Enuresis

from Wikipedia, the free encyclopedia
Classification according to ICD-10
F98.0 Inorganic enuresis
R32 Urinary incontinence, unspecified
ICD-10 online (WHO version 2019)

As enuresis or enuresis (from the Greek s "in" and ourein "urine blank") is the involuntary enuresis after the 3rd or 4th year of life, without there being a physical cause is present. Another name is bedwetting .

It should be noted that children up to the age of 8 occasionally wet themselves, especially in crisis situations, in the event of serious illnesses or in times of increased stress.

definition

In enuresis, a distinction is made between daytime wetting of diurnal enuresis and nocturnal wetting of enuresis nocturna , with combined forms also occurring. Furthermore, a distinction is made between a primary enuresis - the child has never been permanently dry - and a secondary enuresis, in which the child wets itself again after it has been continent for more than six months. Wetting does not only affect children, adults are also affected. From a psychological point of view, one correctly speaks of wetting when a child from the age of 5 (and intellectual intelligence age of 4 years) shows the symptoms of wetting in at least two nights in one month.

Primary enuresis

In primary enuresis, a constitutional delay in development of the child is assumed. This form of wetting can also occur in families and is primarily genetic. In primary enuresis, mental problems are more likely to be a consequence of the disorder, but in individual cases they can also be causal.

The antidiuretic hormone (ADH, vasopressin), which controls the water balance in the body and thus affects the filling of the bladder, plays an important role in nighttime wetting . This hormone, also known as a messenger substance, is normally excreted by the pituitary gland in a daily rhythm that ensures that less urine enters the bladder at night . This hormonal regulation can be disturbed in primary nocturnal enuresis. The interaction between control of the bladder and the depth of sleep is still underdeveloped. Primary nocturnal enuresis is characterized by:

  • seemingly deep sleep (but with only short REM sleep phases)
  • difficult to be awakened with normal sleep behavior
  • Frequent wetting with large amounts of urine
  • high frequency of wetting
  • Polyuria
  • Variation in circadian ADH secretion
  • rare accompanying psychological symptoms

Secondary enuresis

In secondary enuresis, psychological causes probably play the main role. Wetting can be an unconscious signal: "Something is wrong". If a child wet again after it has been dry for a long time, unexpected changes can often be found in the child's life that unsettle them. This can be the birth of a sibling, the loss of a family member, disputes in the family, domestic violence against the child, an experience of separation, a move or the like. In secondary nocturnal enuresis:

  • a relapse after a dry period of at least 6 months
  • often accompanying psychiatric symptoms

The forms of enuresis can be combined with the signs of impaired bladder function. These occur particularly in diurnal enuresis. Attention should also be paid to rare forms of voiding disorders. The distinction between enuresis and urinary incontinence depends on the symptoms. If the unwanted leakage is mainly due to physical causes with structural, neurogenic or functional bladder dysfunction, then it is called urinary incontinence. Bladder dysfunction can have a variety of symptoms depending on the cause, including: a. by:

  • frequent urination
  • Use of "holding maneuvers", e.g. B. Pressing the thighs together, hopping from one leg to the other, crouching position
  • unwanted leakage of urine when there is a strong need to urinate
  • Staccato urination with incomplete emptying of the bladder
  • Urinary incontinence when there is abdominal tension, such as when coughing or sneezing
  • Giggle incontinence enuresis risoria with complete emptying of the bladder when laughing

distribution

This article or the following section is not adequately provided with supporting documents ( e.g. individual evidence ). Information without sufficient evidence could be removed soon. Please help Wikipedia by researching the information and including good evidence.

Wetting is one of the most common disorders of childhood. At night, around 25% of four-year-olds, 10% of seven-year-olds and 1-2% of adolescents wet themselves. The gender ratio between boys and girls is 2: 1. The spontaneous remission rate ( spontaneous remission ) is about 13% per year. During the day, 2-3% of seven-year-olds and less than 1% of young people wet themselves. Research has shown that around 1% of adults do not have their bladder under control at night. According to this, there are around 800,000 affected people in Germany, in Austria there are around 80,000 children, that is 2 per elementary school class and still around 160,000 adults who are bedwetting.

causes

Every form of wetting is an extremely diverse phenomenon that must be precisely described and clarified. When researching the causes of enuresis, some important points have only been clearly clarified in recent years or have been identified as the cause with a high degree of probability.

