1602 | Prevalence of Urinary Incontinence and Low- er Urinary Tract Symptoms in School-Age Children Ipek Ozunan Akil,1 Dilek Ozmen,2 Aynur Cakmakci Cetinkaya2 Corresponding Author: Ipek Ozunan Akil, MD Department of Pediatric Nephrol- ogy, Celal Bayar University, Izmir, Turkey. Tel: +90 236 44 44 228 3164 Fax: +90 236 233 80 40 E-mail: ipekozunan@yahoo.com Received November 2012 Accepted January 2014 1 Department of Pediatric Nephrology, Celal Bayar Univer- sity, Izmir, Turkey. 2 Department of Public Health Nursing, School of Health, Celal Bayar University, Izmir, Turkey. PEDIATRIC UROLOGY Pediatric Urology Purpose: To investigate the prevalence of lower urinary tract symptoms (LUTS) and urinary incontinence (UI) in elementary school aged children in Manisa. Materials and Methods: Dysfunctional Voiding and Incontinence Scoring System (DVIS) which was developed in Turkey is used. A total of 416 children, 216 (51.9%) male and 200 (48.1%) female were recruited in this study. Results: Mean age of children was 10.35 ± 2.44 years (median10 years). Daytime UI fre- quency was 6.7% (28 child), nocturnal incontinence 16.6% (69 child) and combined daytime and nocturnal incontinence 4.1% (17 child). There was no statistically significant difference in the prevalence of nocturnal and or daytime UI between male and female gender. Mean DVIS score was 2.65 ± 3.95 and gender did not affect total DVIS points. The mean ages of achieving daytime bowel and bladder control were all significantly correlated with DVIS points. DVIS points were positively correlated with the history of UI of the family. Total points were increased when the father was unemployed. Conclusion: UI negatively influences health related quality of life of the family and child, so it is important that awareness of the UI and symptoms of lower urinary tract dysfunction. Keywords: lower urinary tract symptoms; child; urination disorders; prevalence; urinary incontinence. 1603Vol. 11 | No. 03 | May - June2014 |U R O LO G Y J O U R N A L Prevalence of LUTS in Children | Akil et al INTRODUCTION Urinary incontinence (UI) is a common and impor-tant health problem in childhood.(1) It may cause considerable impact on health related quality of life of both the affected child and caregivers.(2,3) Nocturnal UI also has negative effects on the child’s sleep quality, be- cause they might be anxious about the risk of urination while asleep.(4) International children’s continence society (ICCS) classifies UI in the storage symptoms of bladder and it defines UI as uncontrollable leakage of urine. It can be continuous associ- ated such as ectopic ureter or intermittent. Nocturnal enuresis (nocturnal incontinence) describes incontinence while sleep- ing. Daytime incontinence is incontinence during the day. The child may have both nocturnal and daytime UI.(1) Few- er than half of the patients presenting with incontinence is thought to be really mono-symptomatic nocturnal enuresis.(5) Also, there is a prominent differentiation in children between with mono-symptomatic nocturnal enuresis and who have lower urinary tract symptoms (LUTS) (non-monosympto- matic nocturnal enuresis) according to pathogenesis, clini- cal findings and treatment modalities.(1) Increased/decreased voiding frequency, daytime incontinence, urgency, hesitancy, straining, a weak stream, intermittency, holding maneuvers, a feeling of incomplete emptying, post-micturition dribble and genital or lower urinary tract pain are LUTS. Nevertheless, general knowledge and interest are often based on noctur- nal enuresis (nocturnal incontinence). Investigations about nocturnal enuresis including pathophysiology, genetics, and prevalence are much frequent than daytime UI.(6-10) There are a lot of data investigating the prevalence and as- sociated factors of mono-symptomatic nocturnal enuresis in general literature and in Turkey.(1,5-13) But, lack of adequate epidemiological data on the prevalence of lower urinary tract symptoms and UI in school-aged children in Turkey led us conduct a cross-sectional study in a representative population in our region. MATERIALS AND METHODS This is a cross-sectional study planned in the center of the province of Manisa including children with the age of 7-15 years. According to data from in the center of Manisa prov- ince of 11 family health center registered by Household As- sessment Sheets (Forms) in 2010, there were 41648 children aged between 7 and 15 years. The sample size was calcu- lated as 381 in Epi Info 2000 program with a margin of error of 95% confidence interval (CI) and with 