Bedwetting

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Bedwetting
Other namesNighttime urinary incontinence, sleepwetting, nocturnal enuresis
Wet bed again.jpg
Urine mark on bedding caused by a nocturnal enuresis episode.
SpecialtyPediatrics
SymptomsInvoluntary loss of urine while asleep[1]
ComplicationsUrinary tract infections[2]
Usual onset> 5 years old[1]
TypesPrimary, secondary[2]
Risk factorsFamily history, urinary tract infections, constipation, ADHD, diabetes, stress, obstructive sleep apnea[2][3][1]
Diagnostic methodBased on symptoms and examination[1]
TreatmentRestricting fluids before bed, voiding before bed, bedwetting alarms, desmopressin[1]
FrequencyCommon[2]

Bedwetting, also called nocturnal enuresis, is the repeated involuntary loss of urine while asleep after the age at which bladder control usually begins.[1] Bedwetting in children and adults can result in emotional stress or physical abuse.[2][1] Occasionally lose of urine may occur during the day or other urinary symptoms may be present.[1] Complications can include urinary tract infections.[2]

Most bedwetting is results from slow development or excess urine production—not an emotional or physical problem.[3] Bedwetting more commonly occurs in those whose parents were affected.[2] Other factors may include urinary tract infections, constipation, ADHD, diabetes, stress, spina bifida, and obstructive sleep apnea (OSA).[2][3][1] The underlying mechanism may involve lack of vasopressin, bladder instability, or an inability to wake up as a result of signals from the bladder.[4] Bedding wetting is classified as primary when a child has not yet had a prolonged period of being dry and secondary when wetting begins after having stayed dry for six months.[2]

Treatment is based on the underlying cause and potentially associated disorders.[1] This may include restricting fluids 2 to 4 hours before bed and voiding before bed.[1] Bedwetting alarms and the medication desmopressin.[1] Other efforts include treating constipation.[1] In those with OSA, tonsillectomy may resolve the disorder.[1] The condition otherwise generally resolves with time.[1] It is recommended that caregivers be counseled regarding appropriate reactions to bedwetting, with punishment having no role.[1]

Bedwetting is common in children affected 17% at age 5, 13% at age 6, 10% at age 7, and 1.5% at age 15.[2] Boys are more frequently affected than girls; though after the age of 10 this difference is less.[1][2] The condition has been described since the time of the Ancient Egyptians.[5] The term "enuresis" is from the Greek meaning "to void urine".[6]

Impact

In bedwetting child are not at fault. Psychological impacts of bedwetting are more important than the physical considerations. "It is often the child's and family members' reaction to bedwetting that determines whether it is a problem or not."[7]

Self-esteem

Whether bedwetting causes low self-esteem remains a subject of debate, but several studies have found that self-esteem improved with management of the condition.[8]

Children questioned in one study ranked bedwetting as the third most stressful life event, after "parental war of words", divorce and parental fighting. Adolescents in the same study ranked bedwetting as tied for second with parental fighting.[8]

Bedwetters face problems ranging from being teased by siblings, being punished by parents, the embarrassment of still having to wear diapers, and being afraid that friends will find out.

The amount of psychological harm depends on whether the bedwetting harms self-esteem or development of social skills. Factors are:[9][unreliable medical source?]

  • How much the bedwetting limits social activities like sleep-overs and campouts
  • The degree of the social ostracism by peers
  • (Perceived) Anger, punishment, refusal and rejection by caregivers along with subsequent guilt
  • The number of failed treatment attempts
  • How long the child has been wetting

Behavior

Bedwetting children are more likely to have behavioral problems. For children who have developmental problems, the behavioral problems and the bedwetting are frequently part of/caused by the developmental issues. For bedwetting children without other developmental issues, these behavioral issues can result from self-esteem issues and stress caused by the wetting.[9][unreliable medical source?]

It is very rare for a child to intentionally wet the bed as a method of acting out.

