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Original Research (Original Article) 


Kharifah Mohammad Sherah et al, 2019;3(8):669–675.

International Journal of Medicine in Developing Countries

Prevalence of nocturnal enuresis in school-age children in Saudi Arabia

Kharifah Mohammad Sherah1*, Mohamed Waheed Elsharief2, Norah Abdullah Abdh Barkat3, Aysha Mayed Ali Jafery3

Correspondence to: Kharifah Mohammad Sherah

*Pediatrics Department, Prince Mohammad Bin Nasser Hospital, Jazan, Saudi Arabia.

Email: kharifahsherah [at] gmail.com

Full list of author information is available at the end of the article.

Received: 09 January 2019 | Accepted: 20 March 2019


ABSTRACT

Background:

Nocturnal enuresis (NE) refers to an inability to control urination during sleep. It is an essential problem for school-age children. This study aimed at determining the prevalence of NE and its associated factors in primary school children studying at Jazan city, Saudi Arabia.


Methodology:

In this cross-sectional questionnaire-based study, 505 male and female children aged between 5 and 12 years were randomly selected from all the grades of 10 public primary schools of Jazan. Questionnaires were completed by the child’s parents or guardian at home. The statistical package for the social sciences software version 22 and Chi-Square test were used to investigate the relationship between NE and the variables, logistic regression was applied to model the factors affecting NE concurrently, considering the significance level of p < 0.05.


Results:

The results showed that 76.4% of the children had NE, including 52.6% corresponding to the primary type of NE. The prevalence of NE in the boys (79.5%) was non-significantly higher than girls (73.3%). The highest prevalence rate was found in the age group between 9 and 12 years (85.6%) and the lowest rate was found in 5-year-old (64.0%) subjects with significant difference (p < 0.05). There were statistically significant relationships between NE and history of pinworms infestation (p = 0.001), no breastfeeding (p = 0.017), low school performance (p = 0.001), and lower father education (p = 0.001).


Conclusion:

This survey clarified the high prevalence of NE among primary school children aged between 5 and 12 years in Jazan, Saudi Arabia. Low school performance, pinworms infestation, and low educational qualification of the respective fathers were identified as significant risk factors for NE among the studied population.


Keywords:

Nocturnal enuresis, prevalence, risk factors, Jazan, Saudi Arabia.


Introduction

Enuresis is defined according to the diagnostic and statistical manual of mental disorders IV (DSM-IV) as the repeated voiding of urine into bed or clothes at least twice a week for at least three consecutive months in a child who is at least 5 years of age. Nocturnal enuresis (NE) refers to voiding during sleep, whereas diurnal enuresis describes wetting while awake [1]. Each of nocturnal and diurnal types can be primary when the child has never been dry or secondary when it happens after at least 6 months of being dry [2]. Primary enuresis constitutes 90% of all enuresis cases. It is often associated with a familial history of enuresis and also could develop be due to the developmental disorder affecting the bladder sphincter. The secondary type of enuresis might be due to urologic or neurological problems, such as recurrent urinary tract infection and disorders of the spinal cord [3]. Other causes of enuresis include diabetes mellitus and occurrence of emotional stresses and family conflicts [4]. NE is an essential problem for school-age children. It can cause behavioral, emotional, and social problems for the child as well for his/her family. These psychological sequels may be more significant and overwhelming to the child than enuresis itself [5]. Therefore, NE is considered as a significant public health problem that requires a thorough identification of children at risk and performing therapeutic interventions. NE is seen worldwide across all races and cultures. It is a common problem amongst school children and the reported prevalence varies across studies [3]. In a few studies, the overall prevalence rate was reported to be 5%–20% [6]. The reported prevalence in Saudi Arabia was 15% [7]. Despite the importance and the devastating consequences of NE, this problem remains under-reported in Saudi Arabia. Comprehensive studies in this regard are considerably lacking. Therefore, the goal of this study was to investigate the prevalence of this disorder and its associated factors in primary school children in Jazan city.


