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Prevalence and predictors of childhood enuresis in southwest Nigeria: Findings from a cross-sectional population study
Journal of Pediatric Urology (2015) 11, 338.e1e338.e6
Prevalence and predictors of childhood enuresis in southwest Nigeria: Findings from a cross-sectional population study C.I. Esezobor a,b, M.R. Balogun c,d, T.A. Ladapo a,b a
Department of Paediatrics, College of Medicine, University of Lagos, Lagos, Nigeria
b
Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria c Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
d
Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria Correspondence to: C.I. Esezobor, Department of Paediatrics, College of Medicine, University of Lagos, P.M.B. 12003 Lagos, Nigeria, Tel.: þ2348058440582 [email protected] (C.I. Esezobor) Keywords Birth order; Constipation; Enuresis; Monosymptomatic enuresis; Incontinence Received 20 February 2015 Accepted 16 June 2015 Available online 30 July 2015
Summary Introduction Childhood enuresis is common, but the prevalence and factors associated with childhood enuresis in Africa have been poorly described. Furthermore, most studies from the continent have not provided data distinguishing monosymptomatic from nonmonosymptomatic enuresis. This distinction is important as it guides enuresis therapy. Objectives The primary objective of this study was to determine the prevalence of enuresis in children aged 5e17 years in a community in Nigeria. The secondary objectives were to determine the relative proportions of monosymptomatic and non-monosymptomatic enuresis and identify independent sociodemographic and clinical predictors of enuresis. Study design Parents or guardians in the community were interviewed using a pretested questionnaire. Standardized definitions were used, as recommended by the International Children’s Continence Society. Results A total of 928 children were included in the study. The prevalence of enuresis or daytime incontinence and enuresis was 28.3% (enuresis 24.4%, and daytime incontinence and enuresis 4%); it decreased with age. Primary and monosymptomatic enuresis were the most common types of enuresis. In multiple logistic regressions, children aged 5e9 years were 10.41 (5.14e21.05) times more likely to have
enuresis or daytime incontinence and enuresis compared with those aged 14e17 years. Other predictors of enuresis or daytime incontinence and enuresis were: male gender (OR 1.56 (1.13e2.14)); constipation (OR 2.56 (1.33e4.93)); and a sibling (OR 2.20 (1.58e3.06)) or parent (OR 3.14 (2.13e4.63)) with enuresis. Enuresis or daytime incontinence and enuresis was 1.92 (1.06e3.48) times more likely in fourth-born, or higher, children compared with firstborn children. Only parents of nine (3.4%) children with enuresis had consulted a medical doctor about it. Discussion The high prevalence of childhood enuresis in the present study was consistent with most studies from developing countries and contrasted sharply with the lower rates reported among children in developed countries. Common reasons for this disparity were the influence of socioeconomic status on enuresis rates and the low utilization of effective enuresis therapies in developing countries. Consistent with published literature, monosymptomatic enuresis was the commonest form of enuresis in the present study. Furthermore, younger age, male gender and a family history of enuresis were strongly associated with enuresis. A major limitation of the study was the lack of use of a voiding diary. Conclusion Childhood enuresis was common in the community but parents rarely sought medical attention. Predictors of enuresis were younger age, male gender, constipation, higher birth order, and a family history of enuresis.
http://dx.doi.org/10.1016/j.jpurol.2015.06.009 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Childhood enuresis in southwest Nigeria
Introduction Enuresis is common in childhood. In most series involving school-aged children, 16e26% of children have enuresis, which is the most common type of urinary incontinence [1,2]. While distinction between primary and secondary enuresis is made in most published studies, information as to whether enuresis is monosymptomatic or nonmonosymptomatic is frequently lacking [3,4]. For instance, two recent studies from children in Africa did not differentiate these forms [2,5]. Making this distinction is important because in addition to enuresis, therapy of nonmonosymptomatic enuresis should address lower urinary tract symptoms [6]. Frequently reported risk factors associated with enuresis include: male gender, younger age, belonging to a family with lower socioeconomic status, and a family history of enuresis [3,7]. However, the frequency of functional constipation, which is a common and treatable association of enuresis, is not determined in most studies [5,8]. The present study aimed to determine the prevalence of enuresis and its various forms among children aged 5e17 years in a community, and to explore the factors associated with it. In addition, it aimed to identify common strategies or treatment modalities employed by parents in the treatment of childhood enuresis.
