The prevalence of nocturnal enuresis: do DSM III criteria need to be changed? A brief research report

Assessment of nocturnal enuresis diagnostic criteria

INTRODUCTION

Nocturnal enuresis (NE) is a common disorder that affects both children and their families. The objective is to determine its prevalence in an extensive sample of children considering different diagnostic criteria.

PATIENTS AND METHODS

Cross-sectional descriptive study using a survey of parents of a selection of primary and secondary school Asturian children (6, 10 and 13 years). The questionnaire consisted of 80 or 55 questions (10 of which were answered by the children) for those who urinated or not in bed, respectively. NE was registered as primary or secondary, and the presence or not of enuresis as the only symptom. In addition, the prevalence was compared according to the different diagnostic criteria.

RESULTS

Of the 3548 questionnaires distributed, 56.6% were answered completed correctly. A total of 102 children urinated in bed (5.52%), which corresponds to a prevalence of 2.82% according to the DSM-IV-TR/5 and the (International Continence Society) ICC, 3.7% with the DSM-III and ICD-10. It was more frequent in boys than in girls (2.8:1), with a predominance of primary forms (81.2%), and non-monosymptomatic (68.66%). The spontaneous resolution in the older age group was higher in boys than in girls, with the different prevalences of previous ages being equal to 13 years.

CONCLUSIONS

The prevalence of NE in the studied region coincides with that observed in some other studies. There are differences according to the criteria used, which should draw attention to the need to unify the methodology of the studies and the criteria used in its diagnosis.

Age as an Ambiguous Variable in Developmental Research: Some Epidemiological Considerations from Developmental Psychopathology

Intra-individual change in behaviour with age constitutes the essential element in developmental research but, unless age is broken down into its component parts, age is devoid of meaning. The issues involved are discussed from the perspective of epidemiology as applied to developmental psychopathology. Methodological concerns are discussed with respect to continuities and discontinuities in development (with special reference to the cumulative emergence of skills and variable consistency over the life span), secular trends, and the distinction between individual and groupaggregated age trends. The different components of chronological age are considered in terms of cognitive level, different types of biological maturity, and the duration of type of life experiences. The same components are discussed with respect to the issues involved in the study of differential effects of experiences according to their timing in the developmental sequence, and maturational delay.

Prevalence of nocturnal enuresis and its associated factors in primary school and preschool children of khorramabad in 2013

Background. Nocturnal enuresis refers to an inability to control urination during sleep. This study aimed to determine the prevalence of nocturnal enuresis and its associated factors in children in the city of Khorramabad. Materials and Methods. In this descriptive-analytic, cross-sectional study, 710 male and female children were divided into two groups with equal numbers. The samples were selected from the schools of Khorramabad using the multistage cluster and stratified random sampling methods based on the diagnostic criteria of DSM-IV. The data was analyzed using the logistic regression. Results. The results showed that 8% of the children had nocturnal enuresis, including 5.2% of primary nocturnal enuresis and 2.8% of secondary nocturnal enuresis. The prevalence of nocturnal enuresis in the boys (10.7%) was higher compared with that in the girls (5.4%) (P = 0.009). There were statistically significant relationships between nocturnal enuresis and history of nocturnal enuresis in siblings (P = 0.023), respiratory infections (P = 0.036), deep sleep (P = 0.007), corporal punishment at school (P = 0.036), anal itching (P = 0.043), and history of seizures (P = 0.043). Conclusion. This study showed that the prevalence of nocturnal enuresis in the boys was higher compared with that in the girls.

Prevalence and risk factors of monosymptomatic nocturnal enuresis in Turkish children

Objectives

To determine the prevalence of primary monosymptomatic nocturnal enuresis (PMNE) and assess risk factors that can cause this disease.

Methods

After the determination of 15 primary schools in the provincial center of Ankara, questionnaires were given to 15,150 students to be answered by their parents. Detailed urologic history was obtained and physical examination applied to the students whose parents answered the questionnaire. After excluding children with polysymptomatic NE, 14060 questionnaires of MNE patients were evaluated. Demographic features with social and medical history of students and their parents, general approach of family to the children, school success of the students and general behavioral attitudes, method of toilet training and the presence of nocturnal enuresis were questioned.

Results

MNE was determined in 9.0% (n: 1266) of the students and nocturnal enuresis frequency was higher in boys than girls (P<0.05). Univariate analysis revealed gender, method of toilet training, sleep problems, school success, and general approach of the family to children and general behavioral attitudes of the children as significant factors. In logistic regression analysis; age, male gender, toilette training with threatening method, deep sleeper, sleep walking, being introverted and shy, significantly increases the risk of nocturnal enuresis.

