Editing Enuresis

{{Short description|Involuntary urination in an older child or adult}}
{{Infobox medical condition (new)
| name          = Enuresis
| synonyms      = Uracratia<ref>medical-dictionary.cc: [http://www.medical-dictionary.cc/what-does/uracratia-mean What does the word Uracratia mean?]</ref>
| image         = He suddenly had to pee.jpg
| caption       = A child may ignore the body's signal of a full bladder in order to engage in a joyous activity, such as playing on a playground.
| pronounce     =
| field         = [[Urology]], [[Clinical Psychology]], [[Pediatrics]]
| symptoms      =
| complications =
| onset         =
| duration      =
| types         =
| causes        =
| risks         =
| diagnosis     =
| differential  =
| prevention    =
| treatment     =
| medication    =
| prognosis     =
| frequency     =
| deaths        =
}}
'''Enuresis''' is a repeated inability to control urination.<ref name="mwDefinition">{{cite web|title=enuresis – Definition|url=http://www.merriam-webster.com/dictionary/enuresis|url-status=live|archive-url=https://web.archive.org/web/20090425171642/http://www.merriam-webster.com/dictionary/enuresis|archive-date=2009-04-25|access-date=2009-06-16|work=Merriam-webster.com|publisher=[[Merriam-Webster]]}}</ref> Use of the term is usually limited to describing people [[age-appropriateness|old enough to be expected to exercise such control]].<ref>{{MeshName|Enuresis}}</ref> Involuntary urination is also known as [[urinary incontinence]].<ref>"[http://www.nps.org.au/health_professionals/publications/nps_news/current/nps_news_66_managing_urinary_incontinence_in_primary_care Managing Urinary Incontinence] {{webarchive|url=https://web.archive.org/web/20120630171922/http://www.nps.org.au/health_professionals/publications/nps_news/current/nps_news_66_managing_urinary_incontinence_in_primary_care|date=2012-06-30}}". National Prescribing Service</ref> The term "enuresis" comes from the {{langx|grc|ἐνούρησις|enoúrēsis}}.

Enuresis has been previously viewed as a psychiatric condition, however, scientific evidence has shown this view to be unsupported through current understanding of the condition and its underlying causes.<ref name=":3" /><ref name=":5" />

Management of enuresis varies and includes either mitigation via [[diaper|specialized nightwear]] or bedding, or identification and correction of the underlying cause, [[Behaviour therapy|behavioral therapy]], and the use of medications.

== Signs and symptoms ==

Nocturnal enuresis usually presents with voiding of urine during sleep in a child for whom it is difficult to wake.<ref name=":9">{{cite journal | vauthors = Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, Rittig S, Vande Walle J, von Gontard A, Wright A, Yang SS, Nevéus T | display-authors = 6 | title = The standardization of terminology of lower urinary tract function in children and adolescents: update report from the Standardization Committee of the International Children's Continence Society | journal = The Journal of Urology | volume = 191 | issue = 6 | pages = 1863–1865.e13 | date = June 2014 | pmid = 24508614 | doi = 10.1016/j.juro.2014.01.110 }}</ref><ref>{{cite journal | vauthors = Ramakrishnan K | title = Evaluation and treatment of enuresis | journal = American Family Physician | volume = 78 | issue = 4 | pages = 489–96 | date = August 2008 | pmid = 18756657 | url = https://www.aafp.org/afp/2008/0815/p489.html }}</ref> It may be accompanied by bladder dysfunction during the day which is termed non-mono symptomatic enuresis.<ref name="auto">von Gontard A. Enuresis. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.</ref> Day time enuresis, also known as urinary incontinence, may also be accompanied by bladder dysfunction.

The symptoms of bladder dysfunction include:<ref name="auto" />

# Urge incontinence – the presence of an overwhelming urge to urinate, frequent urination, attempts to hold the urine and urinary tract infections.
# Voiding postponement – delaying urination in certain situations such as school.
# Stress incontinence – incontinence that occurs in situations when increased intra-abdominal pressure occurs such as coughing.
# Giggling incontinence – incontinence that occurs when laughing.

Secondary incontinence usually occurs in the context of a new life event that is stressful such as abuse or parental divorce.<ref name="auto" />

Signs indicating a child has a daytime wetting condition may include:<ref name=":6" />
* urgency to urinate with leakage of urine
* urinating 8 times a day or more
* urinating less than a regular amount of 4-7 times a day (infrequent urination)
* inability to fully empty the bladder when urinating (incomplete urination)
* avoiding urine leakage through physical compensation, like squatting, squirming, leg crossing, or heel sitting.

