ORIGINAL

Niger J Paed 2013; 40 (4): 370 –374

Paul NI

Alikor EAD

Anochie IC

Factors associated with enuresis

among primary school children in

Port Harcourt

DOI:http://dx.doi.org/10.4314/njp.v40i4,4

Accepted: 15th February 2013

Abstract Background: Enuresis

is a common childhood problem

and can lead to important psycho-

social disturbances.

Objectives: To determine the risk

factors to enuresis, its methods of

management and relationship with

academic performance among

school children in Port Harcourt

City (PHC)

Methods: A cross sectional study

of enuresis among school children

in PHC was performed. Pretested

questionnaires completed by par-

ents/guardians was used to collect

data. Validation of their academic

performances was made using

their results in the past one year

from the schools head teachers’

records. Descriptive statistics and

chi-square test were used for

analysis.

were significantly more frequent in

the enuretic group (p<0.05). Enu-

resis was associated with family

stressors in 45 (21.0%) of the chil-

dren. The enuretic children had

higher rates of poor school per-

formance compared with non-

enuretic children (p < 0.001) how-

ever; there was no statistical sig-

nificant relationship between enu-

resis and social class. None of the

enuretic children visited a physi-

cian for the management of enure-

sis. Prayers, punishment and

(

)

Paul NI

Alikor EAD, Anochie IC

Department of Paediatrics

&

Child Health,

University of Port Harcourt Teaching

Hospital, Port Harcourt, Rivers State,

Nigeria.

E-mail: nsypaul@yahoo.co.uk

Tel: +2348033126056

herbal medication were the meth-

ods of treatment in 89(41.6%), 42

(19.6%) and 6 (2.8%) children

respectively.

Conclusion: Arousal difficulty,

positive family history of enuresis

and family stress were common

risk factors for enuresis. Also,

enuretic children had higher rates

of poor school performance com-

pared with non-enuretic children.

The inappropriate enuresis man-

agement methods requires health

education intervention

Results: A total of 922 children,

consisting of 463 (50.2%) males

and 459 (49.8%) females were

studied. The response rate was

8

2.2%. The prevalence of enuresis

was 23.2%. Arousal difficulty and

positive family history of enuresis

Introduction

Nocturnal enuresis is frequently diagnosed among

school children and it is an important cause of_-₆psychoso-

4

Enuresis, also known as bedwetting, is the involuntary

and undesirable repeated discharge of urine during sleep

into clothes or beds beyond the age of anticipated blad-

der control-usually after five years, by night or day.

Day-time bed-wetting is referred to as Diurnal

Enuresis (DE) while nighttime bed-wetting is referred to

as Nocturnal Enuresis (NE). Combined day and night-

time bed-wetting is referred to as Nocturnal/Diurnal

cial problems for both parents and children. The etiol-

ogy/risk factors of enuresis is multifactorial and not yet

completely understood despite numerous studies. Stud-

ies have implicated functional immaturity of the central

nervous system, genetic disorder, sleep and arousal dis-

orders, organic disorders as well as p₄_,s₇y_-₁c₂hological disor-

ders as risk and or aetiologic factors.

--1-3

4

Enuresis. NE may be primary or secondary. Primary

However, due to its self-limiting nature, many parents/

care–givers often try to manage this problem by obser-

vation and_,₂ traditional methods without proper medical

nocturnal enuresis (PNE) occurs when a child has never

achieved a six month period of continuous nighttime

bladder control while secondary nocturnal enuresis

1

attention. There is evidence that effective intervention

(

SNE) refers to a child who has experienced a minimum

by motivational therapy, behavioral intervention and use

of drugs can reduce the duration of the problem and help

to improve the lives of these children and their families.

six mon₄th period of continence before the onset of bed-

7

wetting.

3

71

Studies have shown restoration and new sense of confi-

dence, improvement in self e₇s_,₈t_,e₁e₃ m and academic per-

formance in treated enuretics.

The objectives of this study was to determine the risk

factors for enuresis among school children in PHC, to

establish its relationship with their academic perform-

ance and to identify common methods of management

used in these enuretic children.

one were included in the final analysis. Of these 922

children, 463 (50.2%) were males while 459 (49.8%)

were females, giving a male female ratio of 1:1. The

mean age of the study group was 8.6years± 1.9years.