Materials and methods Study area and data collection Over a 6-day period in November 2014, a pre-tested questionnaire was administered to parents of children in a periurban, largely residential community bordering a public tertiary hospital, in Mushin Local Government Area of Lagos State, Nigeria. The community was chosen because of its proximity to the tertiary hospital (which obviated distance as a reason for not seeking medical assistance for urinary incontinence). Members of the community are relatively poor, mostly petty traders and semi-skilled workers, and predominantly from the Yoruba ethnic group. A sample size of 950 children was calculated based on the following assumptions: an enuresis prevalence of 28%, a 95% confidence level, a precision of 0.03, and a 10% noncompletion rate of the study questionnaire. Five trained field interviewers with post-secondary education and fluency in the local language, and one of the investigators (CIE) visited houses on each street in the community. A parent was eligible to be interviewed if he/she lived in the community, had a child in the age range of 5e17 years, was available at the time of visit by the study team and provided informed consent. If a parent had more than one child in the age bracket of 5e17 years, a separate questionnaire was completed for each child. A member of the Community Development Association was in attendance each day to help explain the purpose of the study to members of the community. The study questionnaire was developed by reviewing the relevant literature on the subject of childhood enuresis. It was pretested on a group of 50 parents attending a paediatric outpatient clinic of the neighboring public tertiary
338.e2 hospital. It featured sections on: demographics of the child and family; presence and pattern of urinary incontinence, including presence of other lower urinary tract symptoms such as day-time wetting, urgency, straining to pass urine, use of holding maneuvers; stool frequency, nature of stool and if passage of stool was painful; and interventions employed by parents of children with enuresis. Most of the questions in the questionnaire had multiple options to choose from. The level of parental concern about enuresis in their children was measured using a scale of 1e10, where 1 meant ‘not concerned’ and 10 meant ‘greatly concerned’. Before commencement of the study the field interviewers underwent 1-day of training. All of them had participated in community-based health research in the past. The training focused on the study aims, how to obtain informed consent, and the meaning of each question item and its corresponding options.
Definition of terms Enuresis, daytime urinary incontinence, primary and secondary enuresis were defined according to the recommendations of the International Children’s Continence Society (ICCS) [9]. The presence of lower urinary track symptoms, such as holding maneuvers or urgency, was taken as monosymptomatic enuresis. Constipation was defined according to the Rome III criteria, except that the duration of bowel symptoms was not required [10]. Socioeconomic status (SES) of the family was classified using the method described by Olusanya et al. [11], which utilizes the educational level of the mother and occupation of the father.
Statistical analysis Analysis was performed using Microsoft Excel Software 2013 (Microsoft Office 2013, USA) and IBM SPSS Statistics 21.0 (IBM Corporation 2012, USA). Continuous data were summarized as mean (standard deviation) or as median (minimumemaximum), as appropriate. In bivariate analysis, children with enuresis or enuresis and daytime urinary incontinence were compared with children without it. Chisquared test and Student’s t-test, as appropriate, were used to identify independent factors associated with the presence of enuresis or enuresis and daytime urinary incontinence. A multiple logistic regression analysis incorporating simultaneous factors known to be associated with enuresis was performed. In all analyses, P-value <0.05 was considered as statistically significant.
Results Characteristics of children studied Seventy parents refused to participate in the study. It is unknown how this group of parents and their children compared to the group that participated in the study. Parents of 950 children participated in the study, of which the questionnaires of 22 children were discarded for incomplete information.
338.e3 Table 1
C.I. Esezobor et al. Socio-demographic and clinical factors associated with enuresis or daytime incontinence and enuresis.
Independent variables
All groups, n Z 928 (%)
Group with EDIEa, n Z 263 (%)
Group without EDIEa, n Z 665 (%)
P-value
Mean age, years (SD) Female, n (%) Socioeconomic status Low, n (%) Middle-high, n (%) Mother’s educational status None-primary, n (%) Secondary, n (%) Post-secondary, n (%) Marital status of interviewee Married, n (%) Others, n (%) Constipation, n (%) Birth order First, n (%) Second, n (%) Third, n (%) Fourth or higher, n (%) Number of children in family One, n (%) Two, n (%) Three, n (%) Four or more, n (%) Sibling with enuresis, n (%) Parent with enuresis, n (%) Either parent or sibling with enuresis, n (%)
10.2 (3.5) 484 (52.2)
8.4 (2.7) 117 (44.5)
10.9 (3.6) 367 (55.2)
0.00 0.00 0.89
717 (77.3) 211 (22.7)
204 (77.6) 59 (22.4)
513 (77.1) 152 (22.9)
337 (36.3) 528 (56.9) 63 (6.8)
105 (39.9) 141 (53.6) 17 (6.5)
232 (34.9) 387 (58.2) 46 (6.9)
831 (89.5) 97 (10.5) 58 (6.3)
231 (87.8) 32 (12.2) 20 (7.6)
600 (90.2) 65 (9.8) 38 (5.7)
a
0.36
0.28
338 283 182 125
(36.4) (30.5) (19.6) (13.5)
73 87 59 44
(27.8) (33.1) (22.4) (16.7)
265 196 123 81
(39.8) (29.5) (18.5) (12.2)
24 135 257 512 348 163 414
(2.6) (14.5) (27.7) (55.2) (37.5) (17.6) (44.6)
10 43 74 136 137 85 172
(3.8) (16.3) (28.1) (51.7) (52.1) (32.3) (65.4)
14 92 183 376 211 78 242
(2.1) (13.8) (27.5) (56.5) (31.7) (11.7) (36.4)
0.28 0.01
0.29
0.00 0.00 0.00
EDIE, enuresis or daytime incontinence and enuresis.
The mean age (SD) was 10.2 (3.5) years, while the median (minemax) age was 9.8 (5e17.7) years. Adolescents made up 48.7% of the study population. Females were slightly predominant (52.2%). The majority (66.9%) of the children was either the first or second child in the family, and most (55.2%) belonged to a family of four or more children. Most of the interviewed respondents were married (89.5%) and belonged to low socioeconomic class (77.3%) (Table 1).
