الفهرس 
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Abstract
Enuresis is defined as the repeated voiding of urine into clothes or bed at br least twice a week for at least 3 consecutive months in a child who is at least br 5 yr of age. The behavior is not due exclusively to the direct physiologic effect br of a substance (e.g., a diuretic) or a general medical condition (e.g., diabetes, br spina bifida, a seizure dis-#111;-#114;-#100;-#101;-#114;). Diurnal enuresis defines wetting while awake br and nocturnal enuresis refers to voiding during sleep. Primary enuresis occurs in br children who have never been consistently dry through the night, -#119;-#104;-#101;-#114;-#101;as br secondary enuresis refers to the resumption of wetting after at least 6 months of br dryness. Monosymptomatic enuresis has no associated daytime symptoms br (urgency, frequency, daytime enuresis), and nonmonosymptomatic enuresis, br which is more common, often has at least one subtle daytime symptom. br Monosymptomatic enuresis is rarely associated with significant organic br underlying abnormalities. br Nocturnal enuresis is defined as a dis-#111;-#114;-#100;-#101;-#114; in which “an involuntary br voiding of urine during sleep, with a severity of at least twice a week, in br children aged 5 years or older, in the absence of congenital or acquired defects br of the nervous system, nocturnal enuresis occurs alone. br The aim of this study is to discuss updates in pathophysiology and br management of nocturnal enuresis in children. br Nocturnal enuresis (NE) is a common problem that can be troubling for br many children and their families. It is more common in males (3:1). br The prevalence of enuresis at age 5 yr is 7% for males and 3% for females. br At age 10 yr, it is 3% for males and 2% for females, and at age 18 yr, it is 1% br for males and extremely rare in females . br Nocturnal enuresis is a heterogenous entity, which can be caused by br one or more of several pathophysiological mechanisms , it is likely a br Multifactorial condition,. Numerous etiologic factors have been investigated, br and have been proposed. The current belief is that the condition is multifactorial br .including small functional bladder capacity, nocturnal polyuria, and most br commonly arousal dysfunction . br When enuresis is classified according to to pathophysiological condition br of the dis-#111;-#114;-#100;-#101;-#114; , patients can be classified into a type that is associated with a br greater amount of urine at night (polyuria, abundant enuresis type), a type that br is associated with not anatomically but functionally small bladder capacity br (bladder type, underdeveloped voiding function), a type associated with both br of these (mixed type), and a type that does not fall under either of these br (normal type). br Most children with primary nocturnal enuresis require an enuresisfocused br history, physical examination, and urine analysis before initiation of br treatment. Imaging and Urodynamic studies are rarely needed but required . br The best time to investigate and discuss enuresis is when the parent or br patient first raises the issue in the physician’s office. However, the optimal time br for treating enuresis should be based on the motivation of the child . br The most important aspect of the investigation is a meticulous history, br which can establish the diagnosis, lead to more precise treatment br recommendations, and minimize the need for invasive and costly investigations. br Utrasonography is non invasive rapid technique for evaluation of br nocturnal enuretic cases to detect urinary tract abnormalities and the bladder br capacity,and Urodynamic studies should be done in resistant cases specially in br old children and young adolescents to detect detrusor instability in which cases br treatment with anti cholinergic drugs for long duration br The comorbidity of behavioral problems is 2-4 times higher in children br with enuresis in all epidemiologic studies. The emotional impact of enuresis on br a child and family can be considerable. br Management is inappropriate in children under 5 years and it is usually br not needed in those aged under 7 years and in cases -#119;-#104;-#101;-#114;-#101; the child and parents br are not anxious about bedwetting . br Medications can help to control the symptoms of enuresis, but they br generally do not provide a cure. Therefore, non pharmacological methods are br often recommended in conjunction with the pharmaco-therapy, such as br acupuncture, bed-wetting alarm, positive reinforcement systems, responsibility br training and fluid restrictions. br Patients should understand that punishment or negative reinforcement is br counterproductive, both in resolving the enuresis and in protecting the child’s br self esteem. For children and families who are bothered by child’s enuresis, br targeted intervention is recommended by age 8 years at the latest . br According to The National Institute for Health and Clinical Excellence br (NICE,2010), and the Paediatric Society of New Zealand (2011). Management br of primary nocturnal enuresis may involve one or a combination of interventions br as; br I-Non pharmacological therapy br a) Education and reassurance, b) Motivational therapy br c) Behavioral interventions and d) Enuresis alarms br II- Pharmacological:- Currently the mainstays of medical therapy are br desmopressin (DDAVP), imipramine and oxybutinin (uripan). br III- Complementary and Alternative Medicine (CAM) (acupuncture) br IV-Treatment of the cause. br The timing of initiation of treatment for monosymptomatic nocturnal br enuresis varies -#102;-#114;-#111;-#109; child to child. The major determinants are whether the child br and caregivers view the enuresis as a problem and how strongly motivated they br are to participate in a treatment program. br The age at which enuresis is considered to be a ”problem” varies br depending upon the family. If both parents wet the bed until late childhood, they br may not be concerned that their seven-year-old wets the bed. In contrast, parents br may be concerned about a four-year-old who wets if he has a three-year-old br sibling who is already dry. br Once the child agrees to accept some responsibility for the treatment br program, he or she can be motivated by keeping a record of progress. br Motivational therapy is a good first-line therapy for nocturnal enuresis in br younger children (between five and seven years of age) who do not wet the bed br every night. br A bedwetting alarm is an electronic device used as a treatment option for br nocturnal enuresis. The alarm activates when the wearer urinates. Alarms come br in several different styles: wearable alarms, wireless alarms, and pad-type br alarms. While there is some variation in the styles of the alarms, they all br function similarly; each alarm has a moisture sensor component and an alarm br component. When the child first begins to urinate the sensor will detect the br moisture and trigger the alarm. Bedwetting alarms are a treatment tool designed br to teach people to respond to a full bladder by waking and using the toilet. This br alert helps begin to condition the brain to register the bladder’s need to urinate. br This conditioning of the mind and body is also known as behavior modification. br The bedwetting alarm, also referred to in the medical community as an enuresis br alarm, is categorized as D.M.E. (Durable Medical Equipment). As such, the cost br may be a reimbursable covered expense by healthcare insurance carriers when it br is prescribed by a pediatric physician, urologist, or other accepted medical br authority. br Drug therapy is not usually appropriate for children under 7 years of age; br it can be used when alternative measures have failed, preferably on a short term br basis to cover periods away -#102;-#114;-#111;-#109; home. Desmopressin and imipramin (tricyclic br antidepre-ssants) are the primary drugs used in nocturnal enuresis. br Acupuncture treatment exerts strong antienuretic effect in the patients br with primary nocturnal enuresis. It was reported that the average maximum br cystometric bladder capacity increased significantly by the acupuncture br treatment in patients with spinal cord injury.Acupuncture also has been found to br stimulate the hypothalamus and pituitary, resulting in a broad range of br physiologic actions. br Acupuncture, firstly, originating in China, now it has been used in at lea.