|Year : 2020 | Volume
| Issue : 1 | Page : 50-54
Epidemiology of nocturnal enuresis among primary school children (6–12 years) in Gharbia Governorate
Mahmoud E Abu Salem, Hewaida M El Shazly, Safa'a Badr, Faten Younis, Sherin M. Derbala
Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia Governorate, Egypt
|Date of Submission||25-Jun-2018|
|Date of Decision||29-Jul-2018|
|Date of Acceptance||31-Jul-2018|
|Date of Web Publication||25-Mar-2020|
Sherin M. Derbala
25 Syria Street, Hafez Wahby, Tanta
Source of Support: None, Conflict of Interest: None
The aim of this study was to determine the prevalence of nocturnal enuresis (NE) and identify its risk factors among primary school children (6–12 years) in Gharbia Governorate.
NE is a challenging issue, mostly seen during childhood. However, the exact prevalence is often under-reported. Large epidemiological studies suggested the prevalence rates of 15–20% among children 5 years and older.
Participants and methods
A case–control cross-sectional study was conducted during the academic year 2017–2018 in Gharbia Governorate primary schools on 510 school students aged 6–12 years. The students were chosen from two schools using multistage random sample. Student's families were asked to complete a predesigned questionnaire. Urine and stool analyses were done.
The prevalence of NE was 14.3%. The prevalence was slightly higher among boys than girls, with 14.8 and 13.9%, respectively, and it was more common among rural children than urban ones, with 19.1 and 7.5%, respectively. NE prevalence markedly decreases by increase in age. Primary enuresis more than secondary, low socioeconomic standard, low educational level of parents, and family history of NE were the contributing factors of NE among studied children. Deep sleep, constipation, and urinary tract infection were associated with NE.
Enuresis is a pediatric public health problem that is often associated with young age. It may lead to low self-esteem, some secondary psychological problems, and low school success. Consequently, it is necessary to recommended health promotion and prevention programs that are directed toward the screening, diagnosis, and management of NE among primary school students.
Keywords: bed-wetting, epidemiology, Gharbia Governorate, nocturnal enuresis, primary school students, risk factors
|How to cite this article:|
Abu Salem ME, El Shazly HM, Badr S, Younis F, Derbala SM. Epidemiology of nocturnal enuresis among primary school children (6–12 years) in Gharbia Governorate. Menoufia Med J 2020;33:50-4
|How to cite this URL:|
Abu Salem ME, El Shazly HM, Badr S, Younis F, Derbala SM. Epidemiology of nocturnal enuresis among primary school children (6–12 years) in Gharbia Governorate. Menoufia Med J [serial online] 2020 [cited 2020 Aug 15];33:50-4. Available from: http://www.mmj.eg.net/text.asp?2020/33/1/50/281271
| Introduction|| |
Enuresis or bed-wetting is a common problem in children. It means uncontrolled passage of urine by day/night/both in children aged 5 years and older, with two wetting cases per week. It is not only a source of considerable anxiety to both child and family but can also affect self-esteem, relationships with peers, and schooling. In addition, it is a considerable financial and social problem. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th ed.(DSM-IV), clinical enuresis is defined as repeated voiding of urine into bed clothes, whether involuntary or intentional. The International Children's Continence Society has divided enuresis into two major groups. Enuresis in children without any other lower urinary tract symptoms (nocturia excluded) and without a history of bladder dysfunction is classified as monosymptomatic enuresis, whereas children with enuresis with lower urinary tract symptoms are graded as nonmonosymptomatic enuresis.
Several factors have been associated with an increased risk of bed-wetting including younger age, male sex, Black race, history of urinary tract infection, and a family history of enuresis. Obesity is also a likely risk factor. However, low socioeconomic status is not consistently associated with enuresis. Rather multiple conditions affect enuresis, either causative or comorbid. They can also influence management and prognosis. Other conditions include chronic kidney disease, neurogenic bladder, anorexia or other behavioral disorders, sickle cell disease, and hyperthyroidism.
In fact bed-wetting is a distressing disorder and a great burden. This disorder has psychological, social, and financial implications for the child, parents, and family. By identifying and treating bed-wetting at an early age, it is hoped that its effect can be minimized. For the management of a child with nocturnal enuresis (NE), the most important diagnostic procedure is to identify monosymptomatic enuresis by history. Once the history has classified the child as monosymptomatic by the exclusion of pronounced urgency, frequency, or infrequent voiding, and in particular day wetting, only minimal additional diagnostic work is needed. Therefore, it is necessary to early diagnose nocturnal enuresis (NE) among school children as it is a hidden problem and should be treated as soon as possible. Otherwise, it can be a cause of many psychological consequences and poor scholastic achievements.