Genetics of enuresis

The familial accumulation of enuresis has been known since the 1930s. An autosomal dominant inheritance with a penetrance of over 90% is suspected. However, the disease occurs sporadically in 30% of cases. By 2001, all suspected candidate genes had been excluded. In a current Turkish study, a marker for enuresis is again being put up for discussion.

ADH plasma level in nocturnal enuresis

Puri had already examined ADH levels in the urine in enuresis in 1980. Since then, a disruption of the circadian-regulated urine excretion has been suspected during bed-wetting. It is believed that the cause of enuresis is ADH deficiency at night. In elderly patients with nocturnal wetting, as well as in stroke patients , the administration of desmopressin can therefore improve the symptoms. Desmopressin is also recommended for the treatment of enuresis in children according to the international therapy guidelines of the Pediatric Urology Guidelines (from 2009), which were drawn up on the basis of the recommendation of the European Association of Urology [EAU] and the European Society for Pediatric Urology [ESPU] if z. B. polyuria is present, d. H. if more urine is formed at night than the age-appropriate bladder should be able to store. A connection between enuresis and sleep apnea syndrome has also been suggested.

Sleep pattern

The sleep pattern of enuretics is in principle comparable to that of symptom-free children, but those affected are extremely difficult to wake up. A pathologically increased wake-up threshold or a delayed maturation of the wake-up mechanism is postulated today. The stimulus of the filled bladder is not enough to wake the child.

Hydration and night wetting

Drinking abundantly in the evening obviously has an intensifying effect on wetting at night; in a study, more than 25 ml per kilogram of body weight caused enuretic episodes.

This article or the following section is not adequately provided with supporting documents ( e.g. individual evidence ). Information without sufficient evidence could be removed soon. Please help Wikipedia by researching the information and including good evidence.

The influence of a reduced functional bladder capacity is discussed differently. Urodynamic examinations in children with therapy-resistant only night wetting were able to demonstrate a high percentage of pathological functional bladder undercapacity among them.

Psychosocial level

There is no specific association with any particular mental health problem. Risk factors, especially in the secondary enuresis refers on one hand to losses in the broadest sense, such as separation, divorce, deaths, birth of a sibling, extreme poverty, delinquency of parents, deprivation , neglect, lack of support in the development stages, on the other hand, a gain of illness by Regression: the elimination leads to care in the form of care by the parents.

The most common comorbid disorder of nocturnal enuresis is attention deficit / hyperactivity disorder (ADHD), which, like enuresis, is a predominantly genetic, neurobiological developmental disorder.

Unconfirmed and controversial causes

Deep sleep

Many parents report that their bed-wetting children sleep very soundly. The results of research on this aspect do not yet give a complete picture: A recent study confirms that bed-wetting children are harder to wake up, while several older studies show that children bed- wetting during all phases of sleep , not just the deepest (phase 4 or phase 3 and 4). Some publications point to a possible link between insomnia and ADH production. Insufficient ADH could make it more difficult to transition from light sleep to wakefulness.

stress

Stress is not a cause of primary nocturnal enuresis , but it is widely accepted as a reason to return to bedwetting ( secondary nocturnal enuresis ). Researchers who examined children who had not yet learned to stay dry found “no connection to social background, stress in everyday life, family constellations or the number of places of residence.” On the other hand, stress is a reason for some return to bedwetting. Researchers have found that moving to a new city, parental conflict or divorce, the arrival of a new baby, or the loss of a loved one or pet can create insecurity, which can help bring them back to bedwetting.

Food allergies

For some patients, food allergies could play a role. However, this link is not widely recognized and needs further research.

dandelion

Anecdotes and popular wisdom tell that children who play around with dandelions wetting their beds. Dandelions are believed to be a powerful diuretic . Dandelion is called "Bettsaicher" in Swabian and "Bettsächer" in Palatine. Common English names for dandelions are peebeds and pissabeds . In French, dandelions are called pissenlit , which means "to go to bed"; It is similar with piscialletto in Italian, and with meacamas in Spanish.