Punishment

Punishing or shaming a child for bedwetting will frequently make the situation worse. There is a downward cycle where a child punished for bedwetting feels shame and a loss of self-confidence. This can cause increased bedwetting incidents, leading to more punishment and shaming.[10]

In the United States, about 25% of children who wet the bed are punished for it.[11] In Hong Kong, 57% of enuretic children are punished for wetting.[12] Parents with only a grade-school level education punish bedwetting children at twice the rate of high-school- and college-educated parents.[11]

Families

Parents and family members are frequently stressed by a child's bedwetting. Soiled linens and clothing cause additional laundry. Wetting episodes can cause lost sleep if the child wakes and/or cries, waking the parents. A European study estimated that a family with a child who wets nightly will pay about $1,000 a year for additional laundry, extra sheets, disposable absorbent garments such as diapers, and mattress replacement.[8]

Despite these stressful effects, doctors emphasize that parents should react patiently and supportively.[13]

Sociopathy

Bedwetting is not related to sociopathy, as long as caregivers do not shame or punish the child. Bedwetting was part of the Macdonald triad, a set of three behavioral characteristics described by John Macdonald in 1963.[14] The other two characteristics were firestarting and animal abuse. Macdonald suggested that there was an association between a person displaying all three characteristics, then later displaying sociopathic criminal behavior.

MacDonald (1963) observed in his most sadistic patients a triad of childhood cruelty to animals, firesetting and frequent bed-wetting. Such maladaptive childhood behaviors often result from poorly developed coping mechanisms. This triad, although not intended to predict criminal behavior, provides the warning signs of a child under considerable stress. Children under substantial stress, particularly in their home environment, frequently engage in maladaptive behaviors, such as these, in order to alleviate the stress produced by their surroundings.

Up to 60% of multiple-murderers, according to some estimates, wet their beds post-adolescence.[15]

Enuresis is an "unconscious, involuntary, and nonviolent act and therefore linking it to violent crime is more problematic than doing so with animal cruelty or firesetting".[16]

This leads to a difficult distinction: it is not the bedwetting that increases the chance of criminal behavior, but the trauma.[17] For example, parental cruelty can result in "homicidal proneness".[18]

Causes

The cause is not fully understood, although there are three common proposals: excessive urine volume, poor sleep arousal, and bladder contractions. Differentiation of cause is mainly based on patient history and fluid charts completed by the parent or carer to inform management options.[19][20]

Bedwetting has a strong genetic component. Children whose parents were not enuretic have only a 15% incidence of bedwetting. When one or both parents were bedwetters, the rates jump to 44% and 77% respectively.[21]

These first two items are the most common factors in bedwetting, but current medical technology offers no easy testing for either cause. There is no test to prove that bedwetting is only a developmental delay, and genetic testing offers little or no benefit.

As a result, other conditions should be ruled out. The following causes are less common, but are easier to prove and more clearly treated:

In some bed wetting children this increase in ADH production does not occur, while other children may produce an increased amount of ADH but their response is insufficient.[19][22]

  • Attention deficit hyperactivity disorder patients are 2.7 times more likely to have bedwetting issues.[23]
  • Caffeine increases urine production.[24]
  • Chronic constipation can cause bed wetting.[25] When the bowels are full, it can put pressure on the bladder.[26] Often such children defecate normally, yet they retain a significant mass of material in the bowel which causes bed wetting.[27]
  • Infections and disease are more strongly connected with secondary nocturnal enuresis and with daytime wetting. Less than 5% of all bedwetting cases are caused by infection or disease, the most common of which is a urinary tract infection.[23]
  • Patients with more severe neurological-developmental issues have a higher rate of bedwetting problems. One study of seven-year-olds showed that "handicapped and intellectually disabled children" had a bedwetting rate almost three times higher than "non-handicapped children" (26.6% vs. 9.5%, respectively).[28]
  • Psychological issues (e.g., death in the family, sexual abuse, extreme bullying) are established as a cause of secondary nocturnal enuresis (a return to bedwetting), but are very rarely a cause of PNE-type bedwetting.[21][29] Bedwetting can also be a symptom of a pediatric neuropsychological disorder called PANDAS.[30]
  • Sleep apnea stemming from an upper airway obstruction has been associated with bedwetting. Snoring and enlarged tonsils or adenoids are a sign of potential sleep apnea problems.[21]
  • Sleepwalking can lead to bedwetting. During sleepwalking, the sleepwalker may think he/she is in another room. When the sleepwalker urinates during a sleepwalking episode, he/she usually thinks they are in the bathroom, and therefore urinate where they think the toilet should be. Cases of this have included opening a closet and urinating in it; urinating on the sofa and simply urinating in the middle of the room.
  • Stress is a cause of people who return to wetting the bed. Researchers find that moving to a new town, parent conflict or divorce, arrival of a new baby, or loss of a loved one or pet can cause insecurity, contributing to returning bedwetting.[7]
  • Type 1 diabetes mellitus can first present as nocturnal enuresis could be the presenting symptom of. It is classically associated with polyuria, polydipsia, and polyphagia, and weight loss, lethargy, and diaper candidiasis may also be present in those with new-onset disease.

