"Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has."

Margaret Mead
Original article
peer-reviewed

Prevalence of Nocturnal Enuresis among Saudi Children Population



Abstract

Background

Nocturnal enuresis (NE) is the involuntary urination that occurs while asleep after an age when bladder control at night is expected. It has a global incidence of 1.4%-28% among 6-12 years old children. The aim of this study is to show the prevalence, risk factors, types of provided treatment of enuresis among studied children in Kingdom of Saudi Arabia (KSA).

Methods

A cross-sectional descriptive study was carried out among Saudi children, 3-12 years of age, from different cities in Saudi Arabia, during the period from 20 October to 20 November 2019. Data was collected by using a pre-designed questionnaire that was distributed online and included questions designed to fulfill the study objectives.

Results

This study reported that 31.2% of Saudi children of the chosen ages are suffered from enuresis, the majority occurred at day and night by 55.1% while 43.9% occurred only at night. Participants described types of provided treatment as follows: behavioral modification was the most commonly used by 31.6% followed by pharmacological intervention (29.6%), bed-wetting alarm (6.8%), exercises to strengthen the bladder muscles (6.2%) and surgical intervention reported by 1.5% only. It was found that the improvement of enuresis on treatment occurred in 43.6% of cases. There was a significant reduction of the prevalence of NE with age (peak is 63.6% in 5-7 years old) but no significant correlation was found with gender (p = 0.104). However, there was a significant correlation with parent having history of NE (p = 0.001).

Conclusion

The study reported that 31.2% of children found to have nocturnal enuresis; 43.9% of those had nocturnal enuresis alone. There were no significant correlations between nocturnal enuresis and child gender while it significantly correlated with child’s age and having a family history of NE. Behavioral modification therapy was the most commonly provided treatment followed by pharmacological intervention; improvement occurred in less than half of the cases with treatment.

Introduction

Nocturnal enuresis (NE) is the involuntary urination that occurs while asleep after an age when bladder control at night is expected (Involuntary urination that happens during the day is known as diurnal enuresis.) [1]. Nocturnal enuresis is a common problem in children and teenagers. NE is the second most common disorder affecting children 6-14 years of age after allergic disorders [2]. The global incidence of enuresis in children 6-12 years of age was shown to be 15%-25% in one study [3]. While a study in Egypt showed an incidence of 18% among children 9 ± 2 years old [4].

Enuresis may be classified into primary and secondary forms. Primary enuresis is when a child >5 years of age has never achieved a period of complete dryness for six or more months in a row [5]. While secondary enuresis is a condition that develops at least six months or several years after a child has achieved a period of complete dryness.

There are a variety of proposed causes of NE including: low bladder capacity, insufficient antidiuretic hormone production at night, familial/genetic causes, upper airway obstructions or less often structural problems in the urinary tract or nervous system [6]. Other causes include a variety of development, diabetes insipidus, urinary tract infections, stressful circumstances in school or family [7].

Nocturnal enuresis may lead to low self-esteem, a sense of failure, chronic stress and it may affect the child’s social life. It can trigger a range of behavioral, psychological and social problems. Therefore, it is important to identify children at risk and perform therapeutic measures [8].

Nocturnal enuresis is known to have multiple comorbidities which raises the importance of recognizing it and looking for associated symptomatology. Those comorbidities include neuropsychiatric problems like intellectual disability, attention deficit hyperactivity disorder (ADHD), psychological disorders and low self-esteem. Urinary tract infections, obstructive sleep apnea, diabetes, and low hormones as ADH are other disorders known to be associated with NE [3,9].

This study aims to find the prevalence of nocturnal enuresis within children in Saudi Arabia, its risk factors and provided management modalities of enuresis among 3-12-year-old children in different cities in KSA.

Materials & Methods

Participants and methods

A cross-sectional descriptive study was carried out among 2148 Saudi children aged 3-12 years from different Saudi provinces, which represent different localities and cultures of the kingdom. It was conducted during the period from 20 October to 20 November 2019. The sample size of 2148 was calculated according to the sample size using the equation of n = z2p (1-p)/e(n = sample size, z = level of confidence according to the standard normal distribution, p = estimated proportion of the population that presents the characteristic, and e = tolerated margin of error). A convenient sampling technique was followed.