Comorbidities

The most common comorbid disorder of nocturnal enuresis is attention deficit / hyperactivity disorder (ADHD). Children who wet themselves at night and / or during the day are more often affected by ADHD.

Symptoms and diagnostics

Diurnal enuresis

A general distinction is made between different forms of daytime wetting: play wetting, conflict wetting and giggle incontinence. When playing wet, the child is so absorbed in his game that it does not notice the urge. In conflict wetting, wetting is often a result of a previous conflict with adults or other children. In the Giggle incontinence (. Of English giggle : Giggling) is, a form of enuresis, in which (as well as other physical reactions) can result from laughter of Blasensphinkter not be completely controlled and thus (usually only smaller amounts ) empty. Day wetting cannot always be clearly assigned to one of these categories.

Nocturnal enuresis

Typically, it is reported about "soaking wet" beds as a result of being soaked at night, the bed "floats". The child sleeps very deeply and is sometimes difficult to wake up or does not wake up from wetting. Around a third of children wet every night, a good third on several nights a week, and less than 3 nights are a mild form of enuresis. Characteristic nocturnal for primary enuresis is the lack of any daytime symptoms, such as urinary frequency , imperative urination , difficulty of micturition , enuresis or dribbling urine loss during the day and urinary tract infections. The survey must also include the family history, drinking habits and any previous treatments, and stool habits (exclusion of encopresis , constipation ) should also be asked about. This anamnesis is part of the basic diagnosis that is exclusively required here. If, in addition to enuresis, there is abnormal micturition behavior, the nocturnal wetting must be understood as a partial component of a present form of a child's urinary incontinence. Only then is further diagnostics necessary.

General examinations

In addition to the anamnesis, a physical examination and an examination of the urine ( urine status ) are appropriate. In addition, an ultrasound examination ( sonography ) of the kidneys and urinary tract may be indicated to rule out physical malformations. The evaluation of a bladder diary or micturition log is helpful for a diagnosis. In this way, drinking and micturition malfunctions can be detected and information about the bladder size and the amount of urine during the day and the amount produced during the night is obtained.

Basic diagnostics:

Physical examination
The physical examination includes abdominal palpation, inspection of the lower back area (lumbar spine / sacrum) and the genital organs . This allows the doctor to get a first impression of whether there may be other physical causes. The condition of the nervous system is also important.
Urinalysis
The urine test determines whether there is a bacterial infection and the sediment status is also determined. A urine sample must be submitted. Body mass and amount of urine, separated into day and night urine, should be known. In male patients is midstream urine used in female patients is usually by means of a catheter, urine removed. This examination is not painful, but it can often be found uncomfortable when the catheter is removed . The urine sample is then incubated and, through the different growth of the bacteria, the causative strain can then be identified and specifically treated.
Ultrasonic
From the information, the doctor can draw initial conclusions about the possible cause of the enuresis. The abdominal organs are examined and abnormal findings such as kidney and bladder stones, malformations and tumors can be recognized. In the case of the bladder, before and after urination, you can also make statements about the storage volume and any residual urine volume . The thickness of the bladder wall can also be measured.
“Star maps” for dry nights
A calendar is kept to record the severity of nocturnal enuresis and to monitor treatment. This is designed to be child-friendly, for example clouds and stars or sun and rain can be used as symbols. It shows children success in a playful way. For example, a star can be drawn in the log for every dry night.
Bladder diary or micturition log
The micturition volumes and times are recorded over 2 to 3 days and nights, as well as when the child drinks what and how much. Special features are noted, e.g. B. conspicuous daytime symptoms if z. B. the underpants are damp, or whether there was a sudden urge to urinate. In addition, it is noted in the bladder diary when the child had a bowel movement and what it was like.