0.05 error share (based on the expected prevalence of 50%). The survey sam- ple of children admitting family health centers were detected with stratified sampling method according to the number registered in 7-15 age children. Sampling within each family health center, children were randomly selected from house- hold detection plugs. Creating the sample, the plugs were randomly selected from in a row lined up according to the districts. Registered 7-15 age children in these randomly selected plugs were included in the study. If the plug does not have registration for children in this age group, by select- ing a new chip sampling was completed with 416 children. Celal Bayar University hospital ethical committee approved the study. Written permission for the conduct of the study in family health centers was obtained from the Directorate of Health in Manisa. Informed consent was obtained from parents of children participating in the study. The data was collected from home visits using face to face interview tech- nique between 1 March 2011 to 30 May 2011. As the data collection tool two forms were used. The first one was Infor- mation Form developed by researchers and, the second form was Dysfunctional Voiding and Incontinence Scoring Sys- tem (DVIS) which was developed by Department of Pediat- ric Urology Unit of Hacettepe University.(14) DVIS contains 14 questions including daytime symptoms related urination, night symptoms, voiding habits, bowel habits and quality of life of children. High DVIS scores indicate increased risk of disease severity. Additionally, we used socio-demographic information form that we developed. It has 28 questions that describe some properties of the child and family, family’s socioeconomic, training status and micturition habits. Statistical Analysis The statistical analysis of data was performed using the sta- tistical package for the social science (SPSS Inc, Chicago, Illinois, USA) version 15.0. To assess the data points and percentage distributions, Pearson chi-square test, Student’s t test and one way ANOVA variance analysis were used. The Cronbach alpha for intrinsic factors of DVIS was 0.77 for this study. 1604 | RESULTS There were 416 children in the study, 216 (51.9%) of them were boys and 200 (48.1%) were girls. Mean age of chil- dren was 10.35 ± 2.44 years (median 10 years). The majority (70.4%) of the families were defined themselves as moderate income families and 8.4% of them did not have any social security. In this study, 56.2% (234) of children described at least one symptom of lower urinary tract dysfunction. Mean DVIS score was 2.65 ± 3.95 (min: 0, max: 27, median: 1). Of study families 22.6% stated that LUTS were negatively affected their quality of life. LUTS were not found related with gen- der. Cronbach's alpha coefficient of the scale for this study was 0.7401. Table 1 shows the prevalence of LUTS accord- ing to the gender in the study group. The mean ages of achieving daytime bowel and bladder con- trol, family history for UI, sleep arousal, age and whether the father has a job or not were all significantly correlated with DVIS points (Table 2). Consanguineous marriage, the age of mother during pregnancy, the age of father, time of birth, birth weight, breastfeeding, labor (vaginal or opera- tional), the order of siblings, family’s education level were not in relation to UI. Availability of toilet training, the age of toilet training, punishment during toilet training were not statistically correlated with DVIS points. Daytime UI frequency was 6.7% (28 child), nocturnal incon- tinence 16.6% (69 child) and combined daytime and noctur- nal incontinence 4.1% (17 child). There was no statistically significant difference between male and female gender ac- cording to nocturnal and or daytime incontinence (Table 3). The highest prevalence was 7 years for both nocturnal UI and daytime UI (24.3% and 13.5%, respectively) and the preva- lence was decreased with increasing age. When total DVIS points evaluated according to the age, it was decreased while the age was increased. DISCUSSION It is very well known that lower urinary tract dysfunctions are associated with recurrent urinary tract infections (UTI), vesicoureteral reflux (VUR) and permanent kidney dam- age.(15) The relationship between the degree of renal scar and detrusor pressures were reported in literature.(16) Also, detrusor-sphincter dyssynergia is more associated VUR and UTI in comparison with only bladder instability.