Signs indicating a child has a nighttime wetting condition, if they are at least 5 years old, may include:<ref name=":6" />
* bedwetting that occurs at least 2 times a week over at least 3 months
* reoccurrence of bedwetting after 6 months of no bedwetting.

=== Impact ===
It is recommended that children are made aware that bedwetting is not their fault, especially due to preconceived notions of inadequate parenting or psychiatric issues leading to enuresis.<ref name=":3" /> Untreated enuresis may lead to a lack of self-esteem or avoidance of social activities.<ref name=":3" /> Children with nocturnal enuresis are found to have lower quality of life, but it is not clear which aspects are most affected.<ref name=":4" /> More studies are needed to understand the impact of nocturnal enuresis on parents.<ref name=":4">{{cite journal | vauthors = Collis D, Kennedy-Behr A, Kearney L | title = The impact of bowel and bladder problems on children's quality of life and their parents: A scoping review | journal = Child | volume = 45 | issue = 1 | pages = 1–14 | date = January 2019 | pmid = 30328126 | doi = 10.1111/cch.12620 | s2cid = 53525241 | doi-access = free }}</ref>

== 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" />

== Pathophysiology ==
Currently, [[nocturnal enuresis]] is understood to be caused by three main underlying factors: [[Polyuria|excess urine production]] at night, lack of capacity for [[Urinary bladder|bladder]] storage, and inability to wake from sleep, with pathogenesis possibly varying based on presence of daytime symptoms.<ref name=":3" /><ref name=":5" /> The inability to control the [[detrusor muscle]] has been theorized as a possible [[Pathophysiology|pathophysiological]] cause of enuresis, which may explain why [[anticholinergic]] drugs are effective as medication therapy, since they act on the detrusor muscles.<ref name=":1" /><ref name=":3" />

== Diagnosis ==
Clinical definition of enuresis is urinary incontinence beyond age of 4 years for daytime and beyond 6 years for nighttime, or loss of continence after three months of dryness.<ref name="ghai">{{cite book | vauthors = Ghai OP, Paul V, Bagga A | date = 2009 | title = Essential Pediatrics | edition = 7th | publisher = CBS Publishers & Distributors Pvt Ltd. | pages = 22–41 | isbn = 9788123917771 }}</ref>
Current [[DSM-5]] criteria:
* Repeated voiding of urine into bed or clothes (whether involuntary or intentional)
* Behavior must be clinically significant as manifested by either a frequency of twice a week for at least three consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
* Chronological age is at least 5 years of age (or equivalent developmental level).
* The behavior is not due exclusively to the direct physiological effect of a substance (such as a diuretic) or a general medical condition (such as diabetes, spina bifida, a seizure disorder, etc.).
All these criteria must be met in order to diagnose an individual. Generally, healthcare providers may further investigate for bladder control issues if a child is still enuretic in the daytime by age 4, or if they are still enuretic at nighttime by age 5 or 6.<ref name=":6" />

=== Classification ===
The International Children's Continence Society (ICCS) has developed the following standard terminology:<ref>{{Cite report |last=Erdem|first=Erim | name-list-style = vanc |date=2014-09-19|title=Faculty Opinions recommendation of The standardization of terminology of lower urinary tract function in children and adolescents: update report from the Standardization Committee of the International Children's Continence Society.|doi = 10.3410/f.718270635.793500042 |website=Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature |doi-access=free }}</ref>
* Primary enuresis refers to children who have never been successfully trained to control urination.<ref name="LMCC" />
* Secondary enuresis refers to children who have been successfully trained and are continent for at least 6 months but revert to wetting in a response to some sort of stressful situation.<ref name="LMCC">Chowdhury SH, Cozma AI, Chowdhury JH. Incontinence – Child. Essentials for the Canadian Medical Licensing Exam: Review and Prep for MCCQE Part I. 2nd edition. Wolters Kluwer. Hong Kong. 2017.</ref>

There are 2 categories of enuresis:
* Monosymptomatic enuresis (MNE) – Does not include bladder dysfunction during daytime.<ref name=":2" />
* Nonmonosymptomatic enuresis (NMNE) – Includes bladder dysfunction causing daytime incontinence that is frequent and urgent.<ref name=":2" /> Wetting that occurs in the daytime is sometimes referred to as [[diurnal enuresis]].<ref>{{Cite web|title=Daytime Wetting (Diurnal Enuresis)|url=https://www.cincinnatichildrens.org/health/d/wetting|access-date=2020-08-03|website=www.cincinnatichildrens.org}}</ref> Other conditions, or [[Comorbidity|comorbidities]], that commonly accompany enuresis may be expected to be more common with NMNE.<ref name=":3" />