There are two methods that can be used to determine the amount of nocturnal urine in a child:

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  1. During the night, the child is woken up once before (2 hours after falling asleep) and once after midnight (5 hours after falling asleep) and asked to urinate in a measuring cup.
  2. The child wears diaper pants at night. The difference between wet and dry pants is the amount of urine (1 gram = 1 milliliter). The first urine portion is added to the nocturnal amount of urine early after waking up. This gives the total amount of night urine. This should not exceed the age-appropriate bladder capacity, which is calculated as follows:
Age-appropriate bladder capacity: (age of the child +1) × 30 = ml urine (example for a 7-year-old child: (7 + 1) * 30 = 240 ml A seven-year-old child is expected to have a bladder capacity of 240 ml))
Otherwise, an ADH deficiency can be suspected. A direct ADH measurement is hardly possible because the level of this hormone is at the limit of what can be measured (around 1 pg). The use of desmopressin is conceivable if the amount of urine at night exceeds the age-appropriate bladder capacity .

These simple objectification measures often reveal considerable discrepancies between the anamnestic data and the objectively obtained findings.

Further investigations

After the physical examination of the patient, further examinations can be carried out if a serious illness is suspected or if the findings are unclear:

Further investigations

In secondary enuresis, physical causes or triggers can also play a role. The range of causes is very broad.

Associated psychological disorders

Generally, mental comorbidities higher in daytime than nighttime Einnässenden enuretics, higher for urinary incontinence in Miktionsaufschub and the detrusor sphincter dyscoordination as in idiopathic urge incontinence and higher in the secondary than in the primary nocturnal enuresis. Psychological causes are particularly low in primary monosymptomatic nocturnal enuresis. Expansive, externalizing disorders are more common than emotional, introversive disorders, specifically:

Disruption-relevant framework conditions

In order to be able to make a statement as to how much the child is burdened by the enuresis, an exact questioning of the child and the caregivers is necessary. Special emphasis is placed on the level of suffering, social restrictions, negative consequences such as teasing from other children, conceptions of illness, motivation, how parents deal with the symptom. Is it experienced as very stressful, is there sufficient support from the environment to enable the therapeutic interventions to be implemented? Are there any other comorbidities?

Only when all these points have been clarified is there a picture of the actual level of suffering the child is under. It is important to include the parents or the caregiver in the survey. The treatment of enuresis then depends on the results of these surveys. Since successful treatment is only possible if the parents also cooperate, they should be included in the decision on the treatment path.

Therapy of nocturnal enuresis

Therapy for enuresis requires detailed diagnostics and then a corresponding individual approach that corresponds to the causes. The first step is to advise and inform the family about bedwetting. The main focus here is on reinforcement, relief, demystification of the problem, motivation and, if necessary, calendar management . According to the international pediatric urological guidelines of 2009, depending on the results of the evaluation of the bladder diary and the anamnesis, either therapy with desmopressin or apparatus-based behavioral therapy (AVT) using alarm devices ( device-based enuresis therapy , see section alarm devices ) is recommended.

Psychological therapy

Behavior and problem analysis

The basis of every behavior therapy treatment is the behavior and problem analysis for more detailed clarification and diagnosis of the problem. Discussions are held with the parents and the child. Information is provided about the symptom itself, such as the description of bed-wetting (frequency, severity) and aspects that could be temporally related to the symptom are recorded. These can be characteristics such as excitement in the evening, an argument or an upcoming class test. The description of a typical daily routine is also an important point of discussion. This can provide valuable hints that help the therapist understand the relationship between parents and child. For example, there seems to be a clear correlation that girls are more likely to wet themselves after differences of opinion within the family. For example, the different ways in which the parents are brought up could become an important topic of conversation. A possibly problematic relationship between the parents can also come to light and be considered as a possible cause. Another important point is the parents' reaction to bedwetting. In addition, physical characteristics such as fever, cold and depth of sleep are recorded, because a possible connection between such physical aspects and psychological causes must be taken into account. In addition, general development data of the child such as pregnancy, illnesses, accidents and data on early childhood development are collected. One could come across the problem of toilet training in the family and recognize possible connections with bed-wetting. Psychosocial living conditions such as kindergarten or school are also discussed, because school anxiety can also be a trigger for bedwetting.