(17) All type of lower urinary tract dysfunctions present some symptoms and findings of LUTS mainly increased/decreased voiding frequency, daytime incontinence, urgency, and holding ma- neuvers. Among them, nocturnal incontinence has greater emphasis than daytime incontinence and the other symp- toms for the families and families generally do not know their child’s voiding and defecation patterns except noctur- nal incontinence. Sometimes, incontinence is interpreted as resolves with time by both families and health workers. In our country, urological problems comprised the largest group (50.7%) for the underlying etiologies of end stage renal fail- ure in childhood. These were mainly vesicoureteral reflux (18.5%), neurogenic bladder (15.2%) and chronic pyelone- phritis (2.2%).(18) Many of these children may have LUTS. Unfortunately, lower urinary tract dysfunction is frequently diagnosed following established renal damage. So, we want- ed to know the prevalence of LUTS in children elementary school aged children (7-15 years) in our city. We have used DVIS form which has a validation form in Turk- ish.(14) In this scoring system, 8.5 points and higher values have 90% sensitivity and 90% specificity in determining the void- ing dysfunction with a CI of 96.2%. Mean DVIS score was 2.65 ± 3.95 in our study and 38 (9.1%) children received equal or greater than 8.5 points indicating lower urinary tract dys- function. We informed these children and their families about the importance of their complaints and to apply to a pediatric nephro-urological outpatient clinic for treatment and associat- Pediatric Urology Figure. Prevalence of nocturnal urinary incontinence (UI), daytime UI and Dysfunctional Voiding and Incontinence Scoring System (DVIS) points according to ages. 1605Vol. 11 | No. 03 | May - June2014 |U R O LO G Y J O U R N A L Prevalence of LUTS in Children | Akil et al Table 1. Description of symptoms in study group and its distribution according to the gender. LUTS Male (n = 216) No. (%)* Female (n = 200) No. (%)* Total No. (%)** P*** Voiding number (More than 7 per day) Yes 193 (53.6) 167 (46.4) 360 (86.5) .081 No 23 (41.1) 33 (58.9) 56 (13.5) Strain during voiding Yes 208 (52.1) 191 (47.9) 399 (95.9) .682 No 8 (47.1) 9 (52.9) 17 (4.1) Pain during voiding Yes 207 (53.1) 183 (46.9) 390 (93.8) .068 No 9 (34.6) 17 (65.4) 26 (6.3) Intermittently voiding Yes 209 (52.4) 190 (47.6) 399 (95.9) .365 No 7 (41.2) 10 (58.8) 17 (4.1) Needs to go back voiding soon after finishes his/her pee Yes 205 (53.2) 180 (46.8) 385 (92.5) .057 No 11 (35.5) 20 (64.5) 31 (7.5) Sudden feeling of having to urinate immediately Yes 152 (53.3) 133 (46.7) 285 (68.5) .396 No 64 (48.9) 67 (51.1) 131 (31.5) Holding manoeuvres Yes 179 (53.3) 157 (46.7) 336 (80.8) .258 No 37 (46.3) 43 (53.8) 80 (19.2) Wets on the way to the toilet Yes 196 (53.4) 171 (46.6) 367 (88.2) .098 No 20 (40.8) 29 (59.2) 49 (11.8) Constipation Yes 196 (53.6) 170 (46.4) 366 (88.0) .072 No 20 (40.0) 30 (60.0) 50 (12.0) Key: LUTS, lower urinary tract symptoms. *Percentage of row. ** Percentage of column. ***Pearson chi-square test. ed morbidities. As interesting, a large number of children were found to be affected with this scoring system in at least in one question in our study. Whereas, Vaz and colleagues described as affected children number was 21.8 % children (161 in 739) in their study groups.(19) LUTS such as urgency, frequent daytime voiding, nocturia and urge-incontinence were found significantly associated with childhood urinary symptoms in adult females.(20) In our study, DVIS points were positively correlated with the presence of family history of UI. This finding preoccupied us that the prop- er diagnosis and treatment of lower urinary tract dysfunctions were very important in childhood. This study also revealed that DVIS points were associated with the age of children (Fig- ure), father’s job, sleep arousal of the children and the time of urinary and bowel control. It is generally accepted that day- time UI depends more weakly on socioeconomic and stressful events than nocturnal UI, however we found total DVIS points were increased when the father was unemployed.(21) Delaying in bowel and bladder control may be related with lower urinary tract dysfunction. In this study, increasing of the mean ages of achieving of daytime bladder and bowel control were all as- sociated with increased DVIS points. 1606 | Pediatric Urology In literature, there are several different results for the prev- alence of daytime UI in childhood; it varies from 2.1% to 30.7%.(22-25) Lee and colleagues reported the prevalence of daytime UI as 2.1% in 7-12 aged 12570 Korean children (the boys had 1.3%, girls 0.8%).