|Year : 2016 | Volume
| Issue : 4 | Page : 1025-1032
Nocturnal enuresis among primary school children in Zarka district, Damietta governorate, Egypt
Mahmoud E Abu Salem, Hewaida M El-Shazly, Al-Zahraa A Hassan MBBCh
Public Health and Community Medicine, Faculty of Medicine – Menoufia University, Shebin Elkom, Egypt
|Date of Submission||11-Aug-2015|
|Date of Acceptance||20-Sep-2015|
|Date of Web Publication||21-Mar-2017|
Al-Zahraa A Hassan
Public Health and Community Medicine, Faculty of Medicine . Menoufia University Shebin Elkom, 32511
Source of Support: None, Conflict of Interest: None
The objective of this study was to determine the prevalence and risk factors of nocturnal enuresis (NE) among primary school children in Zarka district, Damietta governorate, Egypt.
NE is a common medical and psychological problem worldwide among school-age children.
Participants and methods
The study was a nested case–control study that was conducted during the academic year 2013/2014 on 325 students aged 6–12 years in Damietta governorate. A questionnaire was designed and was filled in by the parents of randomly selected children attending two different primary schools. A comparative study was conducted in which the children having NE (n = 50) were considered as the case group, and a randomly selected group of nonenuretics with matched age, sex, and socioeconomic criteria (n = 100) was considered as the control group.
The prevalence of NE was 15.4%. Logistic regression analysis showed that NE was associated with stressful family events and a history of urinary tract infection. In 60% of the enuretic children living in rural areas, working mothers were found to have less enuretic children than housewives. NE was significantly associated with low socioeconomic status of families. NE was associated with a positive family history: the history of enuresis in the father was 4%, the history of enuresis in the mother was 6%, and in brothers or sisters it was 20%. In addition, intake of diuretic drinks has a significant role. In addition, the analysis of data shows a positive association of lack of comfortable sleep.
The prevalence of NE in primary school children in Damietta governorate constitutes about 15.4%. The family history was seen to have had a markedly significant impact on the occurrence of NE in the studied children. Risk factors include living in rural area, nonworking mothers, psychological troubles, and intake of diuretic drinks.
Keywords: children, nocturnal enuresis, prevalence, risk factors
|How to cite this article:|
Abu Salem ME, El-Shazly HM, Hassan AZA. Nocturnal enuresis among primary school children in Zarka district, Damietta governorate, Egypt. Menoufia Med J 2016;29:1025-32
|How to cite this URL:|
Abu Salem ME, El-Shazly HM, Hassan AZA. Nocturnal enuresis among primary school children in Zarka district, Damietta governorate, Egypt. Menoufia Med J [serial online] 2016 [cited 2020 Apr 6];29:1025-32. Available from: http://www.mmj.eg.net/text.asp?2016/29/4/1025/202516
| Introduction|| |
Nocturnal enuresis (NE) can be defined as an involuntary passage of urine during sleep beyond the age of 5 years . It can be further categorized into primary, which is bedwetting in a child who had never been dry, and secondary, when it occurs after a continuous dry period more than 6 months . The etiology of enuresis is not completely understood. Several pathophysiological mechanisms have been proposed, including bladder dysfunction, small functional bladder capacity, abnormal vasopressin levels, nocturnal polyuria, and abnormal sleep patterns . Chronic renal failure, constipation, diabetes insipidus, diabetes mellitus, hyperthyroidism, pinworm infection, psychological stress, seizure disorders, sickle cell disease, and urinary tract infections were recorded in secondary enuresis . There is an increasing evidence to support the fact that the efficacy of many, if not all, enuresis treatment modalities is dependent upon the underlying pathophysiological mechanisms. Therefore, the use of diagnostic tools is essential to target the treatment modality directly towards the pathophysiological mechanism . NE is crucial to be diagnosed and treated as soon as possible, as it can result in many psychological consequences such as low self-esteem, shame, and embarrassment, which affect how they interact with their friends and families . NE may cause secondary emotional and social problems in children who continue to wet their beds. Although enuretic children seem to have many accompanying psychological problems, it must be investigated whether these problems are the results or etiological factors of enuresis .
The main objective of the study was health promotion of school children with better scholastic achievements.
The objective of this study was to estimate the prevalence of NE among school children in Damietta governorate of Egypt and to determine the associated risk factors.
Type and timing of the study
The study was a community-based cross-sectional comparative study that was conducted during the academic year 2013/2014.
Site of the study
Using a multistage stratified random sampling technique, the study was conducted in two schools, one school from Zarka city and another school from El-Salam village, representing the urban and rural areas of Damietta governorate, respectively.