Data collection

Data was collected using a predesigned online questionnaire distributed to parents/caregivers and included questions designed to fulfill the study objectives.

The questionnaire included questions about the following main items:

· Socio-demographic data of the participants (age, gender, and birth order of the child),

· The personal knowledge of the respondents about nocturnal enuresis and its causes,

· Enuresis-related characteristics like time, relation to sleeping, frequency per week, an improvement in decreasing fluid intake before sleeping, and others,

· Risk factor like a family history of NE in parents or siblings, chronic diseases, anemia, delayed milestones, and others,

· Management modalities used for children who have NE.

Ethical considerations

The questionnaire has a brief introduction explaining its aim and purpose and informing participants that participation is entirely voluntary. No names were recorded in the surveys, neither date of birth nor address has been collected. All answers were kept confidential and safe.

Statistical analysis

Data were analyzed using Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY). Descriptive statistics were used for the prevalence and quantitative variables. Risk factors were determined using the X2 test (x = sample size mean). P-value of less than 0.05 was considered statistically significant.

Results

The questionnaire was distributed online through social media. Two thousand one hundred and forty-eight (2148) responses where received and analyzed. This study identified a prevalence of enuresis of 31.2%.

Most children (59.6%) were 5-7 years of age, 58.2% of the sample were males, and 31.4% of studied children were the first child (Table 1). The majority (61.3%) of respondents knew about nocturnal enuresis, and 34.2% of them believed they know its causes. Nineteen percent identified causes of nocturnal enuresis as weakness in the muscles of the lower urinary tract, 9.1% as problems or damage of the urinary tract or nerves that control the urinary system, 8.0% as psychological problems, and 2.8% as urinary tract infection. About a quarter (25.7%) of participants had at least one other child suffering from nocturnal enuresis.

  Frequency Percent
Child age (in years)    
3-5 556 25.9
5-7 1280 59.6
7-10 216 10.1
>10 94 4.4
Child sex    
Female 898 41.8
Male 1248 58.2
Birth order of the child    
1 674 31.4
2 416 19.4
3 340 15.8
4-5 384 17.9
>5 332 15.5
Participants know about nocturnal enuresis    
No 832 38.7
Yes 1316 61.3
Participants know about its causes    
No 1414 65.8
Yes 734 34.2
Identified causes of nocturnal enuresis (by participants)    
Weakness in the muscles of the lower urinary tract 408 18.9
Problems or damage of the urinary tract or nerves that control the urinary system 196 9.1
Psychological problems 172 8.0
Urinary tract infections 60 2.8
Hereditary 54 2.5
Anemia 12 .6
Irritability 18 .8
Pregnancy and birth-related causes 8 .4
Having a child suffering from nocturnal enuresis    
No 1478 68.8
Yes 670 31.2

Table 2 shows nocturnal enuresis-related characteristics among the studied sample. More than 40% of the children had enuresis at night only, while 55.1% had it during day and night although 78.8% of children improved on decreasing fluid intake before sleeping within 5-7 weeks. The problem caused embarrassment and social shame for 94.3% of studied children, and 76.4% sought medical advice. Of those 29.6% received pharmacological treatment, 31.6% behavioral modification, 6.8% bedwetting alarm, 6.2% by exercise, and only 1.5% had surgery.

Variable Frequency Percentage
Time of enuresis    
At night only 294 43.9
Day and night 376 55.1
Improvement of decreasing fluids intake before sleeping 344 51.3
Frequency per week    
1-2 80 11.9
3-4 102 15.2
5-7 528 78.8
Mother keen to wake the child at night to urinate 610 91.0
The problem causes embarrassment and social shame to the child 632 94.3
Seeking medical advice 512 76.4
Type of provided treatment    
Pharmacological treatment 198 29.6
Surgery 10 1.5
Exercises to strengthen the bladder muscles 42 6.2
Bedwetting alarm 46 6.8
Behavioral modification 212 31.6
Improvement of nocturnal enuresis on different types of treatment 262 43.6

This study has shown significant relationship between enuresis and child’s age (P = 0.05) and gestational age (in months) at birth (P = 0.013), type of delivery, hospital admission after delivery, sibling suffering from the same condition, birth order of the child, parents’ history of NE, diabetes, urinary tract infection, psychological problems and delayed milestones (P < 0.05) (Table 3). While there were no significant correlations between nocturnal enuresis and child gender (P = 0.104).

