016.01.08 }}</ref>

=== Urinary tract infection ===
It is uncommon for nocturnal enuresis, in the absence of other symptoms, to be caused by an infection. [[Pinworm (parasite)|Pinworms]] have also been linked with sudden onset enuresis in young girls.<ref name=":7" />

=== Delay in maturation and development ===
Mastering urinary control during sleep time is a normal part of childhood development and may be delayed by stress and social pressures. The risk for enuresis increases threefold for children who experience stress, demonstrated by the higher prevalence of enuresis in lower socioeconomic groups.<ref name=":7" />

Anxiety experienced by a child between ages 2 to 4 also increases the risk for enuresis because this particular time period is sensitive for the development of nighttime bladder control.<ref name=":7" />

Nocturnal enuresis has been found to be more common in those with developmental delay, physical or intellectual disabilities, and psychological or behavioral disorders.<ref name=":7" />

=== Bladder instability ===
Urodynamic sleep studies show that enuretic children have high pressure bladder contractions more frequently while they are asleep when compared to healthy children.<ref name=":7" />

=== Nocturnal polyuria and antidiuretic hormone secretion ===
Nocturnal polyuria is defined as having more than 130% of the expected bladder capacity, which is specific for each age.<ref name=":8" /> Many children with nocturnal enuresis have altered nighttime secretion levels of [[Vasopressin|antidiuretic hormone]], which controls water retention in the body.<ref name=":8" /> This results in low antidiuretic hormone levels and excessive amounts of urine produced during sleep time.<ref name=":8">{{cite journal | vauthors = Caldwell PH, Deshpande AV, Von Gontard A | title = Management of nocturnal enuresis | journal = BMJ | volume = 347 | pages = f6259 | date = October 2013 | pmid = 24170156 | doi = 10.1136/bmj.f6259 | s2cid = 7172656 | url = https://www.bmj.com/content/347/bmj.f6259 | url-access = subscription }}</ref>

=== Sleep disorders ===
The inability to wake from sleep has been understood as one cause of [[nocturnal enuresis]], however studies focused on the importance of the time of night in which enuresis episodes occur have shown inconsistent results.<ref name=":5">{{cite journal | vauthors = Pedersen MJ, Rittig S, Jennum PJ, Kamperis K | title = The role of sleep in the pathophysiology of nocturnal enuresis | journal = Sleep Medicine Reviews | volume = 49 | pages = 101228 | date = February 2020 | pmid = 31790860 | doi = 10.1016/j.smrv.2019.101228 | doi-access = free }}</ref> Parents often report that their bedwetting children are very difficult to awaken from sleep, therefore research regarding enuresis has also aimed to elucidate why children with enuresis do not awaken from the sensation of a full bladder.<ref name=":5" /> Some studies have led to hypotheses that children with enuresis have altered [[hemodynamics]] during sleep (in terms of measurements of [[blood pressure]] and [[heart rate]]), [[sleep-disordered breathing]], and altered [[hypothalamus]] function leading to a lack of bladder control during sleep.<ref name=":5" />

=== Genetics ===
Enuresis is also theorized to be a [[Heredity|hereditary]] condition based on [[Epidemiology|epidemiological]] and [[Genetics|genetic]] studies.<ref name=":6">{{Cite web|title=Symptoms & Causes of Bladder Control Problems & Bedwetting in Children {{!}} NIDDK|url=https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-bedwetting-children/symptoms-causes|access-date=2020-08-02|website=National Institute of Diabetes and Digestive and Kidney Diseases|language=en-US}}</ref><ref name=":3">{{cite journal | vauthors = Nevéus T, Fonseca E, Franco I, Kawauchi A, Kovacevic L, Nieuwhof-Leppink A, Raes A, Tekgül S, Yang SS, Rittig S | display-authors = 6 | title = Management and treatment of nocturnal enuresis-an updated standardization document from the International Children's Continence Society | journal = Journal of Pediatric Urology | volume = 16 | issue = 1 | pages = 10–19 | date = February 2020 | pmid = 32278657 | doi = 10.1016/j.jpurol.2019.12.020 | s2cid = 213058923 }}</ref><ref name=":1">{{cite journal | vauthors = Nevéus T | title = Pathogenesis of enuresis: Towards a new understanding | journal = International Journal of Urology | volume = 24 | issue = 3 | pages = 174–182 | date = March 2017 | pmid = 28208214 | doi = 10.1111/iju.13310 | doi-access = free }}</ref> Although several genes are considered of interest in relation to enuresis, lack of a single gene that may cause enuresis means that individuals of a family may have differing genetic mechanisms resulting in the condition.<ref name=":1" />