Prevalence and pattern of enuresis Of the 928 children studied: 30.2%, 24.4%, 4.0% and 1.8% had intermittent urinary incontinence, enuresis, combined enuresis and daytime incontinence, and daytime incontinence, respectively; 263 (28.3%) had enuresis or daytime incontinence and enuresis (Fig. 1). Of the 226 children with enuresis, 73.9% had monosymptomatic enuresis. Children with primary enuresis made up the majority (83.2%) of the children with monosymptomatic enuresis. The prevalence of enuresis or daytime incontinence and enuresis decreased with increasing age: 50% at 5 years and 5.4% in the age range 14e17 years (Fig. 2). Also, at every age, the prevalence of enuresis or daytime incontinence and enuresis was higher among males than in females.
Among children with enuresis or daytime incontinence and enuresis, 30.0%, 36.1%, 16.3% and 17.5% had bedwetting frequency of once per month, 1e2 per week, 3e5 per week and 6e7 per week, respectively. The mean age of children who bed wet at least three times per week was similar to those who wet less frequently (8.1 vs 8.5 years).
Factors associated with any enuresis In both univariate and multivariate analysis (Tables 1 and 2), male gender and child’s age remained strongly associated with the presence of enuresis or daytime incontinence and enuresis, as well as the presence of enuresis in siblings and in one parent. In multiple logistic regression, children with constipation were 2.56 times more likely to have enuresis or daytime incontinence and enuresis than those without (P Z 0.01). Similarly, children of fourth birth order or more were more likely to have enuresis or daytime incontinence and enuresis than first-born children (1.92 (1.06e3.48)). In contrast, there was a trend for lower frequency of enuresis or daytime incontinence and enuresis, with a higher number of children, although it was not statistically significant. Socioeconomic class and being a single, widowed or separated parent were not associated with the presence of enuresis or daytime incontinence and enuresis in the child.
Childhood enuresis in southwest Nigeria
Figure 1
338.e4
Pattern of intermittent urinary incontinence.
Interventions employed by parents of children with enuresis Only parents of nine (3.4%) children with enuresis or daytime incontinence and enuresis had spoken to a medical doctor about the condition, despite a median parental score of 5 (1e10) in terms of how worried they were about enuresis in their child. The common interventions used by parents to manage enuresis included: do nothing (n Z 55, 20.9%); punish the child (n Z 79, 30.0%); wake child up at night to urinate (n Z 127, 48.3%); and restrict fluid intake in the evening (n Z 32, 12.2%). The parents of 15 (5.7%) children used scolding and verbal insults, while five children were given herbal medication (1.9%).
Discussion The present study adds to the growing body of evidence documenting a relatively higher prevalence of enuresis in developing countries compared with developed countries [2,4]. In the present study, the high frequency of enuresis persisted at every age and well into adolescence. Overall, with few exceptions [5,12], enuresis prevalence in developing countries such as Nigeria [13], Democratic Republic of Congo [2], Yemen [4] and Iran [7] is about 2e3 times higher than rates from developed countries [3,14,15]. Enuresis was not only more common, but also more severe in the present study. A similarly high frequency of marked enuresis was recently reported in South Africa [16]. This
Figure 2 Age and sex distribution of the children with enuresis or enuresis and daytime incontinence. EDIEa, Enuresis or daytime incontinence and enuresis.
338.e5
C.I. Esezobor et al.
Table 2 Multiple logistic regression analysis of factors associated with enuresis or daytime incontinence and enuresis. Independent variables
Adjusted OR (95% CI)
Child’s age 5e9 years 10.41 (vs. 14e17 years) 10e13 years 5.31 (vs. 14e17 years) Male gender 1.56 Birth order Second (vs. first child) 1.43 Third (vs. first child) 1.58 Fourth or higher 1.92 (vs. first child) Number of children in the family Two (vs. one) 0.50 Three (vs. one) 0.45 Four (vs. one) 0.38 Other marital status 1.58 (vs. married) Low socioeconomic status 0.97 (vs. middleehigh) Enuresis in sibling 2.20 Parents had enuresis 3.14 Constipation 2.56
P-value
(5.14e21.05)
0.00
(2.58e10.93)
0.00
(1.13e2.14)
0.01
(0.93e2.21) (0.95e2.64) (1.06e3.48)
0.11 0.08 0.03
(0.18e1.37) (0.16e1.22) (0.13e1.05) (0.96e2.61)
0.18 0.12 0.06 0.08
(0.66e1.43)
0.89
(1.58e3.06) (2.13e4.63) (1.33e4.93)
0.00 0.00 0.01