Females 87(64.0%) were more represented among the

8year olds, and more males 39 (60.9%) among 11years

old pupils. (Table 1)

Table 1: Age and Sex distribution of the study population

Age(yrs) Males (%)

Females (%) Total (%)

Methodology

6

7

8

9

1

70 (46.4)

95 (54.6)

49 (36.0)

83 (49.4)

72 (56.7)

81 (53.6)

79 (45.4)

87 (64.0)

85 (50.6)

55 (43.3)

151 (16.4)

174 (18.9)

136 (14.8)

168 (18.2)

127 (13.8)

The study was carried out among 922 primary school

children aged 6-12 years in thirteen primary schools

selected by multi-stage stratified random sampling, be-

tween November 2008 and March 2009 in Port Har-

court, Nigeria. The State Ministry of Education and the

Research and Ethics Committee of the University of

Port Harcourt Teaching Hospital (UPTH) approved the

study protocol. Informed written consent was obtained

from the parents or guardians and all children who were

0

1

39 (60.9)

25 (39.1)

64 (6.9)

12

Total

55 (53.9)

463 (50.2)

47 (46.1)

459 (49.8)

102 (11.1)

922 (100.0)

2

X =18.86, df=6, p=0.004

Prevalence of Enuresis

1

2year old gave assent for the study. In each selected

school, 90 pupils (15 from each arm of class1 to 6) aged

- 12 years were recruited by selecting all odd numbers

Out of the 922 pupils, 214 pupils had enuresis, giving a

prevalence rate of 23.2 %.

More males (59.3%) than females (40.7%) were found

to be enuretic (male: female ratio of 1.4: 1). The ob-

served sex difference in proportion was statistically

significant p=0.002. (Table 2)

6

using the class register. Children who dissent and those

whose parents/ guardians refused consent for the study

were excluded from the study.

A pretested questionnaire was used to get information

on socio-demographic data, enuresis data, and family

stressors. The questionnaires were distributed to the pu-

pils with a written consent letter explaining the aims and

procedure of the study in an enclosed envelop to the

parents. The questionnaires were completed by the par-

ents at home and returned to the investigator. The infor-

mation obtained from the questionnaires was augmented

by history obtained from the children and validation of

their academic performances was made using their cur-

rent and previous results in the past one year from the

schools head teachers’ records. Based on the average of

their academic performance, they were classified into;

Excellent, (>80%), Very good (70-79%), Average (50-

Table 2: Prevalence of Enuresis

Males (%)

Females (%) Total (%)

Enuretics

Non-enuretics

127 (59.3)

336 (47.5)

87 (40.7)

372 (52.5)

214 (23.2)

708 (76.8)

Total

463 (100.0) 459 (100.0)

922 (100.0)

2

( X =9.29, p =0.002)

Types of Enuresis

Among the enuretic children, 197(92.1%) had nocturnal

enuresis, 2(0.9%) had diurnal enuresis, while 7% had

nocturnal-diurnal enuresis (Table 3). Out of the 197 with

nocturnal enuresis, 181(92.0%) had primary nocturnal

enuresis (PNE), 15(7.5%) had SNE while in 1(0.5%) it

was not known if it was primary or secondary nocturnal

enuresis.

6

9%) and below average (<50%) pupils. Socio-

economic stratification of the children was done b₄ased

1

on the socio-economic class described by Oyedeji. The

obtained data was analyzed using the computer program

EPI INFO version 6 and SPSS 16.0 and comparisms of

subgroups carried out using the chi square test. Statisti-

cal significance at 95% confidence interval was p value

<

0.05

Table 3: Classification according to type of Enuresis

Type of enuresis

Male (%)

Female (%)

Total (%)

Nocturnal

Diurnal

115 (58.4) 82 (41.6)

197 (92.1)

2 (0.9)

1 (50.0)

4 (26.7)

Results

Nocturnal/Diurnal 11 (73.3)

15 (7.0)

Total

127 (59.3) 87 (40.7)

214 (100.0)

One thousand one hundred and seventy questionnaires

were given to pupils selected from thirteen schools.

Nine hundred and sixty two completed questionnaires

were returned giving an overall response rate of 82.2%.

Forty questionnaires were excluded because of incom-

plete and inconsistent data; therefore 922 questionnaires

Aetiology/predisposing factors of enuresis

Enuresis and arousal difficulty

Two hundred and thirty three (25.3%) of the study popu-

3

72

lation were reported to have arousal difficulty ie

Table 4: Types of family stressors in enuretic children

difficulty waking child to pass urine. Fig 1 shows that

arousal difficulty was more among children with enure-

sis 148 (63.5%) compared to those without enuresis 85

Type of Enuresis

Primary (%) Secondary (%) Total (%)

Family stressors

(

36.5%). The observed difference was statistically

significant

p =0.00, X =284.2)

Birth of a baby

Parental divorce

Parental death

Total

27 (71.1)

2 (40.0)

1 (50.0)

30 (66.7)

11 (28.9)

3 (60.0)