Variables Responses Nocturnal enuresis Total (N = 2148) P value
Yes (n = 670) No (n = 1478)
Child age (in years) 3-5 150 408 558 0.05
22.4% 27.6% 26.0%
5-7 426 854 1280
63.6% 57.8% 59.6%
7-10 64 152 216
9.6% 10.3% 10.1%
>10 30 64 94
4.5% 4.3% 4.4%
Sex Female 300 598 898 0.104
44.8% 40.5% 41.8%
Male 370 880 1250
55.2% 59.5% 58.2%
Gestational age (in months) 9 612 1412 2024 0.013
91.3% 95.5% 94.2%
8 32 24 56
4.8% 1.6% 2.6%
7 18 20 38
2.7% 1.4% 1.8%
<7 8 22 30
1.2% 1.5% 1.4%
Type of delivery Vaginal 520 1290 1810 0.002
77.6% 87.3% 84.3%
Cesarean section 150 188 338
22.4% 12.7% 15.7%
Hospital admission after delivery No 588 1392 1980 0.003
87.8% 94.2% 92.2%
Yes 82 86 168
12.2% 5.8% 7.8%
Sibling suffering from the same condition No 498 1324 1822 0.006
74.3% 89.6% 84.8%
Yes 172 154 326
25.7% 10.4% 15.2%
Birth order of the child 1 204 472 676 0.002
30.4% 31.9% 31.5%
2 108 308 416
16.1% 20.8% 19.4%
3 108 232 340
16.1% 15.7% 15.8%
4-5 164 220 384
24.5% 14.9% 17.9%
>5 86 264 332
12.8% 16.6% 15.5%
History of parents with same condition during their childhood No 550 1354 1904 0.001
82.1% 91.6% 88.6%
Yes 120 124 244
17.9% 8.4% 11.4%
The child has chronic illness No 618 1386 2004 0.210
92.2% 93.8% 93.3%
Yes 52 92 144
7.8% 6.2% 6.7%
Anemia No 594 1356 1950 0.067
88.7% 91.7% 90.8%
Yes 76 122 198
11.3% 8.3% 9.2%
Parasitic infestation No 634 1412 2046 0.306
94.6% 95.5% 95.3%
Yes 36 66 102
5.4% 4.5% 4.7%
Diabetes type I No 630 1438 2068 0.009
94.0% 97.3% 96.3%
Yes 40 40 80
6.0% 2.7% 3.7%
Urinary tract infection No 610 1444 1054 0.000001
91.0% 97.7% 95.6%
Yes 60 34 94
9.0% 2.3% 4.4%
Psychological problems No 546 1368 1914 0.000001
81.5% 92.6% 89.1%
Yes 124 110 234
18.5% 7.4% 10.9%
Delayed milestones No 628 1438 2066 0.005
93.7% 97.3% 96.2%
Yes 42 40 82
6.3% 2.7% 3.8%

Discussion

Nocturnal enuresis (NE) is the involuntary urination that occurs while asleep after an age when bladder control at night is expected. It is more common in children living in unfavorable social conditions who are under psychosocial stress and is known to affect a child’s psychological state [1,10]. It is commonly identified amongst school-aged children with a significant stressor along with psychosocial problems both for parents and children [1]. Multiple mechanisms have been proposed for NE, including dysfunctional bladder, small functional bladder capacity, abnormal antidiuretic hormone levels, and irregular sleep patterns [11].

This is a cross-sectional study that was conducted among 2148 children in KSA and aimed to show the prevalence, risk factors, provided modalities of treatment for nocturnal enuresis among studied children in KSA.