form of enuresis represents a subset that is relatively more difficult to resolve with treatment compared with those who wet less frequently. The disparity in enuresis prevalence between developing and developed countries may be attributed to differences in socioeconomic status, with lower rates among children belonging to families with higher socioeconomic status [1,17]. Furthermore, low usage of effective medical therapies for enuresis in developing countries means that enuresis persists in these children well into adolescence [2,18]. The preponderance of monosymptomatic and primary forms of enuresis in the present study conformed to previous studies, which reported that up to a third of children with enuresis might have daytime lower urinary tract symptoms that deserve attention [16,19,20]. As a guide, the ICCS recommends that daytime symptoms should be successfully managed before attempting treatment of enuresis [6]. In consonance with most studies on enuresis [3,16], in the present study, enuresis was more frequent in males and decreased with increasing age. Also, this study demonstrated a higher frequency of enuresis among children whose siblings or parents had childhood enuresis. The familial clustering of enuresis points to a genetic susceptibility or the influence of home environment on childhood enuresis [7,21]. However, the association between the number of children in the home and enuresis has been inconsistent in studies [8,22]; in the present study, there was a weak negative trend between the number of children and presence of enuresis. Furthermore, the present study showed a trend for increased likelihood of enuresis in
children of higher birth order, implying that birth order may be another factor associated with enuresis. The reason for this trend may be that parents bring up children of different birth orders differently, usually being more permissive with later-born than with first-born children [23]; permissive child rearing style has previously been associated with enuresis [22]. The present study adds to the evidence that constipation is associated with urinary incontinence and should therefore be evaluated and treated in children presenting with enuresis [6]. Despite the high prevalence of enuresis and severe form of enuresis persisting into late adolescence, only a small proportion of parents had spoken to a medical doctor about it, notwithstanding the proximity of a public tertiary hospital to the community and the high level of concern shown by the parents of these children. Instead, parents, similar to other studies [2,16] on enuresis, resorted to either doing nothing or using ineffective methods. This contrasting paradigm of high prevalence of childhood enuresis and low patronage of health facilities is commonly reported in studies from developing countries and differs from experience in developed countries [2,14]. This disparity between needs and utilization of resources creates an opportunity to promote awareness of effective medical interventions to the public.
Limitations The frequent occurrence of enuresis in children with sickle cell disease (SCD) and the high prevalence of SCD in Nigeria suggests an influence of SCD on the enuresis rate in the present study [24,25]; however, there are no reasons to suggest that children with SCD were over-represented in the study sample. Second, the study was likely to have under-reported the prevalence of nonmonosymptomatic enuresis because a urine diary was not used and the number of voids per day was not determined. The study was also limited to children whose parents were available at home at the time of study team visit; this may have impacted on the generalizability of the findings. Furthermore, although parents may not be fully conversant with the defecation habits of their children, especially the adolescents, except in severe cases of constipation, in the present study, parents were interviewed rather than the children because they were more likely to report enuresis in their children than the children themselves.
Conclusion In a peri-urban community in Nigeria, childhood enuresis, including severe forms of enuresis, is common, with prevalence rates two to three times more than those documented in developed countries. In addition to factors such as gender, age and family history of enuresis, which are consistently reported to be associated with enuresis, higher birth order was strongly associated with enuresis. Despite parental concern, a small proportion received medical attention; instead, parents employed methods that have been known to be ineffective in the treatment of enuresis.
Childhood enuresis in southwest Nigeria
Source of funding Nil.
Conflict of interests Nil.
Ethical approval The study was conducted in accordance with the provisions of the Declaration of Helsinki and the Health Research and Ethics Committee of LUTH (approval number: ADM/DCST/ HREC/1927) approved the research protocol. Permission was also received from the Community Development Association, traditional and religious leaders of the study community.
Acknowledgements We are sincerely grateful to Dr. Anne Wright of the Children’s Bladder Clinic, Evelina London Children’s Hospital, UK for her useful comments on the manuscript. We are also grateful to the field interviewers for their high sense of duty and to the members of the community development association, religious and traditional leaders for facilitating community entry.