Conclusions

The current study suggests that the methods of toilet training are extremely important to prevent bedwetting and behavioral disorders due to enuresis. Parents should be well-informed about the appropriate toilet training method.

Prevalence of enuresis and its association with attention-deficit/hyperactivity disorder among U.S. children: results from a nationally representative study

OBJECTIVE

There are no published nationally representative prevalence estimates of enuresis among children in the United States using standardized diagnostic criteria. This study sets out to describe the prevalence, demographic correlates, comorbidities, and service patterns for enuresis in a representative sample of U.S. children.

METHOD

The diagnosis of enuresis was derived from parent-reported data for "enuresis, nocturnal" collected using the computerized version of the Diagnostic Interview Schedule for Children (C-DISC 4.0) from a nationally representative sample of 8- to 11-year-old children (n = 1,136) who participated in the 2001-2004 National Health and Nutrition Examination Surveys.

RESULTS

The overall 12-month prevalence of enuresis was 4.45%. The prevalence in boys (6.21%) was significantly greater than that in girls (2.51%). Enuresis was more common at younger ages and among black youth. Attention-deficit/hyperactivity disorder (ADHD) was strongly associated with enuresis (odds ratio 2.88; 95% confidence interval 1.26-6.57). Only 36% of the enuretic children had received health services for enuresis.

CONCLUSIONS

Enuresis is a common condition among children in the United States. Few families seek treatment for enuresis despite the potential for adverse effects on emotional health. Child health care professionals should routinely screen for enuresis and its effects on the emotional health of the child and the family. Assessment of ADHD should routinely include evaluation for enuresis and vice versa. Research on the explanations for the association between enuresis and ADHD is indicated.

Behavior profiles in children with functional urinary incontinence before and after incontinence treatment

OBJECTIVE

The purpose of this work was to analyze prospectively the prevalence of behavioral disorders in children with urinary incontinence because of nonneuropathic bladder-sphincter dysfunction before and after treatment for incontinence.

METHODS

A total of 202 children with nonneuropathic bladder-sphincter dysfunction were enrolled in the European Bladder Dysfunction Study, in branches for urge syndrome (branch 1) and dysfunctional voiding (branch 2); 188 filled out Achenbach's Child Behavior Checklist before treatment and 111 after treatment. Child Behavior Checklist scales for total behavior problems were used along with subscales for externalizing problems and internalizing problems.

RESULTS

After European Bladder Dysfunction Study treatment, the total behavior problem score dropped from 19% to 11%, the same prevalence as in the normative population; in branch 1 the score dropped from 14% to 13%, and in branch 2 it dropped from 23% to 8%. The prevalence of externalizing problems dropped too, from 12% to 8%: in branch 1 it was unchanged at 10%, and in branch 2 it dropped from 14% to 7%. The decrease in prevalence of internalizing problems after treatment, from 16% to 14%, was not significant.

CONCLUSION

More behavioral problems were found in dysfunctional voiding than in urge syndrome, but none of the abnormal scores related to the outcome of European Bladder Dysfunction Study treatment for incontinence. With such treatment, both the total behavior problem score and the score for externalizing problems returned to normal, but the score for internalizing problems did not change. The drops in prevalence are statistically significant only in dysfunctional voiding.

An exploration of children's views of bed-wetting at 9 years

BACKGROUND

Although some empirical investigations have explored the impact of nocturnal enuresis for sufferers, little is known about how children in general understand nocturnal enuresis. This study employed a large cohort of children at 9 years, asking directly about the perceived difficulty of bed-wetting in relation to an extensive range of life events.

METHOD

The sample comprised 8209 children, 4012 (48.9%) male and 4197 (51.1%) female who, as part of the Avon Longitudinal Study of Parents and Children survey, completed a booklet called 'My World' which included a section of 21 items concerned with childhood difficulties.

RESULTS

Bed-wetting was highly endorsed as a difficulty for children, and factor analysis revealed it to be construed as a social problem. Girls were more likely to consider events of a social and emotional nature to be difficult, whereas boys rated antisocial events as more problematic. Boys and those who suffer from nocturnal enuresis were significantly more likely to view bed-wetting as more difficult for children.

CONCLUSION

Bed-wetting, which is construed as a social issue, tends to be rated as a major difficulty for children, increasingly so for boys and those who suffer from nocturnal enuresis.

Prevalence of nocturnal enuresis, risk factors, associated familial factors and urinary pathology among school children in Iran

AIM

To estimate the prevalence of enuresis in school-age children in Iran and determine associated factors.