The aim of this thesis is to determine the prevalence of NE and identify its risk factors among primary school children (6–12 years) in Gharbia Governorate.
| Participants and Methods|| |
A case–control cross-sectional study was conducted during the academic year 2017–2018 in Gharbia Governorate primary schools on 510 school students aged 6–12 years. The study protocol was approved by the Ethical Committee of Faculty of Medicine, Menoufia University. An informed written consent was obtained from each participant's parents. The eligible participants were selected from two schools using multistage random sample. The list of schools was obtained from Gharbia Educational Administration Office. An official letter was directed to Gharbia Undersecretary of Ministry of Education to get permission for school entry. One district (Tanta) of eight ones was selected randomly. One urban primary school (Al-Shaheed Yehia Alwatan) of 74 urban schools and another rural (Al-Shaheed Moustaf Ali) of 51 rural schools were chosen randomly. One class from each grade was chosen randomly in the selected schools to obtain 409 samples.
The sample size of selected students was 409 students. Additional 116 students were added to the sample, to be a total sample size of 525 students. Of them, 15 had incomplete and nonvalid questionnaires, so the total sample size studied was 510, with response rate of 96.6%. A pilot study was done on 25 children not from the sample size, which was excluded from analysis later on. It aimed to test the validity of the questionnaire, reveal any modifications or additions needed, and explore the various obstacles that could hinder the implementation of this study. The participants were subjected to a predesigned questionnaire, including age, sex, father's and mother's education and occupation, family income, size and birth order, and family history of enuresis. The socioeconomic standard was determined according to the scoring system of modified Fahmi and El-Sherbini scale. It included the education of mother, the occupation and education of father, and the family size. The present history was collected, for example, onset of NE and frequency of urination per week. In addition, questions about symptoms of urinary system affection in the form of dysuria, urgency, dribbling, diurnal, toilet behavior, for example., urinary flow (smooth or interrupted), straining during micturition or defecation, and forcing the child to use the booty early were also examined. Besides, the age at which the child became enuretic as well as physical examination was also studied.
After diagnosing 73 students with NE and studying the remaining negative result children, a randomly selected sample of healthy students (double number of cases = 146) after sex and age matching with the patients was chosen as a control group. They were subjected to urine and stool analyses and compared with the positive participants. Complete urine analysis was done to detect urinary tract infection, and stool analysis was done to detect parasitic infestation.
Sample size calculation
The sample size was calculated using Raosoft program depending on the total number of primary school students in Gharbia Governorate, which was 387 033 students during the academic year 2017–2018. The past review of literature, such as the study by Abu Salem et al., shows that the prevalence of NE among primary school children is 15.4% in Damietta Governorate. The sample size has been calculated at power 80% and 95% confidence interval. Consequently, the calculated sample size was 409 students. To overcome attrition, 116 students were added to the sample size, giving a final sample size of 525 students. Overall, 15 questionnaires were incomplete, resulting in a response rate of 96.9% giving a final sample of 510 students as participants in this work.
Statistical presentation and analysis of this study were conducted by using SPSS, version 23 (IBM Corp., Armonk, New York, USA). Data was expressed as mean, SD, frequency, and percentage. The Student's t-test was used for comparison in quantitative data. χ2-test was used for comparison in qualitative data. However, Z-test was used to compare between two proportions. P value less than 0.05 was considered statistically significant.
| Results|| |
The total number of students was 510. The prevalence of NE among studied primary school students was 14.3%. Sex did not have a significant effect on the prevalence of enuresis, as there was no great difference among boys and girls. However, the NE was more common among boys than girls, with 14.8 and 13.9%, respectively. In contrast, on comparison between prevalence of NE and residence in this study, it showed that the NE was more common among students living in rural area (19.1%) than those living in urban areas (7.5%) [Table 1].
This study also showed that 61.6% of enuretic students had mother and/or father who had a history of NE, whereas 6.8% had a sibling who had a history of enuresis. No family history was detected in 31.5% of cases [Figure 1]. In addition, the study showed that 39.7% of enuretic students had time of onset of training after more than 6 months of control. Primary NE was also more common than secondary enuresis, with 60.3 and 39.7%, respectively [Table 2]. Overall, 49.3% of enuretic children revealed no associated factor with enuresis. Besides, 13.7% of enuretic children had constipation, whereas only 5.4% of nonenuretic children had constipation. Moreover, 37% of enuretic children experienced deep sleep compared with 4.1% of nonenuretic children, and birth order was not a risk factor for NE among studied enuretic children [Table 3]. Familial troubles such as parent divorce were considered a risk factor with NE (P < 0.05) [Table 4]. There was a significant relation between nightmares and NE. Excessive intake of drinks was a risk factor for NE [Table 5].