Unconfirmed

  • The link with food allergies is not well established.[31][32]
  • Improper toilet training is almost never a cause.[2] This theory was more widely supported in the last century and is still cited by some authors today. Some say bedwetting can be caused by improper toilet training,[33] either by starting the training when the child is too young or by being too forceful. Recent research has shown more mixed results and a connection to toilet training has not been proven or disproven.[34] According to the American Academy of Pediatrics, more child abuse occurs during potty training than in any other developmental stage.
  • Dandelions are reputed to be a potent diuretic, and anecdotal reports and folk wisdom say children who handle them can end up wetting the bed.[35] English folk names for the plant are "peebeds" and "pissabeds".[36] In French the dandelion is called pissenlit, which means "piss in bed"; likewise "piscialletto", an Italian folkname, and "meacamas" in Spanish.[37]

Mechanism

Two physical functions prevent bedwetting. The first is a hormone that reduces urine production at night. The second is the ability to wake up when the bladder is full. Children usually achieve nighttime dryness by developing one or both of these abilities. There appear to be some hereditary factors in how and when these develop.[citation needed]

The first ability is a hormone cycle that reduces the body's urine production. At about sunset each day, the body releases a minute burst of antidiuretic hormone (also known as arginine vasopressin or AVP). This hormone burst reduces the kidney's urine output well into the night so that the bladder does not get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six years old, others between six and the end of puberty, and some not at all.[citation needed]

The second ability that helps people stay dry is waking when the bladder is full. This ability develops in the same age range as the vasopressin hormone, but is separate from that hormone cycle.

The typical development process begins with one- and two-year-old children developing larger bladders and beginning to sense bladder fullness. Two- and three-year-old children begin to stay dry during the day. Four- and five-year-olds develop an adult pattern of urinary control and begin to stay dry at night.

Diagnosis

Thorough history regarding frequency of bedwetting, any period of dryness in between, associated daytime symptoms, constipation, and encopresis should be sought. Testing of the urine may be useful in determining if an underlying cause is present.[1] Blood tests are typically not needed.[1]

Parents become concerned earlier than doctors. A study in 1980 asked parents and physicians the age that children should stay dry at night. The average parent response was 2.75 years old, while the average physician response was 5.13 years old.[38]

Voiding diary

People are asked to observe, record and measure when and how much their child voids and drinks, as well as associated symptoms. A voiding diary in the form of frequency volume chart records voided volume along with time of each micturition for at least 24 hours. Frequency volume chart is enough for patients with complaint of nocturia and frequency only. If other symptoms are also present then a detailed bladder diary must be maintained. In a bladder diary, times of micturition and voided volume, incontinence episodes, pad usage and other information such as fluid intake, the degree of urgency and the degree of incontinence are recorded.[39]

Examination

Each child should be examined physically at least once at the beginning of treatment. A full paediatric and neurological exam is recommended.[40] Measurement of blood pressure is important to rule out any renal pathology. External genitalia and lumbosacral spine should be examined thoroughly. A spinal defect, such as a dimple, hair tuft, or skin discoloration, might be visible in approximately 50% of patients with an intraspinal lesion. Thorough neurologic examination of the lower extremities, including gait, muscle power, tone, sensation, reflexes, and plantar responses should be done during first visit.