The prevalence of nocturnal enuresis in children is between 15 and 25% at five years of age, and it goes down as children grow [3]. In this study, the majority of participants had children aged 5-7 years, of whom 63% had NE, while the prevalence significantly decreased to 9.6% in children 7-10 years and 4.5% in children older than 10 years of age (P = 0.05). The prevalence was close to what is reported from Sherah et al. study conducted in Jazan city in Saudi Arabia for children aged 5-12 years which was 76.4% but was higher than those reported from other studies where the overall prevalence of enuresis was found to be 12.95% in children aged 5-16 years from France and 15% in children aged 6-11 years from Saudi Arabia and two studies in Turkey estimated the prevalence to be 12.4 % and 13% [1,12-15]. However, in India, another survey carried out among 1473 children aged between 6 and 10 years reported that the overall prevalence of enuresis was 7.61% [16]. In Iran, a systemic review conducted to estimate the prevalence of enuresis and its related factors among Iranian children found that the prevalence of enuresis among all children was estimated as of 11.01% [17].

Most reported enuresis cases in our study had it at day and night 55.1%, and 43.9% occurred at night only. However, Sherah et al. and Sarici et al. reported that daytime enuresis was seen in only 14.29% and 18% of cases, respectively, of children of school-age [12,18].

The causation of enuresis is generally multifactorial and is the result of the interaction of physical and psychological factors. Participants believed that enuresis could be caused by weakness in the muscles of the lower urinary tract by 18.9%, problems or damage of the urinary tract or nerves that control the urinary system (9.1%), psychological problems (8%), urinary tract infections (2.8%) and anemia, hereditary, pregnancy, and birth-related causes believed to be caused by small percentage of respondents. Schlomer et al. reported that parents in their study believed the most common cause of enuresis to be deep sleeper (56%), unknown (39%), laziness to wake up and go to the bathroom (26%) and small bladder size (21%) [19]. This perception did not change a lot from older studies that have mentioned that parents believed heavy sleeping, emotional problems, and small bladder size to be important causes of NE [19,20].

Participants also reported different practices in terms of modalities of treatment provided where behavioral modification was the most commonly used modality by 31.6%, followed by pharmacological treatment (29.6%), bedwetting alarm (6.8%), exercises to strengthen the bladder muscles (6.2%) and surgery reported by 1.5% only. We found that improvement of nocturnal enuresis on different types of treatment occurred in 43.6% of cases studied. In contrast to our results, Sherah et al. reported using medical treatment in 76% of case and Al-Zahrani et al. reported the treatment methods used to be: enuresis alarm, water restriction, medication, and awaking for voiding in 56.9%, 14.7%, 5.7% and 5.7% of cases, respectively [12,20]. Schlomer et al. reported that parents used some behavioral modifications like voiding prior to sleep (77%), limiting fluid intake at night (71%), and using bedwetting alarm (6%) [19].

A cross-sectional survey, performed in Primary Health Care Centers, found that out of 65 families that have children with NE, 38.7% was the frequency of bedwetting every night, 22.6% of the children were stressed as a result of new childbirth, 14% of the families did not feel a family load of having children with NE, 29% of the families did not try to treat their children because of their improvement with time, and 12% of the families that tried to treat their children used fluid restriction and waked their children up frequently at night [21].

Regarding risk factors of nocturnal enuresis among the studied children, our study found significant correlations between nocturnal enuresis and child age as the prevalence was significantly lower as children grew older (peak is 63.6% in 5-7 years old), and no significant relation was found between enuresis and gender (p = 0.104), which was also reported by a study done in Taif that has shown a prevalence of 7.33% and 8.42% in boys and girls, respectively [20]. In contrast to Bakhtiar et al. who reported the prevalence of nocturnal enuresis in boys (10.7%) to be higher than in girls (5.4%) (P = 0.009) [22]. However, there was a significant correlation with a parent suffering from the same condition in their childhood (p = 0.001). Another study reported that the prevalence of enuresis among boys was 1.65-fold greater than that of girls, and it was more common among children with positive familial history [17]. Another study found that the prevalence of enuresis was found to correlate well with age (p = 0.0001), but not correlate with gender (p > 0.05) [1]. In addition, Bakhtiar et al. reported statistically significant relationships between nocturnal enuresis and history of nocturnal enuresis in siblings (P = 0.023) and deep sleep (P = 0.007) amongst other factors [22].