|Table 2: Prevalence of nocturnal enuresis regarding time of onset and type of enuresis|
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|Table 3: Comparison between enuretic patients and nonenuretic children regarding the history of chronic diseases|
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|Table 4: Comparison between enuretic cases and control group regarding psychological troubles|
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|Table 5: Comparison between enuretic cases and control group regarding factors that may affect nocturnal enuresis|
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| Discussion|| |
The main finding of this study was the prevalence of NE in 14.3% of the children. This prevalence was close to many studies carried out in different Egyptian governorates. For example, in Domietta Governorate, the prevalence was 15.4% as stated by Abu Salem et al., in Benha Governorate was 15.5% as stated by Ashraf et al., and in Al-Sharkia Governorate was 16.37% as stated by El-Sharkawy et al.. Moreover, our results are similar to a study carried out in Turkey by Ali et al., where the prevalence was 14.9%. In a research study performed in Iran, it was reported that the prevalence of NE among primary school children was 17.5%. In other world areas, the prevalence rates of enuresis differed across countries, ranging from 4.3% in Chinese children to 52% in Jamaican primary school children. Such difference among countries may arise from factors such as cultural, racial, environmental, and socioeconomic conditions. As for the prevalence of NE and sex, our findings show that sex did not have a significant effect on the prevalence of enuresis. In fact, there was no great difference among boys and girls. However, the NE was more common among boys than girls, with 14.8 and 13.9%, respectively. This finding agrees with a study carried out in India, which concluded that NE was more common in males than in females.
In contrast, these results did not agree with Abu Salem et al. who reported that NE was more common in girls than boys, where NE was 17.4% in girls. As for the prevalence of NE and residence, this study showed that the NE was more prevalent in students living in a rural area (19.1%) than those living in urban areas (7.5%). Such results are in parallel with another Egyptian study held in Domietta which reported that NE students living in a rural area had higher prevalence (17.3%) than those living in urban areas (13.2%). These results did not agree with another Egyptian study in the New Valley Governorate, Al-Kharga district, which showed that NE was statistically significantly higher in urban than rural community. This study found that 39.7% of enuretic cases occurred after more than 6 months of control and primary NE was more common than secondary enuresis (60.3 and 39.7%, respectively). This result agreed with Abu Salem et al. who reported that primary enuresis represented 68.0% and secondary enuresis was 32.0%. Furthermore; it is also similar to the study conducted by Katayoun et al. who revealed that 5.2 and 2.8% of the children with NE had primary and secondary enuresis, respectively. These results differ from those revealed in a study conducted in Ismailia city, which showed that 46.8% have primary enuresis and that 53.2% of those children have secondary.
This study showed that 61.6% of enuretic cases had mother and/or father with a history of NE, 6.8% has sibling with a history of enuresis, and no family history was seen in 31.5% of cases. These results confirm those of Necmettin et al. who reported that a positive family history was seen in 64.8% of the enuretic children. This study also confirms the finding of Neveus et al. who concluded that genetics probably affect the wetting. The risk of a child being affected is 43% particularly if one parent had NE and 77% if both parents had the same history. This study result is similar to Touchette et al. who report that 75% of children with NE have a first-degree relative who had enuresis.
However, this study concludes that 49.3% of enuretic children reveal no associated factor with enuresis, and 50.7% revealed presence of associated factors with enuresis. For example, the results show that constipation was often associated with NE. The results also reveal that 13.7% of enuretic children had constipation, whereas only 5.4% of nonenuretic children had constipation. In addition, the enuretic children were afraid of defecation. Indeed, pain may be associated with constipation. This result is confirmed by Inan et al. who found that constipation was more frequent in enuretic children. These results were supported by another study by Necmettin et al. who revealed that constipation was seen in 14.9% of enuretic and 9.6% of nonenuretic individuals. Other associated factors in our study were deep sleep which was found in 37% of enuretic children, compared with 4.1% in nonenuretic children. These results support those of Katayoun et al. and Abu Salem et al. who reported that sleep problems were found in 32% of cases. Furthermore, the results clarified that birth order was not a risk factor in NE among studied enuretic children. This finding confirms the results of Ali et al. who reported that birth order was not a significant determinant of NE. Kanaheswari also showed that birth order was not associated with enuresis. In contrast, our results disagree with Katayoun et al. who stated that the prevalence of NE in the preschool children was 2.3 times higher than the rate in the primary school children.
| Conclusion|| |
NE is common disorder in children. Consequently, designing monitoring, and evaluating plans for early detection and diagnosis of NE are very important.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]