The sample size was calculated (at 80% power of study, 95% confidence level, and 5% level of significance) as 325, which was increased to 390 to overcome any refusal, dropping out, or invalid response. The positive cases were compared with randomly selected controls (double number of cases). The objectives of the study were explained to the local educational authorities to get a permission to carry out the study. Students were selected by a multistage random sampling technique as follows:
- The first stage:
One district (Al Zarka district) out of four was chosen using simple random sampling technique.
- The second stage:
One school out of five in an urban area and one out of 10 in a rural area were chosen using simple random sampling technique
- The third stage:
One class from each grade with a total of six classes from each school were chosen randomly; hence, the total number of classes was 12, with a total of 485 students, of whom 433 were regularly attending school. Of those 433 students, the response rate was 90.1% (390 students).
After exclusion of 45 invalid papers and 20 as a pilot study, the total studied sample became 325 students (173 students in rural school and 152 students in urban school).
Tools of the study
A fully designed questionnaire was used for screening of enuretic children depending on the ICD-10 definition of NE, which is at least one wet night per month for 3 consecutive months, and for collection of information about the following:
- Personal data such as age, sex, residence, parental education, and socioeconomic level of the child, which was calculated using the socioeconomic scoring system prepared by Abd Al-Twab 
- Frequency of wetting of the affected children, constipation, encopresis, urinary tract infections, previous treatment modalities, family history of wetting, parental concern toward their enuretic child, and whether the child was suffering from depression, isolation, nervousness, and violence ,
- Urine analysis and stool analysis of the enuretic children and the selected control group to detect risk factors such as urinary tract infection and parasitic infestation.
The questionnaire was in simple Arabic language, and it was distributed to all selected students within sealed envelopes to prevent embarrassment of the children. They were instructed by the school teachers to take it home to their parents.
A brief information leaflet was attached to the questionnaire informing the parents about the voluntary nature of the study to get their consent. The students were instructed to help their parents to fill the questionnaire if needed. The teachers collected the questionnaires from children after 1 week. Those not wishing to participate were recorded as 'not responding'.
Out of 433 questionnaires distributed, 390 (90.1%) were collected, and of these 325 were eligible to be evaluated. A comparative study was conducted in which the enuretic children (n = 50) were considered as a case group; however, a randomly selected group of nonenuretic children matched for age, sex, and socioeconomic criteria (n = 100) was considered the control group.
It was carried out using SPSS statistical program (Statistical Package for Social Sciences, Chicago, USA) version 14.
χ2-Test was used to determine the significant predictive factors for NE at 5% level of significance, and logistic regression analysis was applied to estimate its odds ratio.
| Results|| |
The high response rate (90.1%) was probably because of the distribution method of the questionnaires – that is, by the way of teachers. NE is a common health problem among Egyptian children, as in many other populations .
This study included 325 children in the age group of 6–12 years; among this group, there were 50 children suffering from NE: 15.4% were enuretic and 84.5% were nonenuretic ([Table 1]).
All the enuretic children (n = 50) were compared with a randomly selected group of nonenuretics, matched for age, sex, and socioeconomic criteria (n = 100), which was considered as the control group. Primary NE represents 68% among cases, whereas secondary NE represents 32% ([Table 1]).
As regards age, it ranged from 6 to 12 years, and there was no significant difference between case and control groups ([Table 2]).
|Table 2 Relationship between nocturnal enuresis and sociodemographic characters of the studied group|
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As regards sex, it did not have a significant effect on the prevalence of enuresis ([Table 2]); it was found that NE was significantly more common with rural inhabitation. Among the enuretic children, 60% were living in rural areas, whereas 40% were living in urban areas ([Table 2]).
As regards parental education, NE was related to low parental education level ([Table 2]); this study showed that working mothers were found to have less enuretic children than housewives ([Table 2]).
As regards birth order, it did not have a significant effect on the prevalence of enuresis.
However, among the enuretic children, it is noticed that NE is common in the second and the third child, as the percentages were 38 and 30%, respectively.
It was found that low socioeconomic status of the families was associated with a higher prevalence of NE ([Table 2]).
The study shows that the presence of stressful events (e.g., divorce, death of one of parents … ) is more common among enuretic children; in particular, familial troubles, new house, and scholastic problems had a significant association with NE, and this was considered an effective social and psychological issue affecting the epidemiology of NE ([Table 3]).
|Table 3 Psychological troubles associated with nocturnal enuresis among the studied group|
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It was noticed that there are some risk factors that have a significant effect on the impact of NE, such as urinary tract infections, intake of diuretic drinks, and lack of a comfortable sleep, whereas parents' attitude toward the enuretic children was not a significant factor ([Table 4]).