Subjects and Methods

A cross-sectional survey was conducted in Jazan city. The study population involved boys and girls attending regular public primary schools. These schools in Saudi Arabia include pupils from grade 1 to 6. The aim of this study was explained to the local educational authority to get their permission to carry out the survey. To ensure that the sample is representative of schools in Jazan, all governmental public schools were coded, and then five boys’ schools and five girls’ schools were selected randomly. In each particular school, all educational levels (grades) were included. Then, for each grade, the classes and the pupils were selected through the systematic randomization as well. The children less than 5 years and those older than 12 years were excluded from the study. The minimum sample size required to investigate the prevalence of NE was calculated to be 500 participants (250 girls and 250 boys) using G power program version 3.0.10. Considering a statistical power calculation of 80%, confidence level of 95%, and based on a prevalence of 15% for NE [7], an effect size of 0.05 and a 0.20 loss of response. Questionnaires employed and distributed by trained medical students for the data collection. The questionnaires were completed by the child’s parents or guardian. A letter explaining the aim of the study and a consent form were sent in an enclosed envelope to the parents of the children. The questionnaire applied in this study was previously prepared and tested for validity and reliability by Bakhtiar et al. [3]. It consisted of two parts. The first part contained the demographic and socioeconomic data, including age, gender, parental marital status, parental education, parental kinship, parental occupation, family size, birth order, and other variables, such as new baby’s birth in the family, change of living place, sleep quality, child’s corporal punishment by parents, academic failure, and corporal punishment at school. The second part consisted of various kinds of active enuresis (NE and diurnal enuresis), primary and secondary enuresis, history of active enuresis in other children, history of urinary tract infection and respiratory infection in the child, pinworms, anal itching, seizures, diabetes, hyperactivity, breastfeeding, and history of previous treatments for NE. Primary NE was defined as bedwetting in a child who had never been dried and secondary NE was defined as experiencing dryness for more than 6 months.

The data were analyzed using the Statistical Package for the Social Sciences software version 22. Chi-Square test was used to investigate the relationship between NE and the variables, and logistic regression was applied to model the factors affecting NE concurrently, considering the significance level of p < 0.05.


Results

This study was assessed 505 primary school children, aged between 5 and 12 years. Male subjects constituted 50.3% with nearly equal sex distribution. Parents of the studied children were mostly (93.7%) married, whereas few (5.0%) of them were divorced. Moreover, more than half of their parents (father and mother) attained university education (51.9% and 52.5%, respectively). Furthermore, a great percentage (88.1%) of their fathers were employed, while most (65.7%) of their mothers were housewives (Table 1). Among the studied subjects, 386 participants (76.4%) had NE, while 140 (27.7%) recorded diurnal enuresis. Figure 1 demonstrates that both nocturnal and diurnal enuresis belonged to the primary type (52.6% and 62.1%, respectively) of NE. Table 2 shows that the prevalence of NE was non-significantly higher in boys than girls (79.5% vs. 73.3%, respectively). However, the rate of diurnal enuresis was significantly higher in girls (32.3%) than in boys (23.2%). As regards the relation of enuresis to age, Table 3 demonstrates that the highest prevalence of NE (85.6%) was found in the higher age group (>9–12-year-old) and the lowest rate (64.0%) was reported among the 5-year-old group with a significant difference between the studied age groups (p < 0.001). Likewise, the rate of primary enuresis was significantly higher (53.8%) among the older age group (>9–12-year-old, p = 0.006). Table 4 shows the association of socio-behavioral factors of the family to the frequency of NE. There was no significant relation of parental marital status, mother education, whether parents were working or not, and the frequency of NE. Moreover, neither family size, birth order of the child, the occurrence of stressful events, such as the birth of a new baby or recent change in a living place, nor punishment of the child showed any significant association to NE (p > 0.05). However, father’s education showed a significant association with NE, where children having NE showed the significantly lower percent of university education for their respective fathers compared to those who do not give NE (p = 0.001). Furthermore, children having NE showed mainly (48.4%) good school performance, while the excellent performance was the most frequent (51.7%) among children having no NE (p < 0.05). The development of NE in the studied subjects showed a significant association with the history of NE in one of the family members (p < 0.001). In addition, 66 (17.1%) subjects suffering NE did not have normal breastfeeding with a statistically significant difference (p =0.017). Moreover, the prevalence of NE in the studied children showed a significant relation to pinworms infestation (p = 0.001). The remaining morbidities, including the history of the urinary tract or respiratory infections, diabetes mellitus, and seizures, did not show significant association with NE (p > 0.05) as illustrated in Table 5. Multivariate logistic regression analysis of the factors that showed significant association with NE revealed a significant model, including pinworms infestation, academic performance of the child, and the level of the father’s education, as predictors of NE in the children, with a predictive power of 86%. The risks (odds ratios) of these factors were 6.22, 2.16, and 0.45, respectively. Table 6 illustrates that most (77.4%) of the NE children did not receive the proper treatment. Seeking medical advice was reported only by 38.2% of parents. Moreover, parents depended mainly on advices like voiding before sleep and fluid restriction (75.3% and 21.4%, respectively).