MATERIALS AND METHODS

A total of 7562 children, aged 5-18 years, enrolled in this cross-sectional study. Using a standard questionnaire, data on demographic characteristics, and familial and physical conditions were obtained from the parents by interview. The ICD-10 definition of enuresis was used. In the case of enuretics, a detailed history was taken, and physical and ultrasonographic examinations, urinalysis and urine culture were performed.

RESULTS

The overall prevalence of enuresis was 6.8%. A significant relationship was found between the prevalence of enuresis and age (P=0.001), educational level of parents (P=0.001), number of family members (P=0.028), positive family history of enuresis (P=0.001), parenting methods (P=0.001), and deep sleep (P=0.001). Birth weight (P=0.07), monthly income (P=0.322), employment status of parents (P=0.08), ethnic differences (P=0.09), delayed development (P=0.062), drinking (P=0.072) or urination habit before sleep (P=0.06), and stool incontinence (P=0.062) were not significantly associated with enuresis. Prevalence of urinary tract pathology was 2.9% in enuretics.

CONCLUSIONS

This study provides a quantitative estimate of the prevalence and main risk factors for enuresis in Iranian children.

The epidemiology and factors associated with nocturnal enuresis and its severity in primary school children in Taiwan

PURPOSE

To investigate the prevalence of nocturnal enuresis among children in elementary school in Taiwan and to evaluate its associated factors and severity.

MATERIALS AND METHODS

A randomly selected cross-sectional study was conducted from elementary schools in Changhua county, Taiwan in 2003. In all, 9228 questionnaires were sent to 46 schools in 26 districts.

RESULTS

A total of 92.1% (8496/9228) of questionnaires were completed. The overall prevalence of nocturnal enuresis was 6.8%. The ratio of male to female was about 1.5 (8.0% vs. 5.5%). The prevalence of enuresis according to age group declined from 12.5% at 6 years to 2.0% at 12 years. The prevalence of enuresis in the urban area did not show significant difference from that of rural area (6.2% vs. 6.9%). Of the factors associated with enuresis, gender, age, urinary frequency or urgency, heredity, drinking habit before sleep and difficulty in waking showed significant difference after multiple logistic regression analysis. After multivariate analysis, difficulty in waking and time of wetting were the only factors significantly associated with the severity of enuresis.

CONCLUSION

Our investigation showed the prevalence of enuresis is similar to those reports from the north of Taiwan and most of other western countries, but higher than that of China and Hong-Kong. Difficulty in waking and time of wetting were the only factors significantly associated with the severity of enuresis.

Nocturnal enuresis: a survey of parental coping strategies at 7 1/2 years

BACKGROUND

Childhood nocturnal enuresis is a potentially distressing experience. Parents have been found to adopt many approaches designed to help their child become dry at night. This study sought to understand, through a large cohort of children at 7 1/2 years of age, the strategies parents adopt, both during the child's development and currently, to help their child overcome bed-wetting.

METHODS

A longitudinal cohort of 13,971 children with expected date of delivery between April 1991-December 1992, in the County of Avon (Bristol) formed the population study group. At 7 1/2 years parents were asked, as part of a regular self-report questionnaire, what methods they had tried or were currently using to help their child stop bed-wetting. Eleven options were supplied.

RESULTS

Of 8269 parents responding to the questionnaire, 3376 (40.8%) indicated they had tried at least one of 11 strategies, with restricting night-time fluids and lifting being the predominant methods employed. Amongst strategies employed in the past, lifting and showing displeasure were used significantly more by parents of children with nocturnal enuresis than by those with children dry at 7 1/2 years. However, a greater proportion of parents of dry children encouraged their offspring to toilet more regularly in the daytime than parents of those with nocturnal enuresis or infrequent wetting. In terms of treatment interventions, the enuresis alarm had been employed with 19.2% and medication with 13.1% of those with nocturnal enuresis, although only 31.9% of those with nocturnal enuresis had seen a health worker. The results are discussed in relation to preventative and clinical implications.

Nocturnal enuresis at 7.5 years old: prevalence and analysis of clinical signs

OBJECTIVE

To determine the prevalence of nocturnal enuresis (NE) in a large cohort of children at 7.5 years old, and to examine the frequency of variables such as gender, severity, associated elimination problems, and clinical signs within the identified group.