The study shows the presence of enuresis among families of enuretic cases; no history of enuresis was 70%, history of enuresis in the father was 4%, history of enuresis in the mother was 6%, and in brothers or sisters it was 20% ([Table 5]).
[Figure 1] shows that urinary tract infection plays a significant role in NE.
[Figure 2] shows that oxiuriasis and amoebiasis are not associated with NE.
| Discussion|| |
NE among school children is a hidden problem that is crucial to be diagnosed and treated as soon as possible, as it can result in many psychological consequences and poor scholastic achievements .
In our study, which included 325 primary school students whose ages ranged from 6 to 12 years, there were 50 children suffering from NE, with a percentage of 15.4%. This result is in agreement with a previous Egyptian study that reported that the prevalence of NE among primary school children in Banha city was 15.7% . In a study performed in Menoufia among school children, the prevalence of NE was 14.7% . It differs across the countries, ranging from 4.3% in Chinese children , 12.9% in France , 15% in Saudi Arabia , and 52% in Jamaican primary school children . These differences might be due to the sociocultural, attitude, and behavioral variations among parents.
Primary NE represents the majority among cases – that is, 68% – whereas secondary NE represents 32%, and these results were parallel with another study in Turkey, which reported that NE was primary in 62.8% and secondary in 37.2% of the cases .
Our study showed that sex did not have a significant effect on the prevalence of enuresis; such results were parallel with the Egyptian study in Banha  and in Menoufia Governorate . Both studies approved that sex did not have a significant effect on the prevalence of enuresis, although male predominance was detected in a study performed in Turkey , and other countries ,. The general principle about sex in a Malaysian study showed that enuresis was more common in boys in the early years but equal in the latter years .
Among enuretic children, 60% were living in rural areas, whereas 40% were living in urban areas, and this is parallel with the Egyptian study carried out in Menoufia governorate, which reported that enuresis was significantly more common with rural inhabitation that might be related to poor sanitation, lower educational level of parents, and low monthly income ; a study conducted in Taiwan stated that the prevalence of enuresis in the urban area did not show a significant difference from that of rural area –6.2 versus 6.9%, respectively .
The present study demonstrated that NE is more common among low social class (54%) and among offspring of nonworking mothers (64%), and this is in parallel with another Egyptian study in Banha , which reported that NE is more common among low social class (61.4%) and among offspring of nonworking mothers (57.1%), with a significant difference (P < 0.05), and such results correlated with work carried out by Emad et al. , who mentioned that the prevalence of enuresis is significantly lower among children with high socioeconomic status (11.7%) than those of low socioeconomic status (32.4%).
Such results may be because of low awareness about the problem in low social class and seeking medical treatment late.
In this study, working mothers were found to have less enuretic children than housewives, and this is in agreement with the Egyptian studies in both Banha and Menoufia, which reported that enuresis is more common among offspring of nonworking mothers ,.
Such results were parallel with another Egyptian study held in Ismailia city, which suggests that enuresis could occur commonly (P < 0.01) in children of nonworking mothers (e.g., housewives). This finding is of some interest because it is possible that working mothers encourage early toilet training or seek treatment for such a condition at an earlier age . On the other hand, there is a research performed in Iran that reported that working mothers were found to have more enuretic children than housewives .
The analysis of the present study shows that some familial stressful events (divorce, death of family member,…) were significantly associated with enuretic children (P < 0.05), and this is considered an effective social and psychological issue affecting the epidemiology of NE. These results are supported by the Egyptian study in Banha , which reported that 35.7% of enuretic children suffer from family troubles. These results are supported by the study of Carman et al. , who mentioned that there is a close relationship between disturbed family environment and the frequency of enuresis, and this prevalence is 29.4% among disturbed families. On the other hand, these results are not in agreement with a study in Assiut city conducted by Emad et al. , who found that a nonsignificant difference was present between the enuretics and nonenuretics regardless of whether both parents are living together or not. In the Egyptian study conducted in Ismailia city, carried out by El-Defrawi et al. , it was revealed that enuretic children are at a greater risk for having problems within the family, with siblings (P < 0.05), and at school with school teachers (P < 0.01) than nonenuretic children. This could be explained by the fact that enuresis being a developmental disorder might be associated with a high risk of having other developmental, behavioral, and psychiatric disorders. This finding, however, is of some interest because a large number of enuretic children are seen in child psychiatry clinics in public and private practices outside and within the school health systems [22–24].