Table 1. Socio-demographic characteristics of the studied children (N = 505).

N %
Age groups (years) 5 125 24.8
>5–7 110 21.8
>7–9 110 21.8
>9–12 160 31.7
Sex Female 251 49.7
Males 254 50.3
Parental marital status Widow 7 1.4
Married 473 93.7
Divorced 25 5.0
Education of father Read and write 19 3.8
Primary 56 11.1
Secondary 168 33.3
University 262 51.9
Education of mother Read and write 38 7.5
Primary 48 9.5
Secondary 154 30.5
University 265 52.5
Work of father No 60 11.9
Employee 445 88.1
Work of mother Housewife 332 65.7
Employee 173 34.3

Figure 1. Prevalence of different types of enuresis among the studied children.

Table 2. Prevalence of enuresis in relation to sex of the studied children.

Enuresis Sex Chi-Square test
Female Male Total
N % N % N % p value
Nocturnal No 67 26.7 52 20.5 119 23.6 0.10
Yes 184 73.3 202 79.5 386 76.4
Diurnal No 170 67.7 195 76.8 365 72.3 0.02*
Yes 81 32.3 59 23.2 140 27.7
Primary No 136 54.2 142 55.9 278 55.0 0.70
Yes 115 45.8 112 44.1 227 45.0
Secondary No 201 80.1 202 79.5 403 79.8 0.88
Yes 50 19.9 52 20.5 102 20.2

*significant at p<0.05

Table 3. Prevalence of enuresis in relation to the ages of the studied children.

Age groups (years) Chi-Square test
5 >5–7 >7–9 >9–12 Total
N % N % N % N % N % p value
Nocturnal No 45 36.0 35 31.8 16 14.5 23 14.4 119 23.6 <0.001*
Yes 80 64.0 75 68.2 94 85.5 137 85.6 386 76.4
Diurnal No 86 68.8 87 79.1 78 70.9 114 71.3 365 72.3 0.32
Yes 39 31.2 23 20.9 32 29.1 46 28.8 140 27.7
Primary No 82 65.6 66 60.0 56 50.9 74 46.3 278 55.0 0.006*
Yes 43 34.4 44 40.0 54 49.1 86 53.8 227 45.0
Secondary No 98 78.4 91 82.7 88 80.0 126 78.8 403 79.8 0.84
Yes 27 21.6 19 17.3 22 20.0 34 21.3 102 20.2

*significant at p<0.05

Table 4. Socio-behavioral factors associated with nocturnal enuresis.