SUBJECTS AND METHODS

Of an original cohort of 13 971 infants alive at 12 months, 11 251 who were still active in the Avon Longitudinal Study of Parents and Children (ALSPAC) survey, were followed at 91 months. The mother or main carer was given a questionnaire which asked, amongst other items, about the presence and frequency of bedwetting, other elimination problems, and signs related to the wetting behaviour; 8269 (73.5%) questionnaires were returned and 8151 contained information on the frequency of bedwetting.

RESULTS

In all, 1260 children (15.5%) at 7.5 years wet the bed, but most wet once or less a week, and only 215 (2.6%) met the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria of NE (wetting at least twice a week). A higher prevalence was reported in boys than girls and 266 children (3.3%) had both daytime wetting and bedwetting, with 189 (2.3%) having both daytime soiling and bedwetting. Daytime urgency increased with severity of bedwetting and occurred in 28.9% of children with NE.

CONCLUSION

At 7.5 years old the incidence of bedwetting is high, but only 2.6% of this large population-based sample wet at a frequency meeting the definition of NE. Although a small percentage of children had both daytime wetting and bedwetting, the evidence suggests that these are discrete problems. Amongst children with NE, indicators of bladder overactivity were present, supporting the view of heterogeneity and the importance of individual assessment in deciding on appropriate treatment.

Alarm interventions for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults.

OBJECTIVES

To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised trials register (searched 22 November 2004) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

Fifty five trials met the inclusion criteria, involving 3152 children of whom 2345 used an alarm. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95% CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (4/22 (18%) vs 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69). Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94).

AUTHORS' CONCLUSIONS

Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.

Childhood nocturnal enuresis: Developing a conceptual framework

Nocturnal enuresis has been described as the most prevalent and chronic of all childhood problems. The experience, particularly for the older child, can be extremely distressing and limiting. It is now thought that psychological distress (emotional, behavioural, and self-esteem) arises as a consequence of bedwetting, and reaches clinical importance in only a minority who are vulnerable. Many aetiological theories have been proposed with the cause of nocturnal enuresis now regarded as heterogeneous. Based on empirical findings, a new model, termed 'the three systems,' has facilitated a greater clinical understanding of the problem and identification of the appropriate intervention. The model proposes bedwetting results from excessive nocturnal urine production and/or nocturnal bladder overactivity coupled with an inability to arouse to bladder sensations. Effective treatment arises from identification of the child's particular need and application of the appropriate psychological and pharmacological approach. Treatment methods are reviewed in terms of the new model, the mode of action, effectiveness, and application in combination.

Self-construing in children with primary mono-symptomatic nocturnal enuresis--an investigation of three measures

OBJECTIVE

This study aims to measure different aspects of self-construing in children with primary mono-symptomatic nocturnal enuresis.

METHOD

25 children aged 7-14 years, with nocturnal enuresis were recruited from a paediatric outpatient's unit specialising in enuresis [mean age 10.6 [males], 9.39 [females]] and 25 children acting as controls, were recruited from one primary and one secondary school [mean age 10.08 [males], 9.39 [females]].

MEASURES

The Butler Self Image Profile [SIP], Coopersmith Self Esteem Inventory, Ouvinen-Birgerstam "I think I am" Self Perception Scale were administered.

DESIGN

This study was a matched controlled group comparison.

RESULTS

The only significant difference was the tendency for children with enuresis to construe themselves more negatively on the SIP. There were no significant differences between children with enuresis and the matched controls on all the other measures.

CONCLUSION

Children with nocturnal enuresis generally perceive themselves similar to children without nocturnal enuresis, and are not "psychologically or emotionally disturbed." It is important to assess a child's self-construing in order to identify those children who are more vulnerable to a lower self-esteem. Future research needs to take into account self-construing in different clinical populations, i.e. those children who have non-mono symptomatic nocturnal enuresis.

Sleep disordered breathing and nocturnal polyuria: nocturia and enuresis

Although nocturnal voiding is frequently attributed to urologic disorders, nocturia and enuresis are also important symptoms of sleep-disordered breathing. However, polyuria can be elicited by obstructive sleep apnea as well as bedrest, microgravity and other experimental conditions where the blood volume is shifted centrally to the upper body. The nocturnal polyuria of sleep apnea is an evoked response to conditions of negative intrathoracic pressure due to inspiratory effort posed against a closed airway. The mechanism for this natriuretic response is the release of atrial natriuretic peptide due to cardiac distension caused by the negative pressure environment. This cardiac hormone increases sodium and water excretion and also inhibits other hormone systems that regulate fluid volume, vasopressin and the rennin-angiotensin-aldosterone complex. Treatment of sleep apnea and airway compromise has been shown to reverse nocturnal polyuria and thereby reduce or eliminate nocturia and enuresis. Thus, careful evaluation of nocturia and enuresis for evidence of nocturnal polyuria can increase the diagnostic certainty of referring primary care providers and sleep specialists. In addition, the resolution of these bothersome symptoms after treatment can contribute to patient satisfaction as well as reinforce treatment compliance.