1 (50.0)

15 (33.3)

38 (84.4)

5 (11.3)

2 (4.4)

2

(

45 (100.0)

Figure 1: Enuresis and Arousal difficulty

Enuresis and social class

Of the 214 pupils who were enuretic, 151 (70.6%) be-

longed to social class III and below. Sixty three (29.4%)

of the enuretics were from higher social classes-1 and

1

1. There was no statistically significant difference

between enuresis and social class as shown in Table 5

Table 5: Enuresis and social class

Enuresis

Social class Yes (%)

No (%)

Total

I-II

63 (29.4)

112 (52.3)

39 (18.3)

243 (34.3)

315 (44.5)

306 (33.2)

427 (46.3)

III

Enuresis and positive family history

IV-V

Total

150 (21.2)

189 (20.5)

Positive family history of enuresis was found in 63.6%

of the enuretic group and 10.9% of the non-enuretic

group (Fig. 2). This difference was found to be statisti-

cally significant (P=0.00, X = 291.96). Among the

enuretic children, 84(61.8%) had a positive history of

enuresis in their fathers, 31(22.8%) in their mothers and

214 (100.0) 708 (100.0) 922 (100.0)

2

(

X =4.07 p= 0.131)

2

Types of enuresis and its relationship with other

variables in the study group

2

enuretics had a positive history of enuresis in both the

mother and father.

1(15.4%) in their siblings. Sixty two (45.6%) of the

Among the children with nocturnal enuresis, 135

(

68.5%) had arousal difficulty, 126 (64.0) had a positive

family history of enuresis while 137 (69.5%) belonged

to social class III and below. (Table 6)

Figure 2: Enuresis and positive family history

Table 6: Types of enuresis and its relationship with other

variables in the study group

Types of enuresis

Variables

Nocturnal

n= 197

Diurnal

n= 2

Nocturnal/Diurnal

n=15

Arousal difficulty

Yes

No

135 (68.5)

62 (31.5)

1 (50.0)

12 (80.0)

3 (20.0)

Positive Family

history of enuresis

Yes

No

DK

126 (64.0)

60 (30.5)

11 (5.5)

-

1 (50.0)

10 (66,7)

3 (20.0)

2 (13.3)

Social Class

I-II

Enuresis and family stressors

60 (30.5)

102 (51.8)

35 (17.7)

1 (50.0)

-

1 (6.6)

10 (66.7)

4 (26.7)

III

IV-V

Enuresis was associated with family stressors in 45

(

21.0%) of the enuretic children.

DK-Don’t Know

Thirty (66.7%) of those with PNE had positive family

history of stressors, whereas all of the 15 (33.3%) with

SNE had family history of stressors. Birth of a baby was

the commonest stressor, accounting for 38(84.4%) as

shown in Table 4. Thirty (66.7%) of these children were

classified as primary enuresis as the duration of bladder

control was between three and five months (less than the

required six months in the definition of secondary

enuresis).

Enuresis and academic performance

Significantly more pupils without enuresis had excellent

academic performance 292(41.2%) versus 47(22.0%).

Whereas, more of those with enuresis 23(10.7%) had

below average academic performance compared to non

enuretics (Table 7).

3

73

Table 7: Enuresis and academic performance

In keeping with the proposed genetic basis of enuresis,

many enuretic children (63.6%) had a positive family

history of enuresis compared to 10.9% in the non

enuretic family. Several previous studies reported inci-

dence rates of 40-76% of a history of enuresis in fami-

lies of₅_,w₁₃e_,₁t₇c_-₁h₈ildren, in accordance with the result of this

study.

2

Academic

Performance

Enuresis

No (%)

Total (%)

X

p Value

Yes (%)

47

Excellent

292 (41.2) 339 (36.8) 26.27

233 (32.9) 305 (33.1) 0.04

156 (22.0) 228 (24.7) 11.90

0.000

0.841

0.000

(22.0)

Very Good

Average

12

(33.6)

72

(33.6)

A family history of nocturnal enuresis is found in most

children with the condition and a positive history of enu-

resis in₁f₄ather has been found as a significant predictor

of PNE.

Below Aver-

23

27 (3.8)

50 (5.4)

15.41

age

Total

(10.7)

214

708

922

(100.0)

Studies have shown that in families where both parents

had enuresis, 77% of the children will also have enure-

sis, if only one parent had enuresis, 44% of children will

be affected, and only 15% of c₁_,h₁i₄l_,d₁r₆e_,₂n₂_-₂w₃ill have enuresis

if neither parent had enuresis.

