AND ASSOCIATED FACTORS OF ENURESIS IN TURKISH CHILDREN
Download pdf )
CUNEYT OZDEN, OZDEM
L. OZDAL, SERKAN ALTINOVA, IBRAHIM OGUZULGEN, GUVENC URGANCIOGLU, ALI
of Urology, Numune Education and Research Hospital, Ankara, Turkey
Enuresis, which is frequently diagnosed amongst schoolchildren, is an
important psychosocial problem for both parents and children. In the present
study we aimed to determine the prevalence and associated factors of enuresis
in Turkish children and to identify common methods for its management.
Materials and Methods: A cross sectional
epidemiological study was performed among primary school children living
in Ankara, Turkey. A self-administered questionnaire was prepared for
this study and distributed to the parents of 1,500 schoolchildren whom
aged 6-12 years.
Results: Of the 1,500 questionnaires distributed,
1,339 (89%) were completed. The overall prevalence of nocturnal and diurnal
enuresis were 17.5% (n = 234) and 1.9% (n = 25), respectively. Although
male gender, low age, history of enuresis among parents, low educational
level of the parents, deep sleep, increased number of siblings, increased
number of people sleeping in the child’s room, history of enuresis
among siblings, poor school performance and history of recurrent urinary
tract infections (UTI) were significantly associated with enuresis, but
not with severe enuresis. The percentage of children with enuresis seen
by physician for treatment was 17.2%. The most preferred treatment option
for enuresis was medications (59.5%), whereas alarm treatment was the
least preferred (2.4%).
Conclusions: Our results with enuresis prevalence
and associated factors were comparable to other epidemiologic studies
from various countries. Furthermore we demonstrated that families in Turkey
do not pay sufficient attention to enuresis and most of enuretic children
do not receive professional treatment.
words: Enuresis; family characteristics; prevalence
Int Braz J Urol. 2007; 33: 216-22
enuresis (NE) can be defined as the involuntary passage of urine during
sleep beyond the age of anticipated nighttime bladder control, which is
generally accepted as 5 years of age. Nocturnal enuresis is a very common
clinical problem in children, especially in boys. Despite the fact that
this condition is usually labeled benign, it often leads to considerable
emotional distress and concern in affected children and their parents
(1). Approximately 15% of children wet their bed at night when they are
5 years old. There is a spontaneous resolution rate of about 15% per year;
therefore, by the age 15, only about 1% of adolescents have a problem
with NE (2). The etiology of enuresis is not completely understood. This
condition probably has a multifactor etiology. Most studies have consistently
found that the risk factors for enuresis are male gender, low age, family
history of enuresis, divorced parents and deep sleep (3-7). Our aims in
this study were to determine the prevalence and associated factors of
enuresis in Turkish children and to identify common methods of its management.
prospective cross sectional epidemiological study was performed among
primary school children living in Ankara, Turkey. A self-administered
questionnaire was prepared for this study and distributed to the parents
of 1,500 schoolchildren whom aged 6-12 years. The study consisted of five
schools selected randomly. To minimize any embarrassment to children,
parents were accessed directly to obtain the information.
The questionnaire consisted of two parts
(Figure-1). The first part was designed to investigate associated factors
of enuresis, and the second part was planned to determine type and prevalence
of enuresis and to identify common methods of its management. The questions
in the first part asked about sex, age, education level of parents, other
enuretics in the family, presence of other people sleeping in the child’s
room, sleeping habit, number of siblings, school performance, history
of urinary tract infection (UTI) and upper respiratory system infections
(URSI). The second part of the questionnaire was completed only by the
parents of the enuretic children. The questionnaire in this part asked
about the frequency of bed-wetting at night and/or in daytime, wetting
after a continuous dry period of 6 > months and any history medical
treatment of enuresis. Enuresis was defined as an episode of bed-wetting
occurring at least once a month. Primary enuresis was defined as bed-wetting
in subjects who have never been dry for an extended period. Furthermore
secondary enuresis was defined as the onset of wetting after a continuous
dry period of 6 > months and diurnal enuresis was defined as daytime
wetting when the child awakes.
All the data was analyzed with SPSS software
for windows (Chicago, IL, USA). Univariate chi-square test and multivariate
logistic regression test was used for the statistical analysis and p value
< 0.05 was considered as statistically significant.
the 1,500 questionnaires distributed, 1,339 (89%) were returned from the
parents. The mean age of the children included in the study was 8.8 ±
1.3 years. The overall prevalence of nocturnal and diurnal enuresis were
17.5% (n = 234) and 1.9% (n = 25), respectively. Nocturnal enuresis was
primary in 62.8% (n = 147) and secondary in 37.2% (n = 87) of the cases.