Alarm interventions for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults.

OBJECTIVES

To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (December 2002) and the reference lists of relevant articles. Date of the most recent searches: December 2002.

SELECTION CRITERIA

All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

Fifty three trials met the inclusion criteria, involving 2862 children. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.36, 95% CI 0.31 to 0.43). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents. Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (RR 4/22 (18%) vs 16/24 (67%),RR 0.27, 95% CI 0.11 to 0.69). Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94).

REVIEWER'S CONCLUSIONS

Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm) and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.

Alarm treatment for childhood nocturnal enuresis: an investigation of within-treatment variables

OBJECTIVE

The enuresis alarm has been widely advocated as an effective intervention in the treatment of childhood nocturnal enuresis. Although there is a body of evidence concerning which pretreatment variables are related to outcome, there is little evidence relating to influential within-treatment variables. This study sought to examine a series of treatment variables against outcome.

MATERIAL AND METHODS

A total of 66 children with severe primary nocturnal enuresis but with no day-time wetting were treated with a body-worn enuresis alarm. Pre- and within-treatment variables were collected. Success was considered to be 14 consecutive dry nights during a 16-week period.

RESULTS

A total of 54.5% of children achieved the success criterion, with 12.1% being classed as partial successes. Of the pretreatment variables, only low functional bladder capacity was significantly associated with failure. Inability to be woken by the alarm emerged as the most important within-treatment predictor of failure.

CONCLUSIONS

The success of alarm treatment is dependent on the child's ability to be aroused by the alarm. Interestingly, of those who successfully became dry, 72.2% slept throughout the night for >80% of nights that they were dry, suggesting that the mode of action of the enuresis alarm is more complex than was previously thought.

An investigation of the impact of nocturnal enuresis on children's self-concept

OBJECTIVE

This study sought to evaluate the relationship between the self-esteem and the self-image of children with nocturnal enuresis and to examine these in relation to various aspects of clinical and demographic variables. Previous studies investigating the self-esteem of bedwetting children have had mixed findings. Some studies report that children with nocturnal enuresis have a lower self-esteem than their non-bedwetting peers, but other studies report that children with nocturnal enuresis perceive themselves similarly to non-bedwetting children. However, what have not been studied to date are the self-perceptions of bedwetting children treated in community clinics.

MATERIAL AND METHODS

A total of 114 bedwetting children treated in community clinics provided the sample. School nurses conducted a routine first-visit assessment, collected baseline demographic and social information and invited children to complete the Butler Self-Image Profile and the Coopersmith Self-Esteem Inventory.

RESULTS

Age and extent of wetting were not significantly related to self-concept measures. Girls had significantly (p = 0.008) higher scores on positive self-image compared with boys. Children with secondary enuresis also scored higher on positive self-image compared with those with primary nocturnal enuresis (p = 0.02). The Butler self-image scores indicated a number of significant links between positive self-image and enuresis variables, whereas the Coopersmith self-esteem scores generally failed to distinguish between the enuresis variables and closely reflected those of the negative self-image scores.

CONCLUSIONS

These findings suggest that amongst children with nocturnal enuresis, the most vulnerable in terms of self-image are male, those with primary enuresis and those with a greater number of wet nights a week.

Enuresis and incontinence in children

The terminology used to describe wetting children is defined. The etiologies of monosymptomatic nocturnal enuresis and nonneuropathic bladder-sphincter dysfunction are described. Treatment strategies and the results of recent large scale studies are presented.

Enuresis and encopresis in a south Indian population of children

INTRODUCTION

Though bladder and bowel control are important developmental milestones in all cultures, the prevalence of enuresis and encopresis has rarely been studied in developing countries despite there being factors in these countries that could affect it. This study reports the prevalence and associations of enuresis and encopresis in children in Kerala, India.

METHOD

The parents of 1403 randomly selected 8-12-year-old children were interviewed. The prevalence of enuresis and encopresis was ascertained using Rutter's A2 scale. Subsamples of children underwent psychiatric, physical and psychometric evaluations.

RESULTS

Of the children, 18.6% had had an episode of enuresis in the past year and 4.3% in the past week. Four per cent had had an episode of encopresis in the past year. Enuresis was associated with parents' education, physical and psychiatric symptoms in the child, poor academic achievement and lax parental attitudes to toilet training. Encopresis was associated with male sex, physical and psychiatric symptoms, poor academic achievement, early separation and not having a toilet.