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338.e6 [8] Srivastava S, Srivastava KL, Shingla S. Prevalence of monosymptomatic nocturnal enuresis and its correlates in school going children of Lucknow. Indian J Pediatr 2013;80:488e91. [9] Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: update report from the Standardization Committee of the International Children’s Continence Society. J Urol 2014;191(6):1863e5. e13. [10] Rasquin A, Di Lorenzo C, Forbes D, Guiraldes E, Hyams JS, Staiano A, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology 2006;130:1527e37. [11] Olusanya OE, Ezimokhai M. The importance of socioeconomic class in voluntary fertility in developing countries. West Afr J Med 1985;4:205e7. [12] Sureshkumar P, Jones M, Caldwell PH, Craig JC. Risk factors for nocturnal enuresis in school-age children. J urol 2009;182: 2893e9. [13] Osungbade KO, Oshiname FO. Prevalence and perception of nocturnal enuresis in children of a rural community in southwestern Nigeria. Trop Doct 2003;33:234e6. [14] Bower WF, Moore KH, Shepherd RB, Adams RD. The epidemiology of childhood enuresis in Australia. Br J urol 1996;78: 602e6. [15] Lee SD, Sohn DW, Lee JZ, Park NC, Chung MK. An epidemiological study of enuresis in Korean children. BJU Int 2000;85: 869e73. [16] Fockema MW, Candy GP, Kruger D, Haffejee M. Enuresis in South African children: prevalence, associated factors and parental perception of treatment. BJU Int 2012;110: E1114e20. [17] Carman KB, Ceran O, Kaya C, Nuhoglu C, Karaman MI. Nocturnal enuresis in Turkey: prevalence and accompanying factors in different socioeconomic environments. Urol Int 2008;80:362e6. [18] Bourquia A, Chihabeddine K. Enuresis: epidemiological study in Moroccan children. Saudi J Kidney Dis Transpl 2002;13: 151e4. [19] Merhi BA, Hammoud A, Ziade F, Kamel R, Rajab M. Monosymptomatic nocturnal enuresis in Lebanese children: prevalence, relation with obesity, and psychological effect. Clin Med insights Pediatr 2014;8:5e9. [20] Butler R, Heron J. Exploring the differences between monoand polysymptomatic nocturnal enuresis. Scand J urol Nephrol 2006;40:313e9. [21] von Gontard A, Schaumburg H, Hollmann E, Eiberg H, Rittig S. The genetics of enuresis: a review. J urol 2001;166:2438e43. [22] Safarinejad MR. Prevalence of nocturnal enuresis, risk factors, associated familial factors and urinary pathology among school children in Iran. J Pediatr urol 2007;3:443e52. [23] Price J. Parent-child quality time: does birth order matter? J Hum Resour 2008;43:240e65. [24] Kaine WN, Udeozo K. Incidence of sickle cell trait and anaemia in Ibo pre school children. Nig J Paediatr 1981;8: 87e9. [25] Portocarrero ML, Portocarrero ML, Sobral MM, Lyra I, Lordelo P, Barroso Jr U. Prevalence of enuresis and daytime urinary incontinence in children and adolescents with sickle cell disease. J urol 2012;187:1037e40.
Prevalence and predictors of childhood enuresis in southwest Nigeria: Findings from a cross-sectional population study C.I. Esezobor a,b, M.R. Balogun c,d, T.A. Ladapo a,b a
Department of Paediatrics, College of Medicine, University of Lagos, Lagos, Nigeria
b
Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria c Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
d
Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria Correspondence to: C.I. Esezobor, Department of Paediatrics, College of Medicine, University of Lagos, P.M.B. 12003 Lagos, Nigeria, Tel.: þ2348058440582 [email protected] (C.I. Esezobor) Keywords Birth order; Constipation; Enuresis; Monosymptomatic enuresis; Incontinence Received 20 February 2015 Accepted 16 June 2015 Available online 30 July 2015
Summary Introduction Childhood enuresis is common, but the prevalence and factors associated with childhood enuresis in Africa have been poorly described. Furthermore, most studies from the continent have not provided data distinguishing monosymptomatic from nonmonosymptomatic enuresis. This distinction is important as it guides enuresis therapy. Objectives The primary objective of this study was to determine the prevalence of enuresis in children aged 5e17 years in a community in Nigeria. The secondary objectives were to determine the relative proportions of monosymptomatic and non-monosymptomatic enuresis and identify independent sociodemographic and clinical predictors of enuresis. Study design Parents or guardians in the community were interviewed using a pretested questionnaire. Standardized definitions were used, as recommended by the International Children’s Continence Society. Results A total of 928 children were included in the study. The prevalence of enuresis or daytime incontinence and enuresis was 28.3% (enuresis 24.4%, and daytime incontinence and enuresis 4%); it decreased with age. Primary and monosymptomatic enuresis were the most common types of enuresis. In multiple logistic regressions, children aged 5e9 years were 10.41 (5.14e21.05) times more likely to have
enuresis or daytime incontinence and enuresis compared with those aged 14e17 years. Other predictors of enuresis or daytime incontinence and enuresis were: male gender (OR 1.56 (1.13e2.14)); constipation (OR 2.56 (1.33e4.93)); and a sibling (OR 2.20 (1.58e3.06)) or parent (OR 3.14 (2.13e4.63)) with enuresis. Enuresis or daytime incontinence and enuresis was 1.92 (1.06e3.48) times more likely in fourth-born, or higher, children compared with firstborn children. Only parents of nine (3.4%) children with enuresis had consulted a medical doctor about it. Discussion The high prevalence of childhood enuresis in the present study was consistent with most studies from developing countries and contrasted sharply with the lower rates reported among children in developed countries. Common reasons for this disparity were the influence of socioeconomic status on enuresis rates and the low utilization of effective enuresis therapies in developing countries. Consistent with published literature, monosymptomatic enuresis was the commonest form of enuresis in the present study. Furthermore, younger age, male gender and a family history of enuresis were strongly associated with enuresis. A major limitation of the study was the lack of use of a voiding diary. Conclusion Childhood enuresis was common in the community but parents rarely sought medical attention. Predictors of enuresis were younger age, male gender, constipation, higher birth order, and a family history of enuresis.
http://dx.doi.org/10.1016/j.jpurol.2015.06.009 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Childhood enuresis in southwest Nigeria
Introduction Enuresis is common in childhood. In most series involving school-aged children, 16e26% of children have enuresis, which is the most common type of urinary incontinence [1,2]. While distinction between primary and secondary enuresis is made in most published studies, information as to whether enuresis is monosymptomatic or nonmonosymptomatic is frequently lacking [3,4]. For instance, two recent studies from children in Africa did not differentiate these forms [2,5]. Making this distinction is important because in addition to enuresis, therapy of nonmonosymptomatic enuresis should address lower urinary tract symptoms [6]. Frequently reported risk factors associated with enuresis include: male gender, younger age, belonging to a family with lower socioeconomic status, and a family history of enuresis [3,7]. However, the frequency of functional constipation, which is a common and treatable association of enuresis, is not determined in most studies [5,8]. The present study aimed to determine the prevalence of enuresis and its various forms among children aged 5e17 years in a community, and to explore the factors associated with it. In addition, it aimed to identify common strategies or treatment modalities employed by parents in the treatment of childhood enuresis.