Classification

Nocturnal urinary continence is dependent on 3 factors: 1) nocturnal urine production, 2) nocturnal bladder function and 3) sleep and arousal mechanisms. Any child will suffer from nocturnal enuresis if more urine is produced than can be contained in the bladder or if the detrusor is hyperactive, provided that he or she is not awakened by the imminent bladder contraction.[41]

Psychologists may use a definition from the DSM-IV, defining nocturnal enuresis as repeated urination into bed or clothes, occurring twice per week or more for at least three consecutive months in a child of at least 5 years of age and not due to either a drug side effect or a medical condition. Even if the case does not meet these criteria, the DSM-IV definition allows psychologists to diagnose nocturnal enuresis if the wetting causes the patient clinically significant distress.[42]

Primary

Primary nocturnal enuresis (PNE) is the most common form of bedwetting. Bedwetting becomes a disorder when it persists after the age at which bladder control usually occurs (4–7 years), and is either resulting in an average of at least two wet nights a week with no long periods of dryness or not able to sleep dry without being taken to the toilet by another person.

New studies show that anti-psychotic drugs can have a side effect of causing enuresis.[43]

It has been shown that diet impacts enuresis in children. Constipation from a poor diet can result in impacted stool in the colon putting undue pressure on the bladder creating loss of bladder control (overflow incontinence).[44]

Some researchers, however, recommend a different starting age range. This guidance says that bedwetting can be considered a clinical problem if the child regularly wets the bed after turning 7 years old.[7]

Secondary

Secondary enuresis occurs after a person goes through an extended period of dryness at night (six months or more) and then reverts to night-time wetting. Secondary enuresis can be caused by emotional stress or a medical condition, such as a bladder infection.[45]

Management

There are a number of management options for bedwetting. The following options apply when the bedwetting is not caused by a specifically identifiable medical condition such as a bladder abnormality or diabetes. Treatment is recommended when there is a specific medical condition such as bladder abnormalities, infection, or diabetes. It is also considered when bedwetting may harm the child's self-esteem or relationships with family/friends. Only a small percentage of bedwetting is caused by a specific medical condition, so most treatment is prompted by concern for the child's emotional welfare. Behavioral treatment of bedwetting overall tends to show increased self-esteem for children.[46]

Punishment is not effective and can interfere with treatment.

Approaches

Behavioral methods are recommended as initial treatment.[47] Other treatment methods include the following:

  • Motivational therapy in nocturnal enuresis mainly involves parent and child education. Guilt should be allayed by providing facts. Fluids should be restricted 2 hours prior to bed. The child should be encouraged to empty the bladder completely prior to going to bed. Positive reinforcement can be initiated by setting up a diary or chart to monitor progress and establishing a system to reward the child for each night that he or she is dry. The child should participate in morning cleanup as a natural, nonpunitive consequence of wetting. This method is particularly helpful in younger children (<8 years) and will achieve dryness in 15-20% of the patients.[48][49]
  • Waiting: Almost all children will outgrow bedwetting. For this reason, urologists and pediatricians frequently recommend delaying treatment until the child is at least six or seven years old. Physicians may begin treatment earlier if they perceive the condition is damaging the child's self-esteem and/or relationships with family/friends.
  • Bedwetting alarms create a loud sound when they sense moisture. This can help condition the child to wake at the sensation of a full bladder.[50] These alarms are considered more effective than no treatment and may have a lower risk of side effects than medical therapies but it is still uncertain if alarms are more effective than other treatments.[51] There may be a 29% to 69% relapse rate, so the treatment may need to be repeated.[52]
  • DDAVP (desmopressin) tablets are a synthetic replacement for antidiuretic hormone, the hormone that reduces urine production during sleep. Desmopressin is usually used in the form of desmopressin acetate, DDAVP. Patients taking DDAVP are 4.5 times more likely to stay dry than those taking a placebo.[52] The drug replaces the hormone for that night with no cumulative effect. US drug regulators have banned using desmopressin nasal sprays for treating bedwetting since the oral form is considered safer.
  • DDAVP is most efficient in children with nocturnal polyuria (nocturnal urine production greater than 130% of expected bladder capacity for age) and normal bladder reservoir function (maximum voided volume greater than 70% of expected bladder capacity for age).[53][54] Other children who are likely candidates for desmopressin treatment are those in whom alarm therapy has failed or those considered unlikely to comply with alarm therapy. It can be very useful for summer camp and sleepovers to prevent enuresis.[48]
  • Tricyclic antidepressants: Tricyclic antidepressant prescription drugs with anti-muscarinic properties have been proven successful in treating bedwetting, but also have an increased risk of side effects, including death from overdose.[55] These drugs include amitriptyline, imipramine and nortriptyline. Studies find that patients using these drugs are 4.2 times as likely to stay dry as those taking a placebo.[52] The relapse rates after stopping the medicines are close to 50%.