Conclusions

Our study reported that 31.2% of children suffer from nocturnal enuresis, but there were no significant correlations between nocturnal enuresis and child gender. There was a significant correlation with child age and family history of NE in parents or siblings. Behavioral modification therapy was the most provided treatment followed by pharmacological treatment and the improvement occurred in less than half of the cases. So, we recommend health education about the causes and risk factors in addition to encouraging prompt treatment and close follow-up to prevent associated self-shame and family stress. Further studies are needed to look in-depth into details of the modalities of treatment and how they are conducted and followed in addition to their effectiveness in Saudi children. Families' compliance with those modalities in Saudi culture is worth further investigation.


References

  1. Gür E, Turhan P, Can G, et al.: Enuresis: prevalence, risk factors and urinary pathology among school children in Istanbul, Turkey. Pediatr Int. 2004, 46:58-63. 10.1111/j.1442-200X.2004.01824.x
  2. Özkan S, Durukan E, Iseri E, Gürocak S, Maral I, Bumin MA: Prevalence and risk factors of monosymptomatic nocturnal enuresis in Turkish children. Indian J Urol. 2010, 26:200-205. 10.4103%2F0970-1591.65387
  3. von Gontard A, Mauer-Mucke K, Plück J, Berner W, Lehmkuhl G: Clinical behavioral problems in day- and night-wetting children. Pediatr Nephrol. 1999, 13:662-667. 10.1007/s004670050677
  4. Hamed A, Yousf F, Hussein MM: Prevalence of nocturnal enuresis and related risk factors in school-age children in Egypt: an epidemiological study. World J Urol. 2017, 35:459-465. 10.1007/s00345-016-1879-2
  5. Ghotbi N, Kheirabadi GH: Prevalence of nocturia and its associated factors in primary school children in Sanandaj in 2002. J Kurdistan Univ Med Sci. 2001, 50:30-33.
  6. Yousef K, Basaleem H, Yahiya M: Epidemiology of nocturnal enuresis in basic schoolchildren in Aden Governorate, Yemen. Saudi J Kidney Dis Transpl. 2011, 22:167-173.
  7. Jamali M, Rafiei GH: A comparison between the results of treatment with imipramine and oxybutynin in non-symptomatic 6-12 children with enuresis. J Rafsanjan Univ Med Sci Health Serv. 2004, 3:113-118.
  8. Theunis M, Van Hoecke E, Paesbrugge S, Hoebeke P, Vande Walle J: Self-image and performance in children with nocturnal enuresis. Eur Urol. 2002, 41:660-667. 10.1016/S0302-2838(02)00127-6
  9. Elgohary H, Shalanda A, El lethy S: Prevalence and psychiatric comorbidities of nocturnal enuresis in a sample of basic education students in Sharkia governorate. Zagazig Univ Med J. 2013, 19:1-9. 10.21608/zumj.2013.4291
  10. Melville JL, Walker E, Katon W, Lentz G, Miller J, Fenner D: Prevalence of comorbid psychiatric illness and its impact on symptom perception, quality of life, and functional status in women with urinary incontinence. Am J Obstetric Gynecol. 2002, 187:80-87. 10.1067/mob.2002.124839
  11. Hjalmas K: Nocturnal enuresis: basic facts and new horizons. Eur Urol. 1998, 33:53-57.
  12. Sherah K, Elsharief M, Barkat N, Jafery A: Prevalence of nocturnal enuresis in school-age children in Saudi Arabia. Int J Med Develop Ctries. 2019, 3:669-675. 10.24911/IJMDC.51-1547073432
  13. Ouedraogo A, Kere M, Ouedraogo TL, Jesu F: Epidemiology of enuresis in children and adolescents aged 5-16 years in Ouagadougou (Burkina Faso) (Article in French). Arch Pediatr. 1997, 4:947-951. 10.1016/S0929-693X(97)86089-7
  14. Kalo BB, Bella H: Enuresis: prevalence and associated factors among primary school children in Saudi Arabia. Acta Pediatr. 1996, 85:1217-1222. 10.1111/j.1651-2227.1996.tb18232.x
  15. Gumus B, Vurgun N, Lekili M, Işcan A, Muezzinoglu T, Buyuksu C: Prevalence of nocturnal enuresis and accompanying factors in children aged 7-11 years in Turkey. Acta Paediatr. 1999, 88:1369-1372. 10.1080/080352599750030103
  16. De Sousa A, Kapoor H, Jagtap J, Sen M: Prevalence and factors affecting enuresis amongst primary school children. Indian J Urol. 2007, 23:354-357. 10.4103/0970-1591.36703
  17. Makrani A, Moosazadeh M, Nasehi M, et al.: Prevalence of enuresis and its related factors among children in Iran: a systematic review and meta-analysis. Int J Pediatr. 2015, 3:995-1004. 10.22038/ijp.2015.5142
  18. Sarici H, Telli O, Ozgur B, Demirbas A, Ozgur S, Karagoz MA: Prevalence of nocturnal enuresis and its influence on quality of life in school-aged children. J Pediatr Urol. 2016, 12:159.e1-159.e6. 10.1016/j.jpurol.2015.11.011
  19. Schlomer B, Rodriguez E, Weiss D, Copp H: Parental beliefs about nocturnal enuresis causes, treatments, and the need to seek professional medical care. J Pediatr Urol. 2013, 9:1043-1048. 10.1016/j.jpurol.2013.02.013
  20. Al-Zahrani SS: Nocturnal enuresis and its treatment among primary-school children in Taif, KSA. Int J Res Med Sci. 2014, 2:91-94. 10.5455/2320-6012.ijrms20140218
  21. Alshahrani A, Selim M, Abbas M: Prevalence of nocturnal enuresis among children in Primary Health Care Centers of Family and Community Medicine, PSMMC, Riyadh City, KSA. J Family Med Prim Care. 2018, 7:937-941.
  22. Bakhtiar K, Pournia Y, Ebrahimzadeh F, Farhadi A, Shafizadeh F, Hosseinabadi R: Prevalence of nocturnal enuresis and its associated factors in primary school and preschool children of Khorramabad in 2013. Int J Pediatr. 2014, 2014:7. 10.1155/2014/120686
Original article
peer-reviewed