Nocturnal enuresis Chi-Square test
Yes No Total
N % N % N % p value
Marital status Widow 5 1.3 2 1.7 7 1.4 0.16
Marries 358 92.7 115 96.6 473 93.7
Divorced 23 6.0 2 1.7 25 5.0
Education of father Read and write 17 4.4 2 1.7 19 3.8 0.001*
Primary 45 11.7 11 9.2 56 11.1
Secondary 142 36.8 26 21.8 168 33.3
University 182 47.2 80 67.2 262 51.9
Education of mother Read and write 34 8.8 4 3.4 38 7.5 0.14
Primary 37 9.6 11 9.2 48 9.5
Secondary 121 31.3 33 27.7 154 30.5
University 194 50.3 71 59.7 265 52.5
Work of father No 45 11.7 15 12.6 60 11.9 0.78
Employee 341 88.3 104 87.4 445 88.1
Work of mother Housewife 253 65.5 79 66.4 332 65.7 0.87
Employee 133 34.5 40 33.6 173 34.3
Number of children in the family Only one 29 7.5 17 14.3 46 9.1 0.05
1-3 135 35.0 48 40.3 183 36.2
4-5 123 31.9 32 26.9 155 30.7
>5 99 25.6 22 18.5 121 24.0
Birth order of the child First 118 30.6 45 37.8 163 32.3 0.20
Second 89 23.1 18 15.1 107 21.2
Third 60 15.5 16 13.4 76 15.0
Fourth or more 119 30.8 40 33.6 159 31.5
New baby’s birth in the family No 289 74.9 97 81.5 386 76.4 0.14
Yes 97 25.1 22 18.5 119 23.6
The recent change in living place No 293 75.9 93 78.2 386 76.4 0.61
Yes 93 24.1 26 21.8 119 23.6
Child’s punishment by parents No 202 52.3 66 55.5 268 53.1 0.55
Yes 184 47.7 53 44.5 237 46.9
Child’s school performance Good 187 48.4 36 30.3 223 44.2 <0.001*
Weak 19 4.9 2 1.7 21 4.2
Excellent 180 46.6 81 68.1 261 51.7

*significant at p<0.05


Discussion

The prevalence of NE in this study was 76.4%. In contrast, an earlier cross-sectional study in Saudi Arabia assessing 640 school children aged 6–16 year-old reported a much lower prevalence of 15% [7]. Furthermore, a study on 450 Egyptian students aged 6–12 years in Benha city reported a rate of 15.7% for NE. A lower prevalence of NE was also reported among school children in Isparta (11.5%), Istanbul (12.4%), [1,8,9], and Ankara (17.5%) [3]. Several epidemiological surveys of NE have been undertaken in various parts of the world, including Western Europe [10], Taiwan [11], Thailand [12], and they revealed much lower prevalence among comparable age groups. The observed differences could be attributed to the differences in sample size, sampling method, age range, and definition of NE whether based on the DSM-IV or the internal classification of diseases-10 criteria [13]. In this study, the prevalence of diurnal enuresis was 27.7%, being much higher than recorded in the studies conducted by Bakhtiar et al. [3] and Safarinejad [14] in Iran and Toktamis et al. [15] in Turkey. The current study revealed that the frequency of primary NE represented the majority among cases of both nocturnal and diurnal enuresis (52.6% and 62.1%, respectively). This finding is in line with a study that recorded the frequency of bedwetting among primary school children in Benha city, Egypt [16]; this reported 81.4% frequency of NE. In addition, few other similar studies have also been done in Saudi Arabia (15%) [8] and in China (4.3%) [17]. The current survey explored that prevalence of NE was non-significantly higher in boys than girls (79.5% vs. 73.3%, respectively). The association of NE to gender showed inconsistent results. In accordance with our finding, Liu et al. [17] and Piyasil et al. [18] have reported non-significant differences, whereas significantly higher prevalence among males was recorded in various studies [3,19]. In contrast, some studies in Turkey and Sanandaj have reported a higher prevalence of NE among girls than in boys [9,20]. As regards diurnal enuresis, the present study revealed significantly higher frequency in girls (32.3%) than in boys (23.2%). Similarly, Jarvelin et al. [21] reported the rate of this disorder to be higher in girls, whereas significantly higher prevalence among the boys was reported by Bakhtiar et al. [3]. According to the reports of the study participants, the present study revealed that the frequency of NE significantly increases as the age increases; it was 64% at the age of 5 years, 85.5% at the age of 7–9 years, and 85.6% at the age of 9–12 years. Previous studies from different regions reported a gradual decline in the frequency of NE from the age of 6 years up to 12 years [3,16,22]. As NE improves spontaneously [23], it was anticipated to decrease with age. But, unexpectedly, this did not happen in the present study participants. This could be attributed to a lack of concern regarding the disease among the parents and the persistence of the condition. It was also observed that most children with NE in this study were not treated. Moreover, their parents depended mainly on fluid restriction and bladder emptying before sleep rather than seeking medical advice and using medications. Additionally, about 20% of children in this study developed secondary type NE, which requires more interventions. Comparable to the attitude of the studied parents, Safarinejad [14] reported that 78.6% of the parents applied drug treatments. This could be related to cultural differences and more parental sensitivity toward the treatment of NE. The development of NE in the studied subjects showed a significant association with the history of NE in one of the family member. The existence of a familial history of NE in enuretic children was reported in a number of studies [3,10,23]. The analysis of the factors related to NE revealed non-significant relation of parental marital status, mother’s education, whether parents were working or not, and the frequency of NE. Moreover, neither family size, birth order of the child, occurrence of stressful events, such as the birth of a new baby, or recent change in a living place, nor punishment of the child showed any significant association with NE. These findings contradict with results of an Iranian study [24] reporting that most enuretic children have jobless fathers, working mothers, divorced parents, and crowded family. Few studies reported that parents of enuretic children had low educational level [10,11,24]. In our study, education of the father was significantly associated with NE, where children having NE showed a significantly lower percentage of university education compared to those having no NE. Personal factors that were encountered more among enuretic children included poor school performance, positive history of pinworms infestation, and lack of breastfeeding. Multivariate logistic regression analysis revealed a significant model, including pinworms infestation, academic performance of the child, and the level of the father’s education, as predictors of child NE, with a predictive power of 86%. The risks (odds ratios) of these factors were 6.22, 2.16, and 0.45, respectively. The relation of poor school performance tonight bed wetting was comparable with other epidemiologic studies from various countries [10,24,25]. In addition, Bakhtiar et al. [3] reported a significant association of anal itching to the presence of NE.