Devices

Plastic pants suitable for nocturnal enuresis in larger child or small adult
  • Absorbent underwear: Absorbent underwear or diapers can reduce embarrassment for bedwetters and make cleanup easier for caregivers. These products are known as training pants or diapers when used for younger children, and as absorbent underwear or incontinence briefs when marketed for older children and adults. Some brands of diaper are marketed especially for people with bedwetting. A major benefit is the reduced stress on both the bedwetter and caregivers. Absorbent underwear can be especially beneficial for bedwetting children wishing to attend sleepovers or campouts, reducing emotional problems caused by social isolation and/or embarrassment in front of peers. Extended diaper usage may interfere with learning to stay dry at night, at least in adults with severe disabilities.[56]
  • Waterproof mattress pads are used in some cases to ease clean-up of bedwetting incidents, however they only protect the mattress, and the sheets, bedding or sleeping partner may be soiled.

Unproven

  • Acupuncture: While acupuncture is safe in most adolescents,[57] studies done to assess its effectiveness for nocturnal enuresis are of low quality.[58]
  • Dry bed training: Dry bed training consists of a strict schedule of waking the child at night, attempting to condition the child into waking by himself/herself.[59] [60]Studies show this training is ineffective by itself[61] and does not increase the success rate when used in conjunction with a bedwetting alarm.[52]
  • Star chart: A star chart allows a child and parents to track dry nights, as a record and/or as part of a reward program. This can be done either alone or with other treatments. There is no research to show effectiveness, either in reducing bedwetting or in helping self-esteem.[52] Some psychologists, however, recommend star charts as a way to celebrate successes and help a child's self-esteem.[59]

Epidemiology

Bedwetting is generally self-limiting and most children will outgrow it. Children 5 to 9 years old have a spontaneous cure rate of 14% per year. Adolescents 10 to 18 years old have a spontaneous cure rate of 16% per year.[62]

A portion of bedwetting children will not outgrow the problem. Adult rates of bedwetting show little change due to spontaneous cure. Persons who are still enuretic at age 18 are likely to deal with bedwetting throughout their lives.[62]

Studies of bedwetting in adults have found varying rates. The most quoted study in this area was done in the Netherlands. It found a 0.5% rate for 20- to 79-year-olds. A Hong Kong study, however, found a much higher rate. The Hong Kong researchers found a bedwetting rate of 2.3% in 16- to 40-year-olds.[62]

History

An early psychological perspective on bedwetting was given in 1025 by Avicenna in The Canon of Medicine:[63]

"Urinating in bed is frequently predisposed by deep sleep: when urine begins to flow, its inner nature and hidden will (resembling the will to breathe) drives urine out before the child awakes. When children become stronger and more robust, their sleep is lighter and they stop urinating."

Psychological theory through the 1960s placed much greater focus on the possibility that a bedwetting child might be acting out, purposefully striking back against parents by soiling linens and bedding. However, more recent research and medical literature states that this is very rare.[64][65]