Apparative behavior therapy using alarm devices

Wireless bell pants

An alarm clock is a device for measuring moisture, which (similar to an alarm clock) emits an alarm signal as soon as moisture (urine) reaches the sensor (see also bell pants ). The alarm devices are based on the principle that the children are woken up by the alarm and the micturition reflex is interrupted. The method was first used in the 1930s and has been scientifically researched and developed further since then. The mode of action is still largely unclear, learning-theoretical models of classical conditioning (conditioned voiding inhibition) and avoidance learning (avoidance of the annoying aversive signal through early awakening, cf. negative reinforcement ) are being discussed . The cognitions of the child and his environment probably also play an important role (expectations of success increase, self-assessment improves, etc., see cognitive behavioral therapy ). The average duration of treatment is 7–12 weeks. If the child does not wet 14 nights in a row, this is to be considered a success and the alarm therapy is to be ended. The device should still be kept ready for a period of 6 months. If the child begins to wet again at least twice a week (relapse), follow-up treatment should be carried out. If there is no success after 6 months at the latest (frequency of wetting reduced by at least two thirds), the treatment should be discontinued and (if it has not already happened) a urologist should be consulted. The procedure, which is very exhausting for everyone involved, requires motivation, cooperation and a willingness to learn. However, the healing rates are high (75–85%), around 60% of those healed have no relapse. Most relapses occur in the first four months after the end of therapy, but around 90% of relapses are "dry" in the long term after one or two follow-up treatments.

Wake-up training

If the child is not awake by the Weckgerät, one can after about three nights Wecktraining be carried out (even without Weckgerät possible). The child is first spoken to softly, then loudly by name, then the signal sounds, and then the child is shaken awake. In the event of unfavorable wake-up times, wake-up training can also be used to gradually shift the wake-up time forwards or backwards.

Calendar management and positive reinforcement

The theory of motivation is based on the principle that the child must become active themselves in order to grasp their own problem and to change their behavior. It is helpful to keep a calendar with the entry of the dry nights. These protocols are very popular with younger children and increase their awareness of the learning step to be taken. Then the child should keep a reinforcement plan (sun-cloud calendar) in which they enter a sun for every dry night and a rain cloud for every wet night (this system only makes sense if the child is treated). Rewards can also be helpful. The children are not rewarded for dry nights (because they can't help it if they wet themselves), but for the fact that they work well - e.g. B. if they adhere to the drinking and micturition rules that have been agreed in the context of urotherapy.

Restraint training

Exercises for bladder control (“retention control”) are mainly used in diurnal enuresis. The daytime exercises can be jeref name = "ifas"> Evans, Radunovich: Bedwetting. University of Florida IFAS Extension, accessed February 2, 2008 . but also have a positive effect on bladder control at night. For example, the child should hold back the urine for as long as possible (e.g. first five, then ten minutes, etc.) to make them aware of the distension of the bladder. To this end, it can be useful to increase the daily amount consumed to two liters per day. Both are positively reinforced (see above). Arbitrary interruption of the urine stream also promotes awareness of control.

Intensive training after Azrin / dry bed training

Several therapy components are used here, e.g. B .:

  • high fluid intake and frequent visits to the toilet
  • Discrimination training ( wet versus dry )
  • Alarm device / bell pants
  • Reward / reinforcement for "successes"
  • Token program

The very complex program is particularly recommended for retarded or disabled children.

Pharmacotherapy - desmopressin therapy

The drug desmopressin is approved “as part of an overall therapeutic concept” . This synthetically produced, modified peptide is modeled on the body's own hormone ADH (arginine vasopressin) and, like the hormone itself, can reduce urination. In contrast to the body's own arginine vasopressin, however, desmopressin acts specifically on the V2 receptor (less on the V1 receptor), which is responsible for the reabsorption of water from the primary urine. Its antidiuretic effect is much stronger than that of vasopressin.
A sufficiently high starting dose is recommended, which is carried out over a treatment period of up to 3 months. Thereafter, the treatment should be interrupted to determine whether further treatment is necessary (see). One study has shown that tapering off has a slightly better response to therapy than abrupt discontinuation. The time intervals at which the drug is taken are extended - first every other day for two weeks, then every third and so on. If the child gets wet again during the "tapering off phase", the dose can be increased again to the originally successful one.
Desmopressin is available as a tablet to dissolve in the mouth and as a tablet.
The more common side effects are generally pharmacodynamic related. In particular, if the fluid intake is not reduced, increased water retention can occur (desmopressin is a very effective antidiuretic), resulting in increased volume and a relative lack of electrolytes. Warning signs are headache, nausea / vomiting, weight gain. In severe cases it can lead to cerebral edema, sometimes combined with seizures or impaired consciousness.