Heredity as a causative factor of primary nocturnal enu-

resis has been confirmed by the identification of a gene

marker associated with the disorder, however, different

studies have shown differ₄e_,₂n₄t chromosome loci at chro-

mosome 8, 12, 13 and 16

Management of enuresis

Methods of management of enuresis in the study group

None of the subjects presented to the hospital for medi-

cal treatment. All the subjects were awaken to urinate at

night, though inconsistently. In 89(41.6%) prayers was

the form of treatment given (Table 8).

Table 8: Methods of management of enuresis in the study

group

In this study, bedwetting was associated with psycho-

logical events such as birth of a new sibling, parental

divorce or separation, a death in the family in 45(21.0%)

of the enuretic cases. This is well documented in the

literature that₁S₂_-N₁₃E_, occur after such personal or familial

in keeping with the findings in the

present study. However, in our study, thirty (66.7%) of

these children were classified as primary enuresis as the

duration of bladder control before the reoccurrence of

enuresis was between three and five months, less than

the required six months of continuous nighttime bladder

control in the definition of secondary enuresis.

Treatment received

Medical treatment

Prayers

No

0

Percentage (%)

0.0

89

41.6

Waking up to urinate

Punishment

214 100.0

disturbances

42

6

19.6

2.8

Herbs

Discussion

Bedwetting has been reported to b₁e_,₉_,m₂₂ore in children

from lower socioeconomic class.

In this study,

This study shows that the prevalence of enuresis in pri-

mary school children aged 6-12 years in PH₉C_,₁₅i_-s₁₆23.2%

and it compares favorably with other studies.

7

keeping with other studies,

0.6% of bedwetters were of₁s_,o₇cial class III or lower in

but 66.8% of non-

enuretics were also from this social class. It is thought

that low Socio-economic factors such as unemployed

parents, low educational level and professional status of

parents, large family size and low family income acts as

stressors to the child and therefore affect its rate of de-

velopmental milestones achievement.

Enuresis can be a distressing experience for the child

and may lead to social isolation, emotional distres₅s_-,₆_,l₂o₅_-s₂s₆

of self esteem and poor academic performance.

This study shows that enuretic children had a poorer

school performance than non-enuretic children. The

poor academic performance of some of these children is

worse as they grow older and has been thought to be due

to the emotional stress faced by these children, loss of

self esteem, poor social interaction, punitive measures

meted out on them or a combination of these factors.

Arousal difficulty was reported more frequently in

enuretic children in this₅_,s₁₇tu_,₁₈d_,y and this finding supports

results of other studies.

The sleep patterns of pa-

tients with enuresis have been studied extensively but

are difficult to interpret because of varying findings.

Investigators studying sleep electroencephalography

have reported a higher incidence of increased slow brain

wave activity in patients with nocturnal enuresis; ho₁₉w-

ever this has been considered a none specific finding.

4

2

0

Recent study documented that patients with nocturnal

enuresis have difficulties in waking; they do not wake

up normally in response to an auditory signal, signifying

a relationship between difficulty in arousal and enuresis.

Also, Sleep disordered breathing (SDB), is a disorder

associated with an abnormality in arousal and nocturnal

enuresis. The commonest cause of this condition is ade-

notonsilar hypertrophy which causes an upper aiway

obstruction. Studies have shown that surgical relief of

this obstruction by tonsillectomy, adenoidectomy or

both improves arousal in these children and also dimin₂-₁

ish nocturnal enuresis in up to 76 percent of patients.

In this study consultation for medical treatment was not

used in any of the enuretics, highlighting the need for

public health enlightenment, as many believe that noth-

ing can be done medically and they must wait for their

child to grow out of it, while others fail to report

3

74

enuresis due to the embarrassment it may cause for their

child. As in most previous studies, the rates of consulta-

tion for the management of enu₄_,r₅e_,₈s_,₁i₈s were low all over

preparations which have not been found to offer any

help in the treatment of enuresis.

the world ranging from 0-38%.

The role of prayers

It is concluded from the study that arousal difficulty,

positive family history of enuresis, psychological stress

and lower socioeconomic status were common risk fac-

tors to enuresis. Also, enuretic children were more likely

to have a poorer academic performance and traditional

methods were commonly used to manage enuresis in

PHC.

on the treatment of enuresis has not been documented,

however the spiritual connotation of diseases in the Afri-

can setting makes prayer an important aspect of treat-

ment. The children were punished in 19.6% of the cases,

however, studies have shown that punishment is not

entertained in the management of enuresis because they

advers₁₀e_,l₁y₁_.affect the psychological development of the

child.

In 6(2.8%) children herbal treatment was

Conflict of interest: None

Funding: None

given, herbal treatment is not surprising in our setting

and involves the use of several non specific herbal

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