== 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>

== Epidemiology ==
Approximately 10% of six- to seven-year-olds around the world experience enuresis.<ref name=":2">{{cite journal | vauthors = Vande Walle J, Rittig S, Tekgül S, Austin P, Yang SS, Lopez PJ, Van Herzeele C | title = Enuresis: practical guidelines for primary care | journal = The British Journal of General Practice | volume = 67 | issue = 660 | pages = 328–329 | date = July 2017 | pmid = 28533201 | pmc = 5565868 | doi = 10.3399/bjgp17X691337 }}</ref> While 15% to 20% of five‐year‐old children experience nocturnal enuresis which usually goes away as they grow older, approximately 2% to 5% of young adults experience nocturnal enuresis.<ref name=":0">{{cite journal|vauthors=Cui H, Yu W, Yan H, Zhou Z, Wu J, Cui Y|date=November 2019|title=The efficacy of electrical stimulation in treating children with nocturnal enuresis: A systematic review and meta-analysis|journal=Neurourology and Urodynamics|volume=38|issue=8|pages=2288–2295|doi=10.1002/nau.24136|pmid=31397008|s2cid=199508359}}</ref> About 3% of teenagers and 0.5% to 1% of adults experience enuresis or bedwetting, with the chance of it resolving being lower if it is considered frequent.<ref name=":9" />

== History ==
Enuresis was first documented in the [[Ebers Papyrus]] in 1550 BCE. Roman author Gaius Plinius Secundus (CE 23/24–79) (''Pliny the Elder'') documents nocturnal enuresis in his work, "Natural History" (CE 77), stating that "the incontinence of urine in infants is checked by giving boiled mice in their food."<ref name="Salmon_1975">{{cite journal | vauthors = Salmon MA | title = An historical account of nocturnal enuresis and its treatment | journal = Proceedings of the Royal Society of Medicine | volume = 68 | issue = 7 | pages = 443–5 | date = July 1975 | pmid = 801839 | pmc = 1863929 | doi = 10.1177/003591577506800726 }}</ref> Furthermore, in the eighteenth century, children with enuresis were subjected to a variety of chemical and mechanical treatments including fluid restriction, enemata, the use of an alarm clock, cold baths, warm baths, cold dashes to the perineum and douches to the lower spine.<ref name="Salmon_1975" />

Enuresis has previously been documented as an occurrence in members of the [[military]].<ref>{{Cite web|title=Boots on the Ground|url=https://ushistoryscene.com/article/us-marines-pacific/|access-date=2020-08-02|website=US History Scene|date=7 October 2015 |language=en-US}}</ref><ref>{{cite journal | vauthors = Backus PL, Mansell GS | title = Enuresis in the Army | journal = British Medical Journal | volume = 2 | issue = 4370 | pages = 462–5 | date = October 1944 | pmid = 20785684 | pmc = 2286383 | doi = 10.1136/bmj.2.4370.462 }}</ref> During [[World War II]], bedwetting was considered as part of neuropsychiatric evaluation of a soldier for discharge.<ref>{{Cite book | first1 = Leonard D | last1 = Heaton | first2 = Robert S | last2 = Anderson | first3 = Albert J | last3 = Glass | first4 = Robert J | last4 = Bernucci | name-list-style = vanc |title=Neuropsychiatry in World War II|date=1966–1973|publisher=Office of the Surgeon General, Dept. of the Army|pages=256|oclc=3993673}}</ref>

== See also ==
* [[Nocturnal enuresis]]
* [[Urinary incontinence]]

== References ==
{{reflist}}

== External links ==
{{Medical resources
 | DiseasesDB     = 4326
 | ICD10          = {{ICD10|F|98|0|f|90}}, {{ICD10|R|32||r|30}}
 | ICD9           = {{ICD9|788.30}}, {{ICD9|307.6}}
 | ICDO           =
 | OMIM           =
 | MedlinePlus    =
 | eMedicineSubj  =
 | eMedicineTopic =
 | MeshID         = D004775
}}
{{Mental and behavioral disorders|selected = physical}}
{{Urinary system symptoms and signs}}

[[Category:Urological conditions]]
[[Category:Symptoms and signs: Urinary system]]
[[Category:Elimination disorders]]