1. Development and progression of normal voiding control in the pediatric population In the past, it was thought that the bladder of a newborn or small infant had no inhibition of voiding and that voiding occurred spontaneously through simple spinal reflexes with little or no regulation by higher nerve centers as soon as the bladder was filled. In contrast, current research suggests that even full-term fetuses and infants have higher centers involved in urination. The observation that full-term fetuses can induce voiding in response to acoustic vibrations suggests that the voiding reflex in full-term fetuses may be controlled by higher nociceptors and is well developed as gestation approaches full term. The use of dynamic bladder pressure monitoring combined with polysomnography to assess the voiding pattern of awake and sleeping newborns revealed that the bladder is usually resting and stable, with no voiding occurring during sleep; sleeping infants always awaken before voiding occurs; however, this awakening is usually transient, as evidenced by crying or physical activity for a short period of time before the infant voids, and then The infant then falls back to sleep. This mechanism of awakening during bladder distention is established during the neonatal period, suggesting that complex neural pathways and higher nociceptors are involved in the control of voiding even during infancy. At 2 or 3 years of age, development progresses toward socially conscious control of voiding: through effective learning, the ability to autonomously inhibit and delay voiding when the social environment is inconvenient, and to initiate voiding when the environment allows it, even if the bladder is not completely full and can be completely emptied. This voiding pattern is influenced by voiding training while relying on three additional factors: gradual increase in functional bladder capacity, maturation of forceps-sphincter synergy and progressive development of autonomic control of the entire bladder-sphincter-perineum complex. Finally it is often not until about 3-4 years of age that most children have an adult pattern of urination, with no loss of urine during the day or night. 2. Normal urinary physiology: (1) The detrusor receptors of the bladder wall are stimulated during the storage period, and nerve impulses (including general visceral and proprioceptive sensations) are transmitted to the sacral medulla (S2-4) via myelinated A-delta fibers along the pelvic nerve. (2) Visceral sensory and proprioceptive information is transmitted via the thalamic tract and the thin tract of the spinal cord to the gray matter area adjacent to the midbrain conduction duct, before being transmitted to the dorsomedial detrusor center of the pons and to the ventral lateral storage center, so that the superior central nervous system produces conscious perception of the bladder filling state, while the pons detrusor center is constrained by the higher cortical centers. (3) The bladder emptying process is initiated if conditions permit urination. The parasympathetic nerves of the autonomic nervous system play a dominant role in bladder emptying. (4) If conditions are not ripe for voiding, the process of urinary storage continues. The sympathetic nerves of the autonomic nervous system play a dominant role in the urinary storage process. (5) To summarize, afferent sensory information from bladder traction eventually reaches the superior voiding center located in the cerebral cortex and brainstem. The superior center simultaneously integrates other afferent information and sends out the appropriate efferent impulses depending on whether to urinate or not. (6) Even if the bladder loses its local sacral medullary reflex arc consisting of parasympathetic general visceral afferent fibers, general visceral afferent fibers and pelvic nerves, it can still partially empty the bladder due to the intrinsic contractile properties of smooth muscle. Such a bladder is classified as a lower motor neuron bladder or an autonomic bladder, commonly in sacral medullary, cauda equina or pelvic nerve lesions. The residual urine volume is often greater than that of the upper motor neuron bladder. 3. Relationship between enuresis and sleep In recent years, sleep electroencephalography and polysomnography tracing of patients with enuresis have revealed that bedwetting occurs in the first third of sleep. At that time, they are in the deep sleep of non-eye fast moving sleep stage 3-4. Because bedwetting often occurs in “wet dreams”, such as falling into a river and waking up in a dream, people have long thought that bedwetting occurs in dreams, but in fact, bedwetting is not in dreams at that time. In normal people, there are 4-6 bouts of oculomotor sleep per night, but in children with enuresis, there are only 2-3 bouts of oculomotor sleep on the night of bedwetting. Therefore, it is assumed that bedwetting replaces the oculomotor sleep with dreams, and experimental research proves that bedwetting is in the front and dreaming is in the back, and the feeling of damp clothes and sheets is programmed into the bedwetter’s dreams, which is “wet dreams”. Children whose clothes and sheets have been changed and dried in time do not have “wet dreams”. Many people dream that they are unable to find a toilet when they have to urinate, i.e. they have a “dream of finding a toilet” and wake up in anxiety, maybe their pants and sheets are wet, but most of the urine is still in the bladder and not relieved. This is because the signal of bladder filling is programmed into the dream, which is a normal person’s dream, and children with enuresis usually do not have such dreams. 