Materials and methods Study area and data collection Over a 6-day period in November 2014, a pre-tested questionnaire was administered to parents of children in a periurban, largely residential community bordering a public tertiary hospital, in Mushin Local Government Area of Lagos State, Nigeria. The community was chosen because of its proximity to the tertiary hospital (which obviated distance as a reason for not seeking medical assistance for urinary incontinence). Members of the community are relatively poor, mostly petty traders and semi-skilled workers, and predominantly from the Yoruba ethnic group. A sample size of 950 children was calculated based on the following assumptions: an enuresis prevalence of 28%, a 95% confidence level, a precision of 0.03, and a 10% noncompletion rate of the study questionnaire. Five trained field interviewers with post-secondary education and fluency in the local language, and one of the investigators (CIE) visited houses on each street in the community. A parent was eligible to be interviewed if he/she lived in the community, had a child in the age range of 5e17 years, was available at the time of visit by the study team and provided informed consent. If a parent had more than one child in the age bracket of 5e17 years, a separate questionnaire was completed for each child. A member of the Community Development Association was in attendance each day to help explain the purpose of the study to members of the community. The study questionnaire was developed by reviewing the relevant literature on the subject of childhood enuresis. It was pretested on a group of 50 parents attending a paediatric outpatient clinic of the neighboring public tertiary
338.e2 hospital. It featured sections on: demographics of the child and family; presence and pattern of urinary incontinence, including presence of other lower urinary tract symptoms such as day-time wetting, urgency, straining to pass urine, use of holding maneuvers; stool frequency, nature of stool and if passage of stool was painful; and interventions employed by parents of children with enuresis. Most of the questions in the questionnaire had multiple options to choose from. The level of parental concern about enuresis in their children was measured using a scale of 1e10, where 1 meant ‘not concerned’ and 10 meant ‘greatly concerned’. Before commencement of the study the field interviewers underwent 1-day of training. All of them had participated in community-based health research in the past. The training focused on the study aims, how to obtain informed consent, and the meaning of each question item and its corresponding options.
Definition of terms Enuresis, daytime urinary incontinence, primary and secondary enuresis were defined according to the recommendations of the International Children’s Continence Society (ICCS) [9]. The presence of lower urinary track symptoms, such as holding maneuvers or urgency, was taken as monosymptomatic enuresis. Constipation was defined according to the Rome III criteria, except that the duration of bowel symptoms was not required [10]. Socioeconomic status (SES) of the family was classified using the method described by Olusanya et al. [11], which utilizes the educational level of the mother and occupation of the father.
Statistical analysis Analysis was performed using Microsoft Excel Software 2013 (Microsoft Office 2013, USA) and IBM SPSS Statistics 21.0 (IBM Corporation 2012, USA). Continuous data were summarized as mean (standard deviation) or as median (minimumemaximum), as appropriate. In bivariate analysis, children with enuresis or enuresis and daytime urinary incontinence were compared with children without it. Chisquared test and Student’s t-test, as appropriate, were used to identify independent factors associated with the presence of enuresis or enuresis and daytime urinary incontinence. A multiple logistic regression analysis incorporating simultaneous factors known to be associated with enuresis was performed. In all analyses, P-value <0.05 was considered as statistically significant.
Results Characteristics of children studied Seventy parents refused to participate in the study. It is unknown how this group of parents and their children compared to the group that participated in the study. Parents of 950 children participated in the study, of which the questionnaires of 22 children were discarded for incomplete information.
338.e3 Table 1
C.I. Esezobor et al. Socio-demographic and clinical factors associated with enuresis or daytime incontinence and enuresis.
