There has been no uniform definition of enuresis, which is actually a form of urinary incontinence. Enuresis is usually thought of as the incontinence that occurs when a child is asleep. Daytime enuresis refers to incontinence that occurs during the day. The definition of nocturnal enuresis is more complicated because normal children also have nocturnal incontinence, which gradually disappears as the nervous system matures. Therefore, there is now an age limit for enuresis, which mostly refers to the diagnosis of enuresis if bedwetting occurs at least twice a month after the age of 5 years [9]. Enuresis is a symptom in itself, not a disease. There are many reasons why enuresis may occur, even as a result of a combination of factors (Figure 10-3-1). However, the pathogenesis of enuresis is still poorly understood, especially in those without an obvious primary disease. I. Etiology Table 10-3-1 lists the factors associated with enuresis. The fact that most enuresis resolves spontaneously suggests that delayed maturation of bladder control is the most common cause of enuresis and that children with enuresis experience symptomatic relief in the same manner as normal children with maturation of bladder control, i.e., demonstrating controlled daytime voiding followed by gradual control of nocturnal enuresis. Normally, antidiuretic hormone secretion increases at night to reduce nocturnal urine output, and it has been shown that this endocrine rhythm is lost in children with enuresis, and nocturnal urine output is significantly increased [10]. Some enuresis is associated with a number of sleep disorders, but ground EEG analysis and period sleep patterns in children with enuresis are not significantly different from normal controls [11]. Psychiatric factors clearly have an impact on enuresis, but numerous studies have not found significant psychopathologic changes in children with enuresis. There is a clear genetic component to enuresis, and studies have found that children of one parent with enuresis have about a 44% likelihood of developing enuresis, and children of both parents with enuresis have up to a 77% likelihood of developing enuresis, whereas children of neither parent with enuresis have only a 15% likelihood of developing the disease. There is also direct evidence to support the role of genetics in enuresis in that 36% of dizygotic twins have enuresis, compared to 68% of monozygotic twins. The first-line examination for enuresis includes a thorough history and physical examination, urinalysis and urine culture, and evaluation of the functional capacity of the bladder. The history should reveal the presence of frequent urination, too little urination, urinary urgency, urge incontinence, persistent dribbling, and urinary control in the bent-knee salute position. The presence of bowel dysfunction, such as constipation or fecal incontinence, should also be recognized. Physical examination should focus on the abdomen, lumbosacral region, and external genitalia. Such as the lumbosacral region of the local skin with or without hair, hyperpigmentation, skin depressions and other signs of sacral cleft; abdominal examination to understand the presence of abdominal masses, whether chronic urinary retention; external genital examination should be to understand the presence of developmental deformities that cause urinary incontinence, such as hypospadias, supraspadias, and encopresis, and so on. For those who suspect spina bifida, they should further check the lower limb activity, tendon reflex, bulbocavernosus muscle reflex and anal sphincter tone and other neurological examination. Third, the treatment of enuresis There are many ways to treat enuresis, the main principle should be to avoid invasive diagnostic and treatment methods, unless there may be suspected of more serious organic lesions. Can not be instilled in the child or bedwetting will have to be very painful injections and medication as a punishment, the child will lose interest in the treatment of enuresis after fear, will seriously affect the efficacy of behavioral therapy. Cultivate the child to have a correct understanding of enuresis, do not fear enuresis, should be a temporary phenomenon in the child’s growth, so that the child has the confidence to actively participate in the behavioral treatment of enuresis. This kind of popular education for children to recognize enuresis and build up confidence in treating enuresis is often called awareness of enuresis therapy. It may seem simple, but once the child has a basic understanding of enuresis and eliminates the fear and shyness brought about by enuresis, the efficacy of subsequent behavioral treatments will be greatly increased. (The so-called motivation therapy is to cultivate the child’s initiative to accept the treatment of urine loss. For example, if you keep a detailed record of urine loss or record a diary of urination, you can give the child a certain amount of rewards when there is no bedwetting and when there is progress over a period of time, so as to gradually cultivate the child’s initiative to actively request the treatment of enuresis. Sense of responsibility training refers to letting the child take some responsibility for the consequences of enuresis, such as bedwetting requires the child to take a bath in time, change the wet clothes and sheets and put them into the washing machine, so that the child will know that enuresis will not only bring a lot of trouble to himself, but also to his parents, and minimizing the number of times of enuresis will obviously help his