(23) Sureshkumar and colleagues found the prevalence of daytime UI as 19.2% with a slight girl predominance (boys had 16% and girls 21.8%).(22) From our country, Toktamis and colleagues reported overall preva- lence of daytime UI was 2.6%, with a tendency to decrease with increasing age and with no difference between genders. (19) In another study, prevalence of daytime UI was reported as 8.3%, and there was no statistical difference between the girls and the boys however the girls slightly more had day- time UI (7.2% and 9.5%, respectively).(25) Our study revealed that daytime UI was 6.7%, and the gender did not affect the frequency (the boys had 6.9% and girls 6.5%). Daytime UI prevalence is decreasing with the child’s age increases as in agreement with the other studies (Figure). The overall nocturnal UI prevalence was 16.6%, marked nocturnal UI was 4.3% (more than 2 per week) in our study group. We did not find gender difference for nocturnal UI. Nocturnal UI prevalence was decreasing with age as ex- pected (Figure). Gunes and colleagues reported that overall prevalence of nocturnal UI as 14.9%. They reported that no difference in prevalence of nocturnal UI between boys and girls (14.3% vs. 16.8%).(25) In Ozkan and colleagues’ study the prevalence of whole enuresis was 12.9% and the preva- lence of prominent enuresis (at least weekly) was 9.8%. They revealed that nocturnal UI is more prevalent in boys (male to female ratio 1.6) and the prevalence rates declined by age without gender bias.(11) Our results are consistent with the literature and nocturnal UI is more prevalent health problem in childhood in our country. ICCS consensus states that a normal urinary frequency is between four and seven times per day. The numbers out of these values may point the lower urinary tract dysfunction.(1) In our study, frequent voiding (more than 7) prevalence was 13.5%. There was no gender difference for frequent void- Table 2. Dysfunctional Voiding and Incontinence Scoring System points and associated factors. Variables Number Mean ± SD p Age of children < 10 years 217 3.32 ± 4.41 .000* > 10 years 199 1.92 ± 3.23 Unemployed father Yes 94 2.51 ± 3.79 .042* Unemployed and/or retired 312 3.81 ± 5.07 Urinary incontinence in family Yes 73 5.46 ± 6.09 .000* No 341 2.06 ± 3.02 Sleep arousal Sensitive sleep (a) 42 3.21 ± 4.95 .001** Normal (b) 309 2.25 ± 3.45 a = b > c Deep sleep (c) 65 4.21 ± 4.99 Time of urinary control < 2 year 242 2.1 ± 3.23 > 2 year 166 3.27 ± 4.57 .005* Time of bowel control < 2 year 228 2.15 ± 3.29 > 2 year 179 3.16 ± 4.5 .012* * Student’s t test. ** One way ANOVA test. 1607Vol. 11 | No. 03 | May - June2014 |U R O LO G Y J O U R N A L Prevalence of LUTS in Children | Akil et al ing. Holding maneuver symptoms were detected in %19.2. Although we did not observe a difference for holding ma- neuvers between genders, Vaz and colleagues reported same ratios but girl predominance for this symptom.(19) So, urinary frequency and holding maneuvers should paid attention in clinical practice. Lower urinary tract dysfunction symptoms were reported more frequent among girls than boys by Vaz and colleagues. (19) However, we could not observe difference between gen- ders for LUTS. We thought that each society may have dif- ferent characteristic properties so the problems may vary from one to another. Loening-Baucke has found constipation prevalence as 22.6% in 4-17 aged children.(26) Vaz and colleagues were reported constipation prevalence in their group as 30.7%.(19) There was a close relationship between constipation and lower urinary tract dysfunction. Treatment of constipation was yielded in dissolution of daytime UI in 89% and nighttime UI in 63% of patients.(27) Constipation was detected less from the other stud- ies, as 12% in our study population. We found that constipation was more prevalent in children with nocturnal incontinence, but it was not statistically significant, and we did not found re- lationship between daytime UI and constipation in our group. CONCLUSION As a result, this study points out that UI and LUTS are not uncommon in school aged children, especially in younger group, however, gender does not affect incontinence and general LUTS. When it was thought that UI negatively influ- ences health related quality of life of family, the importance of the awareness of the problem and therapy come forward. Table 3. Prevalence of urinary incontinence types in children and distribution according to the gender. 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