Independent variables
All groups, n Z 928 (%)
Group with EDIEa, n Z 263 (%)
Group without EDIEa, n Z 665 (%)
P-value
Mean age, years (SD) Female, n (%) Socioeconomic status Low, n (%) Middle-high, n (%) Mother’s educational status None-primary, n (%) Secondary, n (%) Post-secondary, n (%) Marital status of interviewee Married, n (%) Others, n (%) Constipation, n (%) Birth order First, n (%) Second, n (%) Third, n (%) Fourth or higher, n (%) Number of children in family One, n (%) Two, n (%) Three, n (%) Four or more, n (%) Sibling with enuresis, n (%) Parent with enuresis, n (%) Either parent or sibling with enuresis, n (%)
10.2 (3.5) 484 (52.2)
8.4 (2.7) 117 (44.5)
10.9 (3.6) 367 (55.2)
0.00 0.00 0.89
717 (77.3) 211 (22.7)
204 (77.6) 59 (22.4)
513 (77.1) 152 (22.9)
337 (36.3) 528 (56.9) 63 (6.8)
105 (39.9) 141 (53.6) 17 (6.5)
232 (34.9) 387 (58.2) 46 (6.9)
831 (89.5) 97 (10.5) 58 (6.3)
231 (87.8) 32 (12.2) 20 (7.6)
600 (90.2) 65 (9.8) 38 (5.7)
a
0.36
0.28
338 283 182 125
(36.4) (30.5) (19.6) (13.5)
73 87 59 44
(27.8) (33.1) (22.4) (16.7)
265 196 123 81
(39.8) (29.5) (18.5) (12.2)
24 135 257 512 348 163 414
(2.6) (14.5) (27.7) (55.2) (37.5) (17.6) (44.6)
10 43 74 136 137 85 172
(3.8) (16.3) (28.1) (51.7) (52.1) (32.3) (65.4)
14 92 183 376 211 78 242
(2.1) (13.8) (27.5) (56.5) (31.7) (11.7) (36.4)
0.28 0.01
0.29
0.00 0.00 0.00
EDIE, enuresis or daytime incontinence and enuresis.
The mean age (SD) was 10.2 (3.5) years, while the median (minemax) age was 9.8 (5e17.7) years. Adolescents made up 48.7% of the study population. Females were slightly predominant (52.2%). The majority (66.9%) of the children was either the first or second child in the family, and most (55.2%) belonged to a family of four or more children. Most of the interviewed respondents were married (89.5%) and belonged to low socioeconomic class (77.3%) (Table 1).
Prevalence and pattern of enuresis Of the 928 children studied: 30.2%, 24.4%, 4.0% and 1.8% had intermittent urinary incontinence, enuresis, combined enuresis and daytime incontinence, and daytime incontinence, respectively; 263 (28.3%) had enuresis or daytime incontinence and enuresis (Fig. 1). Of the 226 children with enuresis, 73.9% had monosymptomatic enuresis. Children with primary enuresis made up the majority (83.2%) of the children with monosymptomatic enuresis. The prevalence of enuresis or daytime incontinence and enuresis decreased with increasing age: 50% at 5 years and 5.4% in the age range 14e17 years (Fig. 2). Also, at every age, the prevalence of enuresis or daytime incontinence and enuresis was higher among males than in females.
Among children with enuresis or daytime incontinence and enuresis, 30.0%, 36.1%, 16.3% and 17.5% had bedwetting frequency of once per month, 1e2 per week, 3e5 per week and 6e7 per week, respectively. The mean age of children who bed wet at least three times per week was similar to those who wet less frequently (8.1 vs 8.5 years).
Factors associated with any enuresis In both univariate and multivariate analysis (Tables 1 and 2), male gender and child’s age remained strongly associated with the presence of enuresis or daytime incontinence and enuresis, as well as the presence of enuresis in siblings and in one parent. In multiple logistic regression, children with constipation were 2.56 times more likely to have enuresis or daytime incontinence and enuresis than those without (P Z 0.01). Similarly, children of fourth birth order or more were more likely to have enuresis or daytime incontinence and enuresis than first-born children (1.92 (1.06e3.48)). In contrast, there was a trend for lower frequency of enuresis or daytime incontinence and enuresis, with a higher number of children, although it was not statistically significant. Socioeconomic class and being a single, widowed or separated parent were not associated with the presence of enuresis or daytime incontinence and enuresis in the child.
Childhood enuresis in southwest Nigeria
Figure 1
338.e4
Pattern of intermittent urinary incontinence.
Interventions employed by parents of children with enuresis Only parents of nine (3.4%) children with enuresis or daytime incontinence and enuresis had spoken to a medical doctor about the condition, despite a median parental score of 5 (1e10) in terms of how worried they were about enuresis in their child. The common interventions used by parents to manage enuresis included: do nothing (n Z 55, 20.9%); punish the child (n Z 79, 30.0%); wake child up at night to urinate (n Z 127, 48.3%); and restrict fluid intake in the evening (n Z 32, 12.2%). The parents of 15 (5.7%) children used scolding and verbal insults, while five children were given herbal medication (1.9%).
Discussion The present study adds to the growing body of evidence documenting a relatively higher prevalence of enuresis in developing countries compared with developed countries [2,4]. In the present study, the high frequency of enuresis persisted at every age and well into adolescence. Overall, with few exceptions [5,12], enuresis prevalence in developing countries such as Nigeria [13], Democratic Republic of Congo [2], Yemen [4] and Iran [7] is about 2e3 times higher than rates from developed countries [3,14,15]. Enuresis was not only more common, but also more severe in the present study. A similarly high frequency of marked enuresis was recently reported in South Africa [16]. This
Figure 2 Age and sex distribution of the children with enuresis or enuresis and daytime incontinence. EDIEa, Enuresis or daytime incontinence and enuresis.
338.e5
C.I. Esezobor et al.