DISCUSSION

The prevalence of enuresis compares with western countries, but encopresis is commoner. The associations of enuresis suggested a multifactorial model in which parental competence was prominent. This study de-emphasized the importance of neurodevelopmental factors in enuresis and encopresis in this age group.

Attaining nocturnal urinary control, nocturnal enuresis, and behavioral problems in Chinese children aged 6 through 16 years

OBJECTIVE

To estimate the prevalence of nocturnal enuresis and to examine associations between nocturnal urinary control or enuresis and behavioral problems in Chinese children.

METHOD

A community sample of 3,600 children aged 6 through 16 years was drawn from Shandong Province of China in 1997; 3,344 (93%) returned completed questionnaires. The Child Behavior Checklist and Teacher's Report Form were used to measure children's behavioral problems.

RESULTS

The proportion of children attaining nocturnal urinary control before age 2 was 7.7%; by age 3, this had increased to 53.1%, and by age 5 to 93%. The overall prevalence of nocturnal enuresis was 4.3%, with a significantly higher prevalence in boys than girls. There was no significant decrease in the prevalence of enuresis between 6 and 16 years of age. Multiple logistic regression analyses showed that attaining nocturnal urinary control after age 4 and current enuresis were significantly associated with an increased risk of behavioral, emotional, and academic problems.

CONCLUSIONS

Chinese children attain nocturnal urinary control earlier than Western children. The prevalence of nocturnal enuresis is low but fairly stable in children between 6 and 16 years. The findings support the link between nocturnal enuresis and psychopathology in children and adolescents.

The three systems: a conceptual way of understanding nocturnal enuresis

Childhood nocturnal enuresis has traditionally been regarded as a multifaceted problem with a variety of treatment interventions. This paper proposes a model based on the notion that nocturnal enuresis arises through the ill functioning of one or more of the following three systems - a lack of vasopressin release during sleep; bladder instability; and/or an inability to arouse from sleep to bladder sensations. Clinical signs of each system are outlined and the appropriate treatment intervention for each is discussed. It is argued that addressing nocturnal enuresis in this way will enhance overall treatment effectiveness.

An epidemiological study of enuresis in Korean children

OBJECTIVE

To estimate the prevalence of enuresis in children of elementary school age, to evaluate the impact of enuresis on these children and their parents, and to identify the methods and effectiveness of managing enuresis. Subjects and methods A randomly selected cross-sectional study was conducted in one elementary school in each urban ward (nine schools) in Pusan, Korea. The parents of these 12 570 children aged 7-12 years were asked to complete questionnaires which included items about the presence and frequency of enuresis, its perceived impact and management. Enuresis was defined as an episode of wetting occurring at least once per month.

RESULTS

The overall response rate to the questionnaire was 55.8% (girls 28.2%, boys 27.6%). The prevalence of nocturnal, diurnal and combined enuresis was 9.2%, 2.2% and 1.4%, respectively. The overall prevalence of enuresis declined with age from 20.4% at 7 years old to 5.6% at 12 years old; 342 (57.0%) parents and 318 (55. 6%) children were concerned about enuresis. The common self-help strategies were waking the child at night to void (38.1%) and restriction of water intake (25.7%). Of the enuretic children, only 13.7% had consulted a health worker.

CONCLUSION

The prevalence rates for enuresis in Pusan are similar to those reported from European countries. Enuretic children and their parents were moderately concerned about enuresis and the parents primarily used self-management within the family.

An Italian epidemiological multicentre study of nocturnal enuresis

OBJECTIVE

To estimate the prevalence of enuresis in schoolchildren in Italy.

SUBJECTS AND METHODS

The Italian Club of Nocturnal Enuresis promoted a prevalence study of nocturnal enuresis using a self-administered questionnaire in seven cities in Northern, Central and Southern Italy. The association between enuresis and potential risk factors, e.g. a family history of enuresis, stress, socio-economic status and abnormal diurnal voiding habits, was investigated. The perceived impact on the child and on the family was also evaluated. A random-cluster sampling scheme was used to obtain a sample of primary and secondary schoolchildren from each city. One primary school and one secondary school for each socio-economic level was sampled in each city, giving a total of 42 schools surveyed; 9086 children were covered by the survey. In a cluster sampling method, the variance of prevalence is divided into two components, binomial and extra-binomial variability. Both the DSM III and DSM IV definitions of enuresis were used because at present, there is no consensus on the diagnostic criteria.