In our study, we focused on factors associated with NE; we found that intake of diuretic drinks is a risk factor for NE with a significant difference (P < 0.05), and these results are supported by another study that was conducted by Yousef et al. , who reported that tea-drinking habit in enuretic children was of significance.
Our results clarified that urinary tract infection is a common problem among NE children, and this infection was manifested as dribbling, frequency, burning micturition, and urgency; our results were strengthened by the results of urine analysis, which revealed urinary tract infection, and by the study conducted by Loening , who found that urinary tract infection is a common cause of NE and that it is associated with 11% of NE children.
In our study, we found a positive association of heavy sleep, snoring, and lack of comfortable sleep with NE, which was consistent with Cederblad and Rahim , who found that two-third of the school-age enuretics used to sleep very heavily. Kalo and Bella  found that deep sleep was significantly more among enuretic children compared with nonenuretics.
There is ongoing debate regarding the relationship between obstructive sleep apnea syndrome (OSAS) and NE .
Although NE has been reported in 8–47% of children with OSAS caused by adenotonsillar hypertrophy , the prevalence of OSAS in children with NE is unknown.
In addition, OSAS is a risk factor for several cardiovascular conditions, including arterial hypertension, congestive heart failure, coronary arterial disease, and cardiac arrhythmias .
The present study revealed that 30% of cases reported that NE was a problem in their families, 4% reported that their father had a history of enuresis, 6% reported that their mother had a positive history of enuresis, whereas 20% reported that their brother/sister had a positive history of enuresis.
Our results were supported by the Egyptian study carried out in Banha city; it is mentioned that 22.8% of cases reported that NE was a problem in their families, 1.4% reported that their father had a history of enuresis, 4.3% reported that their mother had a positive history of enuresis, whereas 17.1% reported that their brother/sister had a positive history of enuresis .
Furthermore, previous studies reported the prevalence of family history in enuretic children as 22–48%. Twin studies also support a genetic basis for enuresis .
In our study, it was found that oxyuriasis is not associated with enuresis, and this is in agreement with another study carried out by Safarinejad ; on the other hand, Ghotbi and Kheirabadi  reported a significant relationship between anal itching and NE, which may suggest an association between enuresis and oxyuriasis.
Our results clarified that birth order was a significant determinant of NE, as it is common in the second and the third child as the percentages were 38 and 30%, respectively. Our results were supported also by the Egyptian study carried out in Menoufia , which mentioned that birth order plays a significant role in the epidemiology of NE; in addition, in a study in England and Scotland, it was found that primary NE was more likely in a child who was not the first born in the family, which may be because of a sense of neglect .
On the other hand, our results disagree with the Malaysian study , and another study in Yemen reported that birth order had no relation with NE .
| Conclusion|| |
NE is 15.4% among the selected children, and it was more frequent in rural areas than in urban areas and more common in low socioeconomic levels than high levels and among nonworking mothers.
The presence of family troubles, as well as family history of enuresis, has a significant effect among enuretic children.
Primary enuresis is more frequent than secondary enuresis.
| Recommendation|| |
At the end, we can recommend that great efforts at all levels regarding NE among school children should be made including preventive, etiological determination, psychological, and behavioral exploration and management. The misconceptions among parents require health education intervention. Therefore, the family physician is in a prime position to screen, detect early, and treat the affected school children by conducting health education programs.
The enuretic children and their parents should be provided pediatrician support when needed.
The author thanks the parents of the school children for their collaboration. In addition, he also thanks the ministry of education for their support and help in this research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: diagnostic criteria for research
. Geneva: WHO; 1993.
Ozden C, Altinova S, Oguzulgen I, Urgancioglu G, Memis A. Prevalence and associated factors of enuresis in Turkish children. Int Braz J Urol 2007; 33
Hjalmas K. Nocturnal enuresis: basic facts and new horizons. Eur Urol 1998; 33
Hagglof B, Andren O, Bergstrom E, Marklund L, Wendelius M. Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scand J Urol Nephrol 1997; 183
Abd Al-Twab A Family socio-economic status scale, Revised edition [thesis in educational basics]. Egypt: Faculty of Education, Assiut University; 2004
Holmbeck GN, Thill AW, Bachanas P, Garber J, Miller KB, Abad M, et al.
Evidence-based assessment in pediatric psychology: measures of psychosocial adjustment and psychopathology. J Pediatr Psychol 2008; 33:958-80.
Achenbach T. Manual for the Teacher's Report Form Department of Psychiatry
. Burlington: University of Vermont; 1991b.