Therapy of diurnal enuresis

Compared to bed-wetting, wetting is treated a little differently during the day. Treatment depends on the type of discomfort.

Treatment of idiopathic urge incontinence

The goal is to perceive and control the urge symptoms without holding maneuvers (like pressing your legs together). The children should notice the urge to urinate, go to the toilet immediately and refrain from holding maneuvers as countermeasures. Treatment with the drug oxybutynin can be helpful. This will calm the bladder by relaxing the hollow muscle of the bladder. The side effects quickly subside after stopping the drug.

Treatment of urinary incontinence when urination is delayed

First, parents and child are advised and relieved. The relationship between holding back urine and wetting can be explained and explained. The goal is to get the child to go to the bathroom more often. This can be logged in a calendar, for example. Due to the frequency of other behavioral problems, further therapeutic measures are often necessary.

Treatment of detrusor-sphincter dyscoordination

Special treatments with biofeedback methods are most effective here. The flow of urine and the tension in the pelvic floor while urinating is reflected to the child optically or via sounds using special devices. The goal is a conscious perception of physical processes that are otherwise not perceived. After just a few days of training, most children show a clear improvement.

Ping-pong between dysfunction and inflammation

Cystitis may be involved, which should be clarified by a doctor, especially if only small amounts of urine pass during the day. Loss of urine, a sign of sphincter and bladder disorder, is very common with bladder infections. In a Swedish study of seven year olds, 8.4% of girls and 1.4% of boys were affected.

This article or the following section is not adequately provided with supporting documents ( e.g. individual evidence ). Information without sufficient evidence could be removed soon. Please help Wikipedia by researching the information and including good evidence.

Scientists also found similar frequencies in a study of ten to eleven year olds. When the researchers questioned the parents for this study, they realized that they attach much more importance to the mostly harmless night wetting than to urinary incontinence during the day, which can be behind an infection. So-called urge incontinence is one of the consequences. The muscles that empty the urinary bladder are overactive and contract before the bladder is full. In some children, some of the urine flows back into the bladder. This residual urine is an ideal breeding ground for bacteria. This leads to inflammation of the urinary bladder again and again. It is therefore important to treat the cystitis at the same time as the incontinence and identify the cause of recurrent infections.

Antibiotics may be needed if you have a bladder infection. In the case of urge incontinence, so-called anticholinergics are used in addition to bladder training .

This article or the following section is not adequately provided with supporting documents ( e.g. individual evidence ). Information without sufficient evidence could be removed soon. Please help Wikipedia by researching the information and including good evidence.

Previous studies show no significant difference in the effects of anticholinergics, placebo and bladder training.

Inpatient treatment

Inpatient treatment of enuresis may be indicated if the above-mentioned therapy methods cannot be carried out in a family setting, if the child is under severe psychological stress or if there is a pronounced psychological concomitant problem.

Wetting children often have a lower self-esteem than non-enuretic children, whereby it is questionable here whether the lower self-esteem is a result of wetting or vice versa. Unfortunately, wetting is still a taboo subject , parents and children are ashamed to talk about it. On the other hand, the problem of wetting is often discussed with relatives or friends outside of the family, which does not exactly promote the relationship of trust between the child and his or her parents, as the child feels exposed in front of others.