See also

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 Gomez Rincon, M; Leslie, SW; Lotfollahzadeh, S (January 2020). "Nocturnal Enuresis". PMID 31424765. Cite journal requires |journal= (help)
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 "Definition & Facts for Bladder Control Problems & Bedwetting in Children". National Institute of Diabetes and Digestive and Kidney Diseases. September 2017. Archived from the original on 25 October 2017. Retrieved 25 October 2017.
  3. 3.0 3.1 3.2 "Symptoms & Causes of Bladder Control Problems & Bedwetting in Children | NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 19 November 2020.
  4. Butler RJ, Holland P (August 2000). "The three systems: a conceptual way of understanding nocturnal enuresis". Scandinavian Journal of Urology and Nephrology. 34 (4): 270–7. doi:10.1080/003655900750042022. PMID 11095087. S2CID 35856153.
  5. Encyclopedia of Sleep. Academic Press. 2012. p. 154. ISBN 978-0-12-378611-1.
  6. Urogynecology and pelvic reconstructive surgery (First ed.). New Delhi. 2016. p. 147. ISBN 9789385891984.
  7. 7.0 7.1 7.2 Radunovich HL, Evans GD. "Bedwetting". University of Florida IFAS Extension. Archived from the original on 2008-01-19. Retrieved 2008-02-02.
  8. 8.0 8.1 8.2 Berry A. "Helping Children with Nocturnal Enuresis". www.nursingcenter.com. Archived from the original on 2008-01-21. Retrieved 2008-02-03.
  9. 9.0 9.1 "Psychology Today's Diagnosis Dictionary: Enuresis". Psychology Today. Retrieved 2008-02-02.
  10. "Bedwetting". Archived from the original on 2009-09-22. Retrieved 2009-09-12.
  11. 11.0 11.1 Haque M, Ellerstein NS, Gundy JH, Shelov SP, Weiss JC, McIntire MS, et al. (September 1981). "Parental perceptions of enuresis. A collaborative study". American Journal of Diseases of Children. 135 (9): 809–11. doi:10.1001/archpedi.1981.02130330021007. PMID 7282655.
  12. "Primary Nocturnal Enuresis: Patient Attitudes and Parental Perceptions". Hong Kong Journal of Paediatrics. New Series. 9: 54–58. 2004. Archived from the original on 2008-01-21. Retrieved 2008-02-03.
  13. "Bedwetting". www.kidshealth.org. Archived from the original on 2008-02-02. Retrieved 2008-02-03.
  14. Macdonald JM (1963). "The threat to kill". Am J Psychiatry. 120 (2): 125–130. doi:10.1176/ajp.120.2.125.
  15. Gavin H (2013). Criminological and Forensic Psychology. p. 120.
  16. Hickey E (2010). Serial Murderers and their Victims. Belmont, CA: Wadsworth, Cengage Learning. p. 101. ISBN 978-4-9560081-4-3.
  17. Department of Research, 1919, California Bureau of Juvenile Research, Whittier State School, Department of Research,  (1919). "The Journal of Delinquency, Volumes 4-5". The Journal of Delinquency. California Bureau of Juvenile Research. 4–5: 41–55.CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link)
  18. Dicanio M (2004). Encyclopedia of Violence. iUniverse. ISBN 0-595-31652-2.
  19. 19.0 19.1 Magura R (2015-01-05). "Nocturnal enuresis in children". The Pharmaceutical Journal. 294 (7843/4). doi:10.1211/pj.2015.20067378.
  20. Hallgren B (1956). "ENURESIS". Acta Psychiatrica Scandinavica. 31 (4): 405–436. doi:10.1111/j.1600-0447.1956.tb09699.x. S2CID 221430598.
  21. 21.0 21.1 21.2 Fritz G, Rockney R, Bernet W, Arnold V, Beitchman J, Benson RS, et al. (December 2004). "Practice parameter for the assessment and treatment of children and adolescents with enuresis". Journal of the American Academy of Child and Adolescent Psychiatry. 43 (12): 1540–50. doi:10.1097/01.chi.0000142196.41215.cc. PMID 15564822.
  22. Eggert P, Kühn B (December 1995). "Antidiuretic hormone regulation in patients with primary nocturnal enuresis". Archives of Disease in Childhood. 73 (6): 508–11. doi:10.1136/adc.73.6.508. PMC 1511443. PMID 8546506.