Table 5. Association of family history, and nature of the child’s feeding and medical condition to nocturnal enuresis.

Nocturnal enuresis Chi-Square test
Yes No Total
N % N % N % p value
Family history No 111 28.8 58 48.7 169 33.5 <0.001*
Don’t know 159 41.2 29 24.4 188 37.2
Yes 116 30.1 32 26.9 148 29.3
Breastfeeding No 66 17.1 27 22.7 93 18.4 0.017*
Don’t know 99 25.6 16 13.4 115 22.8
Yes 221 57.3 76 63.9 297 58.8
Urinary tract infection No 216 56.0 77 64.7 293 58.0 0.23
Don’t know 131 33.9 33 27.7 164 32.5
Yes 39 10.1 9 7.6 48 9.5
Diabetes mellitus No 231 59.8 75 63.0 306 60.6 0.13
Don’t know 48 12.4 7 5.9 55 10.9
Yes 107 27.7 37 31.1 144 28.5
Respiratory infection No 263 68.1 89 74.8 352 69.7 0.18
Don’t know 89 23.1 18 15.1 107 21.2
Yes 34 8.8 12 10.1 46 9.1
Seizures No 323 83.7 105 88.2 428 84.8 0.24
Don’t know 47 12.2 8 6.7 55 10.9
Yes 16 4.1 6 5.0 22 4.4
Pinworms No 229 59.3 87 73.1 316 62.6 0.001*
Don’t know 148 38.3 25 21.0 173 34.3
Yes 9 2.3 7 5.9 16 3.2

*significant at p<0.05

Table 6. Responses of the study participants about the treatment of nocturnal enuresis.

N %
Was NE treated? No 391 77.4
Don’t know 37 7.3
Yes 77 15.2
Folk treatment No 458 90.7
Don’t know 22 4.4
Yes 25 5.0
Medical advice No 312 61.8
Yes 193 38.2
Type of treatment Fluids restriction 103 21.4
Medications 12 2.5
Drugs 4 0.8
Voiding urine before sleep 362 75.3

Conclusion

This survey clarified the high prevalence of NE among primary school children aged between 5 and 12 years in Jazan, Saudi Arabia. Low school performance, pinworms infestation, and low educational qualification of the respective fathers were identified as significant risk factors. Therefore, taking therapeutic measures and training parents in dealing with children are essential to control NE.