It was particularly more prevalent in boys than in girls, but diurnal
enuresis did not reveal a gender bias (Table-1).
Furthermore the prevalence of enuresis decreased
with age. Of the 6-year-old children 30.8% still wetted their beds, while
none of those aged 12 years did so. The prevalence of enuresis in males
and females according to age group are shown in Table-2.
Several parental factors that are related
to enuresis were history of enuresis and low educational level of the
parents. These factors were significantly higher in children with enuresis
when compared to non-enuretics (Table-3). The rate of male gender, low
age, deep sleep, poor school performance, history of enuresis in siblings,
increased number of siblings, increased room sharing with other siblings
and recurrent UTI were significantly higher in enuretics when compared
to non-enuretics (Table-4). We adjusted the data for age and the factors
that were related with enuresis were gender, family history of enuresis,
deep sleep, parents’ educational level and the history of enuresis
in siblings (Table-5).
The severities of enuresis for four categories
of frequency (every night, 4-6 times per week, 1-3 times per week and
1-2 times per month) were 33.3%, 10.7%, 25.6% and 30.3%, respectively.
On the other hand the factors that were significantly related to enuresis
were not related to severe enuresis (every night) (p > 0.05).
The percentage of children with enuresis
seen by physician for treatment was 17.2%. The treatment modalities offered
to these children were medications (59.5%), waking to void (26.2%), wait
for maturity (7.1%), fluid restriction (4.8%) and alarm treatment (2.4%).
is one of the common disorders in pediatric population. In most countries
the prevalence of enuresis among 6-11 years old children is reported as
1.4-28% (3-5,8). Likewise in the present study we obtained the prevalence
of enuresis in children at 6-12 years of age as 17.5%. In previous studies
reported from different Turkey provinces, the prevalence of enuresis was
reported as 11.5-13.7%, which was lower than our study’s prevalence(6,7,9).
Previous studies demonstrated that the prevalence
of enuresis tended to decrease with increasing age, and it was more common
in boys rather than girls. Similarly in the present study 30.8% of the
children were wetting their beds at age 6 whereas none of them were wetting
their beds at age 12. However a small number of children in the age group
6 and 12 (n = 13 and 34 respectively) was the limitation of our study.
Furthermore the prevalence of enuresis in boys and girls were 20.1% and
15% respectively. In another study which was conducted by Lee et al reported
the prevalence of enuresis at age 7 as 20.4% and this rate decreased to
5.6% by age 12 (4).
The parental factors that were significantly
related to the prevalence of enuresis in our study were history of enuresis
and the low educational level of the parents. The rate of history of enuresis
in the parents was 30.8% in the enuretic children whereas this rate was
only 11% in the non-enuretic children. Furthermore previous studies reported
the prevalence of family history in enuretic children as 22-48% (3,7,9,10)
Twin studies also support a genetic basis for enuresis. The concordance
rate is much higher in monozygotic twins (36%) (11). Danish researchers
were the first to report an unidentified enuresis gene (ENUR1) in chromosome
region 13q (12). Later studies have also shown linkage to chromosome 12q
and chromosome 22 (13,14).
Corresponding with the previous studies,
in our study the factors that are significantly related to enuresis were
male gender, low age, deep sleep, poor school performance, history of
enuresis in the siblings, increased number of siblings, room sharing and
recurrent UTI. However URSI and the behavioral profile of the children
were not related with enuresis. Not even previous studies could demonstrate
a specific behavioral profile in enuretic children (1,15). On the other
hand further reported factors that significantly related to enuresis were
divorced parents, low birth rate, growth retardation, constipation, bronchial
asthma, allergy and liquid intake before go to sleep (3,5,16,17).
We defined severe enuresis as bed wetting
every night (33.3%) which did not relate to any of the factors stated
above. However Chang reported that deep sleep is significantly related
with bed wetting more than three times a week (5). Watanabe and Kawauchi
showed that the arousal centre was activated to turn deep sleep into light
sleep when the bladder was distended (18). They also found that a disturbance
in this arousal system might result in sustained deep sleep and hence
In the present study only 17.2% of the children
were seen by a physician and previous series reported as 11-34% (4,6,9).
These low rates demonstrate that most of the children with enuresis were
not treated. Oge and associates from Turkey reported that the families
mostly choose the traditional methods in order to treat enuresis (6).