parents. Other behavioral treatments include limiting the amount of water consumed at night, urinating before going to bed, encouraging children to drink more water during the day, avoiding bladder-stimulating foods such as soda, caffeinated beverages, chocolate and lemons, etc.; and avoiding irritating soaps when bathing the perineum. (ii) Bladder training Bladder training plays a role in the treatment of enuresis. Regardless of the treatment method, the relief of enuresis is more or less related to the reduction of the number of daytime urination and the increase of the functional capacity of the bladder. Bladder training involves learning how to inhibit the micturition reflex and gradually lengthening the interval between micturitions. The child should be made to realize that he should not go to the toilet immediately when he has the urge to urinate, but can find a place to sit down, squat, cross his legs, or contract his anal sphincter, and so on, to inhibit the sensation of urination in various ways. It is also important to keep a voiding diary to keep abreast of the progress of bladder training. The empirical formula for normal bladder capacity in children (ounces) = age (years) + 2 [13], e.g., for a 7-year-old child, the normal bladder capacity is 7 + 2 = 9 (ounces, each ounce = 28,4 g). Gradual expansion of the functional bladder capacity to that calculated with the age formula above is sufficient. Increasing water intake during the day can help increase the efficacy of bladder training. However, increasing bladder capacity alone is not an effective treatment for nocturnal enuresis and is often used as one of the adjunctive treatments [14]. (C) Conditional action therapy Conditional action therapy mainly refers to the use of an electronic device, which is placed in the urinary pads, and alarmed when bedwetting is encountered, waking up the child and urinating in time to avoid complete wetting. At present, little is known about the mechanism of electronic alarm type conditioning therapy, that the bladder filling induces the urethral muscle reflex to urinate, the electronic device measures a small amount of urine and then alarms, the child can be woken up to inhibit the urethral muscle reflex, and finally normal urination; the above process is repeated for a long period of time and a direct link between bladder filling and urethral muscle reflex inhibition at night may have been established to ultimately cure enuresis [15]. (Anticholinergic drugs Commonly used anticholinergic drugs include oxybutynin and probenecid. Anticholinergic drugs can increase bladder capacity, but placebo randomized controlled study showed that the efficacy of treating nocturnal enuresis with anticholinergic drugs alone was not significantly different from that of placebo [16]. Therefore, for those with relatively small functional bladder capacity, behavioral therapy can be supplemented with anticholinergic medication, which can reduce or accelerate the relief of enuresis [17]. Common side effects of anticholinergic drugs include dry mouth, dry eyes, and in severe cases, increased urinary output or difficulty in urination and can lead to the development of urinary tract infections; also, personality changes, hallucinations, and nightmares in some children may be related to the central adverse effects of the drug.The dosage of Oxybutynin for children over 5 years old can be started from 2, 5mg twice a day, and the dose can be gradual according to the therapeutic efficacy and the side effects tolerated. 2, tricyclic antidepressants commonly used drugs for promethazine. Although the drug has been used in the treatment of enuresis for a long time, the mechanism of promethazine in the treatment of enuresis is still not clear, and the most likely mechanism is also related to the increase of bladder capacity [18], and the efficacy of the increase of bladder capacity may be related to its anticholinergic effect. Another mechanism may be related to its own antidepressant mechanisms, which may also affect the secretion pattern of antidiuretic hormones, etc. It is generally recommended that promethazine therapy be considered only in children over 6 years of age. The starting dose is 25 mg orally once at bedtime. This can be gradually increased to 50mg orally at bedtime, depending on efficacy and tolerance of side effects, and to 75mg orally at bedtime for those over 12 years of age. The maximum dose should not exceed 2,5mg/Kg/day. Because promethazine has cardiotoxicity, drug users should regularly review the electrocardiogram, the P-R interval prolongation or the emergence of ventricular transmission abnormalities should be promptly discontinued. Promethazine not only has various side effects of anticholinergic drugs, more serious, such as overdose, can cause serious cardiotoxic reactions, hypotension, respiratory insufficiency and other fatal complications. 3, desmopressin is a kind of ADH analog, has a strong antidiuretic effect. The main mechanism of treating enuresis is to reduce the formation of nocturnal urine volume, which is less than the functional capacity of the bladder, thus preventing the occurrence of urinary incontinence. The drug is available in the form of a spray, and the starting dose is one spray in each nostril at bedtime (about 20 mg in total). The dose can be increased gradually, but should not exceed 40mg per day.Side effects include runny nose, nasal congestion and nosebleeds. This class of medication is not suitable for daily treatment and is mostly used for special occasions, such as staying with classmates.