Prevalence of Nocturnal Enuresis among Saudi Children Population


Author Information

Elham H. Alhifthy Corresponding Author

Clinical Sciences, Pediatrics, Developmental and Behavioural Pediatrics, Princess Nourah Bint Abdulrahman University, College of Medicine, Riyadh, SAU

Lura Habib

Medicine, Taif University, Taif, SAU

Azahir Abu Al-Makarem

Medicine, Umm Alqura University (UQU), Makkah, SAU

Maryam AlGhamdi

Medicine, Aljouf University, Al-Jouf, SAU

Doaa Alsultan

Medicine, King Faisal University, Riyadh, SAU

Fatemah Aldhamer

Medicine, Princess Nourah University, Riyadh, SAU

Rawan Buhlagah

Medicine, King Faisal University, Riyadh, SAU

Fatimah M. Almubarak

Medicine, King Faisal University, Riyadh, SAU

Eatesam Almufadhi

Medicine, Al Jouf University, Al-Jouf, SAU

Ghaida M. Bukhamsin

Medicine, King Faisal University, Riyadh, SAU

Maria H. Zadah

Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, SAU


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. IRB of Princess Nourah Bint Abdulrahman University KACST, KSA: H-01-R-059 issued approval 19-0145. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.


Original article
peer-reviewed

Prevalence of Nocturnal Enuresis among Saudi Children Population


Figures etc.

SIQ
-
RATED BY 1 READER
CONTRIBUTE RATING

Scholary Impact Quotient™ (SIQ™) is our unique post-publication peer review rating process. Learn more here.