On the contrary in the present study most of the children (61.9%) were
treated with professional methods provided by physicians. On the other
hand the use of alarm treatment was significantly lower when compared
to medications (2.4% vs. 59.5%). However at present the use of alarm for
enuresis treatment is the preferred treatment modality because of high
success rate and low relapses (19).
results with enuresis prevalence and associated factors which were male
gender, low age, history of enuresis among parents, low educational level
of the parents, deep sleep, increased number of siblings, increased number
of people sleeping in the child’s room, history of enuresis among
siblings, poor school performance and history of recurrent UTI, were comparable
to other epidemiologic studies from various countries. However severe
enuresis did not relate to any of the mentioned factors. We documented
that most of the children with enuresis were not treated and the families
in Turkey do not have adequate attention about enuresis and most of the
enuretic children do not receive professional treatment.
- Moffatt ME: Nocturnal enuresis: psychologic implications of treatment
and nontreatment. J Pediatr. 1989; 114: 697-704.
- Forsythe WI, Redmond A: Enuresis and spontaneous cure rate. Study
of 1129 enuretis. Arch Dis Child. 1974; 49: 259-63.
- Kalo BB, Bella H: Enuresis: prevalence and associated factors among
primary school children in Saudi Arabia. Acta Paediatr. 1996; 85: 1217-22.
- Lee SD, Sohn DW, Lee JZ, Park NC, Chung MK: An epidemiological study
of enuresis in Korean children. BJU Int. 2000; 85: 869-73.
- Chang P, Chen WJ, Tsai WY, Chiu YN: An epidemiological study of nocturnal
enuresis in Taiwanese children. BJU Int. 2001; 87: 678-81.
- Oge O, Kocak I, Gemalmaz H: Enuresis: point prevalence and associated
factors among Turkish children. Turk J Pediatr. 2001; 43: 38-43.
- Gumus B, Vurgun N, Lekili M, Iscan A, Muezzinoglu T, Buyuksu C: Prevalence
of nocturnal enuresis and accompanying factors in children aged 7-11
years in Turkey. Acta Paediatr. 1999; 88: 1369-72.
- Bower WF, Moore KH, Shepherd RB, Adams RD: The epidemiology of childhood
enuresis in Australia. Br J Urol. 1996; 78: 602-6.
- Serel TA, Akhan G, Koyuncuoglu HR, Ozturk A, Dogruer K, Unal S, et
al.: Epidemiology of enuresis in Turkish children. Scand J Urol Nephrol.
1997; 31: 537-9.
- Hogg RJ: Genetic factors as predictors for desmopressin treatment
success. Scand J Urol Nephrol Suppl. 1997; 183: 37-9.
- Bakwin H: Enuresis in twins. Am J Dis Child. 1971; 121: 222-5.
- Eiberg H, Berendt I, Mohr J: Assignment of dominant inherited nocturnal
enuresis (ENUR1) to chromosome 13q. Nat Genet. 1995; 10: 354-6.
- Arnell H, Hjalmas K, Jagervall M, Lackgren G, Stenberg A, Bengtsson
B, et al.: The genetics of primary nocturnal enuresis: inheritance and
suggestion of a second major gene on chromosome 12q. J Med Genet. 1997;
- Eiberg H: Total genome scan analysis in a single extended family
for primary nocturnal enuresis: evidence for a new locus (ENUR3) for
primary nocturnal enuresis on chromosome 22q11. Eur Urol. 1998; 33 Suppl
- Couchells SM, Johnson SB, Carter R, Walker D: Behavioral and environmental
characteristics of treated and untreated enuretic children and matched
nonenuretic controls. J Pediatr. 1981; 99: 812-6.
- Rawashdeh YF, Hvistendahl GM, Kamperis K, Hansen MN, Djurhuus JC:
Demographics of enuresis patients attending a referral centre. Scand
J Urol Nephrol. 2002; 36: 348-53.
- Cher TW, Lin GJ, Hsu KH: Prevalence of nocturnal enuresis and associated
familial factors in primary school children in taiwan. J Urol. 2002;
- Watanabe H, Kawauchi A: Locus coeruleus function in enuresis. Scand
J Urol Nephrol Suppl. 1999; 202: 14-7.
- Jensen N, Kristensen G: Frequency of nightly wetting and the efficiency
of alarm treatment of nocturnal enuresis. Scand J Urol Nephrol. 2001;
November 23, 2006
Dr. Cuneyt Ozden
Cevizlidere Mah. 14. Cad. Balgat 12/25
Ankara, 06100, Turkey