In such cases it can be helpful for the young person to contact a youth counseling center .

literature

Web links

Individual evidence

  1. ^ T. Poehlke: Psychiatry. 15th edition. Georg Thieme Verlag, Stuttgart / New York 2001, ISBN 3-13-112975-1 , p. 75 ff.
  2. ↑ A. von Gontard et al. a .: The genetics of enuresis: a review. In: J Urol . 2001 Dec, 166 (6), pp. 2438-2443, PMID 11696807 .
  3. ↑ A. Balat et al. a .: Nitric oxide synthase gene polymorphisms in children with primary nocturnal enuresis: a preliminary study. In: Ren Fail. 2007, 29 (1), pp. 79-83, PMID 17365914 .
  4. ^ VN Puri: Urinary levels of antidiuretic hormone in nocturnal enuresis. In: Indian Pediatr. 1980 Aug, 17 (8), pp. 675-676, PMID 7228357 .
  5. ↑ JP Guignard et al. a .: Endocrine theory of idiopathic nocturnal enuresis. In: Arch Pediatr. 1997, 4 Suppl 1, pp. 3s-6s, PMID 9181001 .
  6. ↑ R. Sakakibara et al. a .: Nocturnal polyuria with abnormal circadian rhythm of plasma arginine vasopressin in post-stroke patients. In: Intern Med. 2005 Apr, 44 (4), pp. 281-394, PMID 15897635 .
  7. ↑ A. Ali et al. a .: Nocturia in older people: a review of causes, consequences, assessment and management. In: Int J Clin Pract. 2004 Apr, 58 (4), pp. 366-373, PMID 15161122 .
  8. ↑ MG Umlauf u. a .: Sleep disordered breathing and nocturnal polyuria: nocturia and enuresis. In: Sleep Medicine Reviews . 2003 Oct, 7 (5), pp. 403-411, PMID 14573376 .
  9. ↑ Alexander von Gontard: Closing Word. In: Deutsches Ärzteblatt. Volume 116, Issue 29 f., (July 22) 2019, p. 506.
  10. ^ Bed Wetting And Its Causes. drgreene.com, accessed February 2, 2008 .
  11. ↑ a b What is the Most Effective Treatment for Primary Nocturnal Enuresis? pediatriceducation.org, accessed February 2, 2008 .
  12. ↑ Evans and Radunovich: Bedwetting. University of Florida IFAS Extension, accessed February 2, 2008 .
  13. ↑ NA Mungan, I. Seckiner, C. Yesilli, B. Akduman, IO Tekin: Nocturnal enuresis and allergy . In: Scand. J. Urol. Nephrol . tape 39 , no. 3 , 2005, p. 237-241 , doi : 10.1080 / 00365590510007739 , PMID 16118098 .
  14. ^ Allergies and Sensitivities. (No longer available online.) Cedars-Sinai Health System, archived from the original on May 15, 2008 ; Retrieved February 2, 2008 .
  15. ^ Dandelions: Time to Throw in the Trowel. Retrieved August 3, 2018 .
  16. ↑ English folklore. Retrieved December 23, 2010 .
  17. ^ Benefits of herbal tea. (No longer available online.) Archived from the original on January 6, 2008 ; Retrieved December 23, 2010 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.herbalteatips.com
  18. ↑ Eberhard Kuwertz-Bröking, Alexander von Gontard (ed.): S2k guideline 028/026: Enuresis and non-organic (functional) urinary incontinence in children and adolescents. AWMF Online, December 2015, p. 19 (PDF). According to: Baeyens et al. 2005, 2007, Shreeram et al. 2009, Park et al. 2013, from Gontard and Equit 2014.
  19. ↑ Alexander von Gontard: ADHD and elimination disorders. In: Christine M. Freitag, Wolfgang Retz (Ed.): ADHD and comorbid diseases. Kohlhammer, Stuttgart 2007, ISBN 978-3-17-019081-8 , p. 50 ff.
  20. ↑ H. Stegat: Instrumental Enuresistherapie . In: Behavioral Therapy Manual . 5th ed. 2005, pp. 103-109.
  21. ^ A b Gerhard W. Lauth , Friedrich Linderkamp, ​​Silvia Schneider, Udo B. Brack : Behavioral therapy with children and adolescents . BeltzPVU
  22. ↑ a b c Red List : 50.2.1.1.Desmopressin; MINIRIN (R) 60 / -120 / -240 micrograms oral lyophilisate orodispersible tablets, Rote-liste.de, accessed April 18, 2012.
  23. ↑ D. Marschall-Kehrel and a .: Structured desmopressin withdrawal improves response and treatment outcome for monosymptomatic enuretic children. In: J Urol. 2009 Oct, 182 (4 Suppl), pp. 2022-2026, PMID 19695616