4. Diagnosis Children ≥5 years old who urinate involuntarily ≥2 times/week during sleep state for more than 6 months can be diagnosed with enuresis. However, in children with enuresis, the first step is to determine whether it is functional or organic. History, physical examination, urinalysis and imaging are used to identify organic diseases, of which ultrasound of the bladder is very important. In addition to history and physical examination, routine urine examination or urine culture should be done, and intravenous pyelogram should be done if necessary. ② Neurological diseases, such as occult spina bifida, spinal cord injury, epilepsy, cerebral hypoplasia, etc. These diseases have their own characteristics and neurological symptoms and signs, and are generally not difficult to diagnose. In the case of spina bifida, local X-ray can be done to determine. ③Other, such as diabetes mellitus, urolithiasis, urine loss due to polyuria; pinworm disease local irritation, constipation, etc. should be noted. 5. Treatment points (for children over 5 years old with primary enuresis) The mental burden of enuresis to the child and parents is great, and it will have a negative impact on the child’s psychology. Therefore, it is important to pay attention to the problem of urine loss in children, treat pediatric enuresis correctly, and actively treat pediatric enuresis. (1) Set a schedule From the first day of treatment, set a schedule so that you can keep a daily record (you can use a calendar). When bedwetting occurs, try to find factors that may be contributing to bedwetting and record them on the schedule, such as not sleeping on time, being too excited before bedtime, being too excited during the day, too much fluid intake in the evening, etc. When the patient is bedwetting-free, a star is drawn on the schedule. Meet with the physician once a week. (2) Urine loss alarm Easy to use, safe and effective. It is done by placing a wetting sensor on the bed sheet, and as soon as the child wets, the alarm wakes the child up to drain the remaining urine and clean the bed sheet, and through this repeated training the child can eventually feel the urge to urinate and wake up to urinate on their own. The alarm system has been proven to be the most effective treatment for primary nocturnal enuresis (70%-80% efficiency), but it requires a lot of attention and patience from the patient and parents, as well as constant encouragement from the doctor. (3) Bladder function training Generally, children’s bladder can hold about 300ml of urine, so children should be encouraged to drink more water during the day and consciously make their bladder store more urine. The purpose of this method is to train the bladder sphincter to control urination. This method is more suitable for children who wet the bed several times at night or during the day. (4) Medication ①Desmopressin (Minirin) has been successfully used to treat nocturnal enuresis in children by concentrating the urine and reducing the production of urine. Dosage: desmopressin 0.2mg (can be increased to 0.4mg for poor results) is given to the child orally half an hour before bedtime each night, and water and beverages should not be consumed one hour before and after the dose to avoid water retention. The total duration of treatment is 3 to 6 months. Those who are not effective after 6 weeks of medication are considered ineffective. Autonomic drugs and central excitatory drugs Among the autonomic drugs, anticholinergic drugs can increase functional bladder capacity and reduce uninhibited bladder contraction, so they are effective for enuresis caused by urodynamic disorders, with an efficiency of 50% for simple nocturnal enuresis and only 11% for children with enuresis with normal cystometry, but with an efficiency of 90.6% for uninhibited bladder contraction. The most commonly used drugs are belladonna and probenecid, which are taken orally before going to sleep, or three times a day if there is also enuresis or frequent or urgent urination during the day. Central excitatory drugs commonly used ephedrine 25 mg, taken orally before going to sleep, has an enhanced effect on the contraction of the bladder neck and posterior urethra. In recent years, there are some enuresis, mainly acting on the central peripheral nervous system to increase bladder capacity, the effect on the central nervous system includes anti-inhibitory activities, so that it is easy to “wake up” the sleeping children, about 50% of enuresis can be cured, 15%-20% have progress, but after stopping the drug 60% can relapse, similar drugs are still nortriptyline ( nort Similar drugs include nort riptyline, aventyl, amitriptyline, elavil, desipramine, etc. Autonomic drugs and central excitatory drugs, generally 1 month as a course of treatment, and then gradually reduce the dosage to stop the drug. The dosage is 8~10 tablets for 5~10 years old and 12 tablets for 10~15 years old, both taken twice a day with warm water 1 hour before breakfast and 2 hours after dinner and 1 hour before bedtime. 15 days is a course of treatment, for those who have not taken 4 courses of treatment and have been cured, 4 courses of treatment will be observed, and for those who have taken 4 courses of treatment and have stopped urinating for 15 days, 1 month will be observed. If the patient has not been cured by taking 4 courses, the course of treatment can be extended as appropriate according to the symptoms. ④Chinese herbal medicine: mulberry cuttlebone 10, saposhnikov 7.5, bone marrow 10, puzzle nut 10, Wu Wei Zi 15, Shu Di Huang 10, calamus 15, Yuan Zhi 10, Poria 10, dragon bone 30, red stone fat 15, licorice 7.5, gold cherry 15, unit is grams, one payment per day, divided into two times. ⑤ In addition, on the outer side of the transverse stripe at the end of the little finger of both hands (here is the point of urination), pressed on with small green beans every night before going to bed, and taken off the next morning, the intensity is felt and slightly painful, but not pressed too dead, so as to avoid blood flow, causing necrosis.