Al-Kot M, Deeb M. Nocturnal enuresis among school children in Menoufia Governorate: a hidden problem. J Am Sci 2012; 8
Mohammed AH, Saleh AG, Al-Zoheiry I. Frequency of bedwetting among primary school children in Benha city, Egypt. Egypt J Med Hum Genet 2014; 15
Liu X, Sun Z, Uchiyama M, Li Y, Okawa M. Attaining nocturnal urinary control, nocturnal enuresis, and behavioral problems in Chinese children aged 6 through 16 years. J Am Acad Child Adolesc Psychiatry 2000; 39
Kalo B, Bella H. Prevalence and associated factors among primary school children in Saudi Arabia. Acta Pediatr 1996; 85
Readett R, Bamigbade T, Serjeant R. Nocturnal enuresis in normal Jamaican children, implications for therapy. West Indian Med J 1991; 40
Oge O, Kocak I, Gemalmaz H. Enuresis prevalence and associated factors among Turkish children. Turk J Pediatr 2001; 43
Ouedraogo A, Kere M, Ouedraogo T, Jesu F. Epidemiology of enuresis in children and adolescents aged 5-16 years in Ouagadougou. Arch Pediat 1997; 4
Spee-van D, Wekke J, Hirasing R, Meulmeester J, Radder J. Childhood nocturnal enuresis in The Netherlands. Urology 1998; 51
Kanaheswari Y. Epidemiology of childhood nocturnal enuresis in Malaysia. J Paediatr Child Health 2003; 39
Tai HL, Chang YJ, Chang SC, Chen GD, Chang CP, Chou MC. et al.
The epidemiology and factors associated with nocturnal enuresis and its severity in primary school children in Taiwan. Acta Paediatr 2007; 96
Emad M, Hammad O, Sabra M. Prevalence and risk factors of nocturnal enuresis in a rural area of Assiut Governorate. Alex J Pediatr 2005; 19
El-Defrawi MH, Sobhy SA, El-Tony A. Epidemiological study of enuresis in children aged 6-12 years in Ismailia. Egypt J Psychiatry 1994; 17
M Hashem, A Morteza, K Mohammad, N
Ahmad-Ali. Prevalence of nocturnal enuresis in school aged children, the role of personal and parents related socio-economic and educational factors. Iran J Pediatr 2013; 23
Carman KB, Ceran O, Kaya C, Nuhoglu C, Karaman MI. Nocturnal enuresis different socioeconomic environments. Urol Int 2008; 80
Shaffer D, Gardner A, Hedge B. A critical examination of classification systems of nocturnal enuresis. In: editors. SB. Guze, FJ Earb, JE Barrett. Childhood psychopathology and development
. New York: Raven; 1983: 75-101.
Shaffer D, Gardner A, Hedge B. Behavior and bladder disturbance in enuretic children. Dev Med Child Neurol 1984; 26
Shaffer D. Enuresis. In: editors. M Rutter, L Hersov. Child psyhciatry, modern approaches
ed. Oxford: Blackwell; 1985. p. 35-70.
Yousef KA, Basaleem HO, bin Yahiya MT. Epidemiology of nocturnal enuresis in basic school children in Aden Governorate, Yemen. Saudi J Kidney Dis Transpl 2011; 22
Loening BV. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics 1997;100
Cederblad M, Rahim S. Epidemiology of nocturnal enuresis in a part of Khartoum, Sudan. II. The intensive study. Acta Paediatr Scand 1986; 75
Kovacevic L, Jurewicz M, Dabaja A, Thomas R, Diaz M, Madgy D, Lakshmanan Y. Enuretic children with obstructive sleep apnea syndrome: should they see otolaryngology first?. J Pediatr Urol 2012; xx
Brooks LJ, Topol H. Enuresis in children with sleep apnea. J Pediatr 2003; 142
Gazareena SS, Abd-El Attya EA, Dalaa AG, Mohamed MH. Predictors of cardiovascular risks in obstructive sleep apnea syndrome. Menoufia Med J 2014; 27
MR Safarinejad. Prevalence of nocturnal enuresis, risk factors, associated familial factors and urinary pathology among school children in Iran. J Pediatr Urol 2007; 3
Ghotbi, G Kheirabadi. Prevalence of nocturia and its associated factors in primary school children in Sanandaj in 2002. J Kurdistan Univ Med Sci 2001; 5
Rona R, Li L, Chinn S. Determinants of nocturnal enuresis in England and Scotland in the 90s. Dev Med Child Neurol 1997; 39
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]