RESULTS

Completed questionnaires were received from 7012 children, an overall response rate of 77.2%. Those aged 6-14 years were analysed, restricting the sample to 6892 children. There were 250 enuretic children using the DSM III definition of enuresis and 112 using the DSM IV definition. The overall prevalence was 3.88% and showed a decreasing trend with increasing age. Bedwetting was more frequent in boys than in girls. The prevalence of enuresis was higher when the child was from a family of low socio-economic status despite the child's age group. The logistic analysis showed that familiality, stress, birthweight, age of attaining diurnal continence, soiling and, for girls, menstruation, were statistically significant variables and thus contributed to predicting the probability of bedwetting, confirming the findings of previous studies. There was a large difference in prevalence using the two DSM definitions; a high percentage of DSM III enuretic children had more than two wet nights per week.

CONCLUSION

It is important that a consensus about the 'working definitions' of enuresis is reached to avoid bias in the recruitment step, to carry out comparable epidemiological studies and to obtain adequate therapeutic responses.

Epidemiology of enuresis in Turkish children

To establish the prevalence of enuresis in Turkish children and to identify common methods of managing enuresis, a self-administered questionnaire was distributed to parents of 5754 children aged 7-12 years. From a response rate of 96% the overall prevalence of any reported nocturnal enuresis was 11.5% and diurnal enuresis was 0.5%. The prevalence of enuresis was higher in boys than in girls. Turkish parents primarily administered behavioural techniques for the management of enuresis. These results suggest that prevalence rates for nocturnal enuresis in Turkish children are similar to those in previous studies reported from Western Europe, the USA and Australia.

Sex and sociocultural correlates of urinary incontinence in Israeli preschool children

Urinary incontinence in children aged 2 to 6 years whose mothers varied in ethnic descent, in level of education, and in immigration status was studied in Israel. Mothers of 302 children were interviewed in well-baby clinics regarding primary and secondary urinary incontinence of their children. A significant age trend was found for attaining primary urinary continence. However, various interactions between mothers' ethnic descent, mothers' level of education, and mothers' immigration status were associated with different rates of primary and secondary urinary incontinence in their children. Moreover, sex differences in rates of primary and secondary urinary incontinence were also associated with mothers' ethnic descent and level of education. It is suggested that different levels of maternal emotional availability to the child in the various subgroups can account for most of the findings.

Psychosocial implications of nocturnal enuresis

Primary nocturnal enuresis (PNE), a biobehavioral problem affecting approximately 5,000,000 children in the United States, is among the most bothersome and frustrating disorders of childhood. Negative psychosocial consequences are common, secondary to the impact of enuresis on family members and others. The enuretic child may be at increased risk for emotional or even physical abuse from family members and may experience stress related to fear of detection by peers. These factors contribute to the loss of self-esteem that the enuretic child often experiences. Fortunately, a number of treatments--most commonly pharmacologic or behavioral intervention--are often effective in improving or correcting PNE. This disorder not only can be addressed but should be addressed because effective treatment benefits both the patient and the patient's family.

Behavioral management of toilet training, enuresis, and encopresis

Toileting problems are a matter of great concern to parents and are a frequent source of family discord, but proper handling of toilet training as well as enuresis and encopresis can ameliorate any untoward effects of these problems. Both the pediatrician and the pediatric psychologist can play a major role in this area.

Sex distribution of adult idiopathic detrusor instability in relation to childhood bedwetting

The urodynamic case records of 1000 consecutive men and women were reviewed to study the link between idiopathic detrusor instability (DI) and childhood nocturnal enuresis and to determine whether a sex difference in this relationship may exist. Idiopathic DI was found in 10% of the men, 63% of whom had suffered from childhood bedwetting; 29% of the women had idiopathic instability, of whom 38% had been nocturnal enuretics. Thus the link between adult idiopathic DI and childhood bedwetting appeared to be stronger for men than for women. The sex distribution of subjects is not always reported in urodynamic studies of bedwetters and adults with an unstable bladder. We suggest that this should become routine practice as it may help to shed light on the aetiology of idiopathic detrusor instability.

A 6 year follow-up of childhood enuresis: prevalence in adolescence and consequences for mental health

Recent studies have shown an association between enuresis and behavioural or emotional problems. The direction or causality of the association and its duration, however, remain unclear. This study followed a large group of children from ages 11 to 15 years and reported the prevalence of enuresis to age 13 years. The enuretic status of the sample at age 11 years was established relative to the history of enuresis at age 9 years. At age 11 years a significant association was found between enuresis and measures of psychopathology. This association was particularly evident for those children with secondary enuresis, and those who had a history of enuresis but had ceased to wet the bed. Current primary enuresis was not significantly associated with disorder. Similar associations were found between enuresis at age 11 and later disorder at age 13. At age 15 years no significant associations between enuresis and disorder were found. These findings have implications for parents of children with enuresis and for clinicians dealing with the disorder.