  23. 23.0 23.1 "CKS: Enuresis — nocturnal – In depth – Background information". National Library for Health, National Health Service. Archived from the original on 2007-10-10. Retrieved 2008-02-02.
  24. "MedlinePlus Medical Encyclopedia: Urination – bed wetting". www.nlm.nih.gov. Archived from the original on 2007-06-09. Retrieved 2008-02-02.
  25. Medical Association, Texas (1910). "Texas State Journal of Medicine, Volume 5, Issue 12". Texas State Journal of Medicine. Texas Medical Association., 1910. 5 (12): 433.
  26. Reynoso Paredes P. "Case Based Pediatrics For Medical Students and Residents". Department of Pediatrics, University of Hawaii John A. Burns School of Medicine. Archived from the original on 2008-01-20. Retrieved 2008-02-02.
  27. "Bedwetting and Constipation". www.wakehealth.edu. Archived from the original on 22 February 2018. Retrieved 22 February 2018.
  28. Järvelin MR, Vikeväinen-Tervonen L, Moilanen I, Huttunen NP (January 1988). "Enuresis in seven-year-old children". Acta Paediatrica Scandinavica. 77 (1): 148–53. doi:10.1111/j.1651-2227.1988.tb10614.x. PMID 3369293. S2CID 34177052.
  29. Butler RJ (December 2004). "Childhood nocturnal enuresis: developing a conceptual framework". Clinical Psychology Review. 24 (8): 909–31. doi:10.1016/j.cpr.2004.07.001. PMID 15533278.
  30. "PANDAS: Frequently Asked Questions about Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections". NIMH. Archived from the original on 2010-05-27. Retrieved 2010-06-01.
  31. Mungan NA, Seckiner I, Yesilli C, Akduman B, Tekin IO (2005). "Nocturnal enuresis and allergy". Scandinavian Journal of Urology and Nephrology. 39 (3): 237–41. doi:10.1080/00365590510007739. PMID 16118098. S2CID 33708606.
  32. "Allergies and Sensitivities". Cedars-Sinai Health System. Archived from the original on 2008-05-15. Retrieved 2008-02-02.
  33. Mowrer OH, Mowrer WM (July 1938). "Enuresis—a method for its study and treatment". American Journal of Orthopsychiatry. 8 (3): 436–459. doi:10.1111/j.1939-0025.1938.tb06395.x.
  34. "Enuresis". University of Illinois Medical Center:Health Library. Archived from the original on 2008-01-26. Retrieved 2008-02-02.
  35. "Dandelions:time to throw in the trowel". CBC News. 2007-06-13. Archived from the original on 2007-07-17. Retrieved 2007-07-10.
  36. "English folklore". Archived from the original on 2009-06-15.
  37. "Benefits of herbal tea". Archived from the original on 2008-01-06.
  38. Shelov SP, Gundy J, Weiss JC, McIntire MS, Olness K, Staub HP, et al. (May 1981). "Enuresis: a contrast of attitudes of parents and physicians". Pediatrics. 67 (5): 707–10. PMID 7255000.
  39. Wang CC, Chen JJ, Peng CH, Huang CH, Wang CL (2008). "Use of a voiding dairy in the evaluation of overactive bladder and nocturia" (PDF). Incontinence & Pelvic Floor Dysfunction. 2: 9–11.
  40. Von Gontard A (2012). "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.
  41. Nevéus T (August 2011). "Nocturnal enuresis-theoretic background and practical guidelines". Pediatric Nephrology. 26 (8): 1207–14. doi:10.1007/s00467-011-1762-8. PMC 3119803. PMID 21267599.
  42. Mellon MW, McGrath ML (June 2000). "Empirically supported treatments in pediatric psychology: nocturnal enuresis". Journal of Pediatric Psychology. 25 (4): 193–214, discussion 215-8, 219–24. doi:10.1093/jpepsy/25.4.193. PMID 10814687.
  43. Barnes TR, Drake MJ, Paton C (January 2012). "Nocturnal enuresis with antipsychotic medication". The British Journal of Psychiatry. 200 (1): 7–9. doi:10.1192/bjp.bp.111.095737. PMID 22215862.
  44. "Nocturnal Enuresis". ucsf.edu. Archived from the original on 2014-05-17.
  45. "Enuresis". University of Chicago Pritzker School of Medicine. Archived from the original on 2008-02-06. Retrieved 2008-02-02.
  46. Friman PC, Jones KM (2005). "Behavioral treatment for nocturnal enuresis". Journal of Early and Intensive Behavior Intervention. 2 (4): 259–267. doi:10.1037/h0100319.