List of Abbreviations

DSM-IV Diagnostic and Statistical Manual Of Mental Disorders-IV
NE Nocturnal Enuresis

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

The study received ethical approval from the Institutional Review Board, Jazan Hospital. NO. 1848, dated: 18 October 2018.


Author details

Kharifah Mohammad Sherah1, Mohamed Waheed Elsharief2, Norah Abdullah Abdh Barkat3, Aysha Mayed Ali Jafery3

  1. Pediatric Resident, Pediatrics Department, Prince Mohammad Bin Nasser Hospital, Jazan, Saudi Arabia
  2. Assistant Professor, Department of Pediatrics, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
  3. Medical Intern, Jazan University, Jazan, Saudi Arabia

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How to Cite this Article
Pubmed Style

Sherah KM, Elsharief MW, Barkat NAA, Jafery AMA. Prevalence of Nocturnal Enuresis in school-age children in Saudi Arabia. IJMDC. 2019; 3(8): 669-675. doi:10.24911/IJMDC.51-1547073432


Web Style

Sherah KM, Elsharief MW, Barkat NAA, Jafery AMA. Prevalence of Nocturnal Enuresis in school-age children in Saudi Arabia. http://www.ijmdc.com/?mno=25434 [Access: July 23, 2019]. doi:10.24911/IJMDC.51-1547073432


AMA (American Medical Association) Style

Sherah KM, Elsharief MW, Barkat NAA, Jafery AMA. Prevalence of Nocturnal Enuresis in school-age children in Saudi Arabia. IJMDC. 2019; 3(8): 669-675. doi:10.24911/IJMDC.51-1547073432



Vancouver/ICMJE Style

Sherah KM, Elsharief MW, Barkat NAA, Jafery AMA. Prevalence of Nocturnal Enuresis in school-age children in Saudi Arabia. IJMDC. (2019), [cited July 23, 2019]; 3(8): 669-675. doi:10.24911/IJMDC.51-1547073432



Harvard Style

Sherah, K. M., Elsharief, . M. W., Barkat, . N. A. A. & Jafery, . A. M. A. (2019) Prevalence of Nocturnal Enuresis in school-age children in Saudi Arabia. IJMDC, 3 (8), 669-675. doi:10.24911/IJMDC.51-1547073432



Turabian Style

Sherah, Kharifah Mohammad, Mohamed Waheed Elsharief, Norah Abdullah Abdh Barkat, and Aysha Mayed Ali Jafery. 2019. Prevalence of Nocturnal Enuresis in school-age children in Saudi Arabia. International Journal of Medicine in Developing Countries, 3 (8), 669-675. doi:10.24911/IJMDC.51-1547073432



Chicago Style

Sherah, Kharifah Mohammad, Mohamed Waheed Elsharief, Norah Abdullah Abdh Barkat, and Aysha Mayed Ali Jafery. "Prevalence of Nocturnal Enuresis in school-age children in Saudi Arabia." International Journal of Medicine in Developing Countries 3 (2019), 669-675. doi:10.24911/IJMDC.51-1547073432



MLA (The Modern Language Association) Style

Sherah, Kharifah Mohammad, Mohamed Waheed Elsharief, Norah Abdullah Abdh Barkat, and Aysha Mayed Ali Jafery. "Prevalence of Nocturnal Enuresis in school-age children in Saudi Arabia." International Journal of Medicine in Developing Countries 3.8 (2019), 669-675. Print. doi:10.24911/IJMDC.51-1547073432



APA (American Psychological Association) Style

Sherah, K. M., Elsharief, . M. W., Barkat, . N. A. A. & Jafery, . A. M. A. (2019) Prevalence of Nocturnal Enuresis in school-age children in Saudi Arabia. International Journal of Medicine in Developing Countries, 3 (8), 669-675. doi:10.24911/IJMDC.51-1547073432