Table 2 Multiple logistic regression analysis of factors associated with enuresis or daytime incontinence and enuresis. Independent variables
Adjusted OR (95% CI)
Child’s age 5e9 years 10.41 (vs. 14e17 years) 10e13 years 5.31 (vs. 14e17 years) Male gender 1.56 Birth order Second (vs. first child) 1.43 Third (vs. first child) 1.58 Fourth or higher 1.92 (vs. first child) Number of children in the family Two (vs. one) 0.50 Three (vs. one) 0.45 Four (vs. one) 0.38 Other marital status 1.58 (vs. married) Low socioeconomic status 0.97 (vs. middleehigh) Enuresis in sibling 2.20 Parents had enuresis 3.14 Constipation 2.56
P-value
(5.14e21.05)
0.00
(2.58e10.93)
0.00
(1.13e2.14)
0.01
(0.93e2.21) (0.95e2.64) (1.06e3.48)
0.11 0.08 0.03
(0.18e1.37) (0.16e1.22) (0.13e1.05) (0.96e2.61)
0.18 0.12 0.06 0.08
(0.66e1.43)
0.89
(1.58e3.06) (2.13e4.63) (1.33e4.93)
0.00 0.00 0.01
form of enuresis represents a subset that is relatively more difficult to resolve with treatment compared with those who wet less frequently. The disparity in enuresis prevalence between developing and developed countries may be attributed to differences in socioeconomic status, with lower rates among children belonging to families with higher socioeconomic status [1,17]. Furthermore, low usage of effective medical therapies for enuresis in developing countries means that enuresis persists in these children well into adolescence [2,18]. The preponderance of monosymptomatic and primary forms of enuresis in the present study conformed to previous studies, which reported that up to a third of children with enuresis might have daytime lower urinary tract symptoms that deserve attention [16,19,20]. As a guide, the ICCS recommends that daytime symptoms should be successfully managed before attempting treatment of enuresis [6]. In consonance with most studies on enuresis [3,16], in the present study, enuresis was more frequent in males and decreased with increasing age. Also, this study demonstrated a higher frequency of enuresis among children whose siblings or parents had childhood enuresis. The familial clustering of enuresis points to a genetic susceptibility or the influence of home environment on childhood enuresis [7,21]. However, the association between the number of children in the home and enuresis has been inconsistent in studies [8,22]; in the present study, there was a weak negative trend between the number of children and presence of enuresis. Furthermore, the present study showed a trend for increased likelihood of enuresis in
children of higher birth order, implying that birth order may be another factor associated with enuresis. The reason for this trend may be that parents bring up children of different birth orders differently, usually being more permissive with later-born than with first-born children [23]; permissive child rearing style has previously been associated with enuresis [22]. The present study adds to the evidence that constipation is associated with urinary incontinence and should therefore be evaluated and treated in children presenting with enuresis [6]. Despite the high prevalence of enuresis and severe form of enuresis persisting into late adolescence, only a small proportion of parents had spoken to a medical doctor about it, notwithstanding the proximity of a public tertiary hospital to the community and the high level of concern shown by the parents of these children. Instead, parents, similar to other studies [2,16] on enuresis, resorted to either doing nothing or using ineffective methods. This contrasting paradigm of high prevalence of childhood enuresis and low patronage of health facilities is commonly reported in studies from developing countries and differs from experience in developed countries [2,14]. This disparity between needs and utilization of resources creates an opportunity to promote awareness of effective medical interventions to the public.
Limitations The frequent occurrence of enuresis in children with sickle cell disease (SCD) and the high prevalence of SCD in Nigeria suggests an influence of SCD on the enuresis rate in the present study [24,25]; however, there are no reasons to suggest that children with SCD were over-represented in the study sample. Second, the study was likely to have under-reported the prevalence of nonmonosymptomatic enuresis because a urine diary was not used and the number of voids per day was not determined. The study was also limited to children whose parents were available at home at the time of study team visit; this may have impacted on the generalizability of the findings. Furthermore, although parents may not be fully conversant with the defecation habits of their children, especially the adolescents, except in severe cases of constipation, in the present study, parents were interviewed rather than the children because they were more likely to report enuresis in their children than the children themselves.
Conclusion In a peri-urban community in Nigeria, childhood enuresis, including severe forms of enuresis, is common, with prevalence rates two to three times more than those documented in developed countries. In addition to factors such as gender, age and family history of enuresis, which are consistently reported to be associated with enuresis, higher birth order was strongly associated with enuresis. Despite parental concern, a small proportion received medical attention; instead, parents employed methods that have been known to be ineffective in the treatment of enuresis.
Childhood enuresis in southwest Nigeria
Source of funding Nil.
Conflict of interests Nil.
Ethical approval The study was conducted in accordance with the provisions of the Declaration of Helsinki and the Health Research and Ethics Committee of LUTH (approval number: ADM/DCST/ HREC/1927) approved the research protocol. Permission was also received from the Community Development Association, traditional and religious leaders of the study community.
Acknowledgements We are sincerely grateful to Dr. Anne Wright of the Children’s Bladder Clinic, Evelina London Children’s Hospital, UK for her useful comments on the manuscript. We are also grateful to the field interviewers for their high sense of duty and to the members of the community development association, religious and traditional leaders for facilitating community entry.
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