  47. Caldwell PH, Nankivell G, Sureshkumar P (July 2013). "Simple behavioural interventions for nocturnal enuresis in children". The Cochrane Database of Systematic Reviews. 7 (7): CD003637. doi:10.1002/14651858.cd003637.pub3. PMID 23881652.
  48. 48.0 48.1 Jain S, Bhatt GC (February 2016). "Advances in the management of primary monosymptomatic nocturnal enuresis in children". Paediatrics and International Child Health. 36 (1): 7–14. doi:10.1179/2046905515Y.0000000023. PMID 25936863. S2CID 21887776.
  49. Doleys DM (January 1977). "Behavioral treatments for nocturnal enuresis in children: a review of the recent literature". Psychological Bulletin. 84 (1): 30–54. doi:10.1037/0033-2909.84.1.30. PMID 322182.
  50. Martin B, Kubly D (February 1955). "Results of treatment of enuresis by a conditioned response method". Journal of Consulting Psychology. 19 (1): 71–3. doi:10.1037/h0042300. PMID 14354096.
  51. Caldwell PH, Codarini M, Stewart F, Hahn D, Sureshkumar P (May 2020). "Alarm interventions for nocturnal enuresis in children". The Cochrane Database of Systematic Reviews. 5: CD002911. doi:10.1002/14651858.CD002911.pub3. PMC 7197139. PMID 32364251.
  52. 52.0 52.1 52.2 52.3 52.4 Evans JH (November 2001). "Evidence based management of nocturnal enuresis". BMJ. 323 (7322): 1167–9. doi:10.1136/bmj.323.7322.1167. PMC 1121645. PMID 11711411.
  53. Neveus T, Eggert P, Evans J, Macedo A, Rittig S, Tekgül S, et al. (February 2010). "Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the International Children's Continence Society". The Journal of Urology. 183 (2): 441–7. doi:10.1016/j.juro.2009.10.043. PMID 20006865.
  54. Janknegt RA, Smans AJ (November 1990). "Treatment with desmopressin in severe nocturnal enuresis in childhood". British Journal of Urology. 66 (5): 535–7. doi:10.1111/j.1464-410X.1990.tb15005.x. PMID 2249126.
  55. Robson WL (April 2009). "Clinical practice. Evaluation and management of enuresis". The New England Journal of Medicine. 360 (14): 1429–36. doi:10.1056/nejmcp0808009. PMID 19339722.
  56. "Extended Diaper Wearing: Effects on Continence in and Out of the Diaper" (PDF). Journal of Applied Behavior Analysis. Archived from the original (PDF) on 2007-06-28. Retrieved 2008-02-03.
  57. Jindal V, Ge A, Mansky PJ (June 2008). "Safety and efficacy of acupuncture in children: a review of the evidence". Journal of Pediatric Hematology/Oncology. 30 (6): 431–42. doi:10.1097/MPH.0b013e318165b2cc. PMC 2518962. PMID 18525459.
  58. Bower WF, Diao M, Tang JL, Yeung CK (2005). "Acupuncture for nocturnal enuresis in children: a systematic review and exploration of rationale". Neurourology and Urodynamics. 24 (3): 267–72. doi:10.1002/nau.20108. PMID 15791606.
  59. 59.0 59.1 Fackler A. "Dry-bed training for bed-wetting". Yahoo! Health. Archived from the original on 2008-02-08. Retrieved 2008-02-03.
  60. Wood, W. (1918). "Medical Record". Medical Record. 94 (1–12): 204.
  61. Makari J, Rushton HG (May 2006). "Nocturnal enuresis". American Family Physician. 73 (9): 1611–3. PMID 16719255. Archived from the original on 2007-09-29.
  62. 62.0 62.1 62.2 Nappo S, Del Gado R, Chiozza ML, Biraghi M, Ferrara P, Caione P (December 2002). "Nocturnal enuresis in the adolescent: a neglected problem". BJU International. British Journal of Urology. 90 (9): 912–7. doi:10.1046/j.1464-410X.2002.03030.x. PMID 12460356. S2CID 19386118.
  63. Golbin AZ, Kravitz HM, Keith LG (2004). Sleep Psychiatry. Taylor and Francis. p. 171. ISBN 1-84214-145-7.
  64. "Department of Surgery, UMDNJ-RWJMS". rwjsurgery.umdnj.edu. Archived from the original on 2008-02-06. Retrieved 2008-02-03.
  65. "Many Older Children Struggle With Bedwetting". MUSC Children's Hospital. Archived from the original on 2008-02-06. Retrieved 2008-02-03.

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