Isle of Wight revisited: twenty-five years of child psychiatric epidemiology

Child psychiatric epidemiology over the last 25 years is reviewed in terms of conceptual and methodological issues arising out of substantive findings. The Isle of Wight surveys undertaken in the mid-1960s are briefly described to establish a starting point, and progress since then is reviewed in terms of topics not originally covered--especially problems in preschool children and specific psychiatric disorders. The use of epidemiology to study causal hypotheses is considered, methodological advances are noted, and challenges for the future are discussed.

The school-age child: putting it all together

The school-age period offers many opportunities to the pediatrician for creative, interesting evaluations and interventions. Many problems are not apparent in bold colors but rather in muted pastels. Often we are aware of an at-risk status, but let it ride because there are other more acute concerns going on with children in infancy and adolescence. Awareness of the consolidation of growth, the coordination of cognitive and other functions and the establishment of self-awareness and self-esteem during this period should help pediatricians focus their efforts on ensuring that the children's physical, cognitive, and psychological foundations are built firmly and maintained solidly. Far from being a period of "latency," school age is a critical era in the development of children, and pediatricians have a responsibility to participate actively in that development.

Enuresis in cross-cultural perspective: a comparison of training for elimination control in three Israeli ethnic groups

Enuresis was investigated in the context of different styles of training for bladder control among three Israeli ethnic groups (Jews of Moroccan, Kurdish or Eastern European descent). Semistructured interviews were conducted in ethnically homogeneous agricultural villages with 46 mothers of 248 children between the ages of 3 and 18 years. In contrast to previous British and American studies, no sex differences were found, but there were higher rates of primary enuresis and lower rates of secondary (regressive) enuresis. Enuresis was correlated among siblings in the Kurdish group only and with disorderly sleeping arrangements in the Moroccan group. The Moroccan and Kurdish groups had higher rates of enuresis than the Ashkenazi group. The higher rates appear to be related to differences in the age of onset of training and a lack of age-appropriate changes in the parent-child interaction, which led to chronic enuresis and the inability to seek effective assistance. These results are discussed in terms of a proposed typology for training: an early symbiotic style, a strict toddler style, and a communicative partnership.

A preventive context for enuresis

Prevention of enuresis has not been studied directly. Positive results from a randomized clinical trial evaluating early intervention for children at risk for enuresis would establish the value of prevention and help to promote its practice. Enuresis is not a disease process, and therefore a clinical trial may never be conducted, but the treatment of enuresis can be a threat to the child's health, as can the parental, professional, and peer response to the wetting. Children cannot die from wetting the bed. They can die from the medicine given to them to stop the bed wetting. Wet beds cannot cause contusions, abrasions, and concussions. Punishments administered for bed wetting can. Urine cannot cause emotional disturbance. Ridiculing, admonishing, or singling out a child for urinating can. Numerous suggestions are available to help to prevent the problems linked to enuresis, and perhaps to prevent enuresis itself. They range from the simple (e.g., waiting for the problem to resolve itself) to the very complex (e.g., promoting a change in the DSM-III criteria). The preventive suggestions in this paper are by no means exhaustive. Rather, they are an example of suggestions that can come from the literature on each aspect of enuresis: diagnosis, incidence, etiology, and treatment. A review of this literature reveals that, no matter which aspect of enuresis a researcher investigated or which body of findings a clinician examined, increased prevention could be the outcome. Child health should be the provider's abiding concern when choosing a treatment for enuresis. Management by parents and health care providers constitutes the primary threat that enuresis poses to emotional and physical health. Historically, the choice of treatment was governed more by the possibility of continence than by possible side effects on child health. The decision to use a treatment should be guided by the pediatrician's assessment of the child's readiness, willingness of the child and parents, and family resources. Although treatment is evolving, some interventions are highly rigorous and appear to focus primarily on dryness (e.g., the original dry-bed training). Treatment for enuresis has not yet been conceptualized into an encompassing context of health as have other medical maneuvers (e.g., physical examinations are now part of health maintenance). Enuresis is a presenting complaint that is not of itself a threat to health. Prevention, therefore, is its most appropriate context, and the pediatrician is the primary promoter of that context.