PEDIATRIC UROLOGY The Prevalence of Diurnal Urinary Incontinence and Enuresis and Quality of Life: Sample of School Sevim Savaser1, Nezihe Kizilkaya Beji2, Ergul Aslan3*, Duygu Gozen4 Purpose: Enuresis can cause loss of self-esteem in children, change relations with family and friends, and decrease the school success. This study was conducted to determine the prevalence of urinary incontinence (UI) in school children aged between 11-14 years and identify the emotions and social problems of enuretic children. Materials and Methods: A mixed methods approach was used on a group of students who reported UI by com- bining quantitative data from school population-based cross-sectional design with qualitative data using in-depth interview techniques. The data of this descriptive and cross-sectional study were collected from 2750 primary school students aged between 11-14 years in Istanbul. Results: The overall prevalence of UI was 8.6% and decreased with age. Prevalence of the diurnal enuresis in children was 67.9% and all of them had non-monosymptomatic enuresis. 83.3% of the children were identified with secondary enuresis for 1-3 years. UI was significantly more common in boys and those who had frequent urinary infections, whose first degree relatives had urinary incontinence problem in childhood, and who reported low socioeconomic level in the family. The emotional and social effects of urinary incontinence were given in the context of children's own expressions. Conclusion: Urinary incontinence is an important problem of school-age children. In this study the prevalence of UI was found to be 8.6%, diurnal UI and secondary enuresis were very common, and all of the children were non-monosymptomatic. Enuresis has negative emotional and social effects on children. Keywords: child; urinary incontinence; enuresis; epidemiology; quality of life; risk factors; schools. INTRODUCTION Urinary incontinence is the involuntary leakage of urine that may occur as “continuous” or “intermit- tent”. Intermittent incontinence is the leakage of urine in discrete amounts. The subgroups of intermittent in- continence are diurnal incontinence and enuresis. Diur- nal incontinence occurring while the person is awake is identified as intermittent incontinence(1). Enuresis is among the most common conditions in childhood(2). The International Children’s Continence Society de- fines enuresis as bed-wetting while asleep/nocturnal incontinence after five years(1). The enuresis has two types. The non-monosymptomatic enuresis is charac- terized by symptoms of diurnal incontinence, sudden jamming, incontinence before catching up on the toilet, and intermittent voiding and straining during voiding and nocturnal enuresis. The nocturnal incontinence without other symptoms is defined as “monosympto- matic enuresis”. The primer enuresis is described as the fact that the child has never been able to control urine. The secondary enuresis signifies that the child had con- trolled urine for at least 6-month dry period after 5 years of age. It is important to identify enuresis type for man- agement(1,3). Primary enuresis accounts for 80-90% of all enuretic cases(4), toilet training is never achieved, and genetic 1Department of Child Development, Biruni University Faculty of Health Sciences, Istanbul, Turkey. 2Department of Nursing, Biruni University Faculty of Health Sciences, Istanbul, Turkey. 3Department of Women Health and Diseases Nursing, Florence Nightingale Faculty of Nursing, Istanbul University, Istanbul, Turkey. 4Department of Pediatric Nursing, Florence Nightingale Faculty of Nursing, Istanbul University Istanbul, Turkey. *Correspondence: Department of Women Health and Diseases Nursing, Florence Nightingale Faculty of Nursing, Istanbul University, Istanbul, Turkey. Tel : +(90) 212 440 00 00 – 27030. Fax : +(90) 212 224 49 90. E-mail : ergul34tr@hotmail.com / e.aslan@istanbul.edu.tr. Received May 2017 & Accepted November 2017 disposition and biological and developmental factors play a major role(3). In secondary enuresis, the child re- sumes wetting after at least six months of dryness. Sec- ondary enuresis is suggested to be often triggered by psychological factors(3,4). Related studies have revealed that the prevalence of in- termittent incontinence is 3.2-9.0 % and the prevalence of diurnal incontinence is 1.8-9.0 % among 7 year-old children. The prevalence of intermittent incontinence is 1.1-12.5 % and the prevalence of diurnal incontinence is 0.9% in 11-13 year old children(5). Studies have showed that 5-7 million children aged 7 or over are affected by enuresis and its prevalence increas- es in boys and with family history of enuresis(6). It is reported that prevalence decreases with age(6,7) and de- creases to 1-3% at the age of 15(8). While enuresis does not result in serious physical discomfort in childhood, it is a problem with adverse effects on the quality of life among many children and their parents due to its social and psychological results(9,10). The aim of this study was to determine the prevalence of diurnal UI and enuresis in children aged between 11- 14 years and evaluate the emotional and social effects of enuresis on a group of students, who reported enure- sis, by using in-depth interview methods. Vol 15 No 04 July-August 2018 173 MATERIALS AND METHODS Study design This is a mixed methods study. The data were collect- ed using “descriptive questionnaire form” for the first stage of this descriptive and cross-sectional study. For the study, written approvals were obtained from the Ethics Committee of IU (IRB approval number: 26211); the Governorship of city; and the Provincial National Education Authority (IRB approval number: 120). In the second stage, the data were collected from pri- mary enuresis cases who reported UI, were voluntary to participate in the study, and met DSM-V diagnosis cri- teria for enuresis, which is among qualitative research methods(11). The Population of the Study The population of the study consisted of the 5th, 6th, 7th and 8th-graders of public primary schools in Istanbul. The sample size of the study was determined by using the calculation formula of the sample size (n = t2xP x q/d2). Prevalence (P) was taken 13%(12) as a mean value, ac- ceptable sampling error was d = .03, and minimum sample size was determined as n = 483 for each grade. It was determined that a total of 1932 students must be contacted for the sample group, as a minimum require- ment. The cluster sampling method for simple randomization was used to determine the schools where the data would be collected. Each school was considered a cluster and the mean number of students in each grade of prima- ry schools located in Istanbul was assumed to be 30. When taking any possible data loss into consideration, it was ascertained that it was required to include stu- dents from 73 classes (target number-2200 / 30-size of class) and those 73 classes must be selected from 18 pri- mary schools. In the first stage, 18 districts were chosen out of 32 districts in Istanbul by drawing lots. The data were collected from the students studying in branch A of 5th, 6th, 7th and 8th grades of 18 schools (Figure 1). First stage: The questionnaire was distributed to the students in each of the designated schools within the same day and was completed in a classroom setting. All voluntary students were enrolled in the study. Evalua- tion was made over 2750 forms. The forms were filled by voluntary students in the classroom except for the course. Second stage: The effect of enuresis on the quality of life was evaluated using in-depth interview technique as a qualitative research method on a group of students who reported enuresis. The interviews were conducted by one of the researchers with 16 students reporting UI in a quiet room at the school by incorporating themes associated with enuresis-related emotional and social problems in children. Among these 16 students who were interviewed, 11 were girls and 5 were boys. Data collection After the questionnaire was prepared based on relevant literature and submitted to 6 faculty members for re- marks to ensure the content validity, a pilot study was conducted with 20 students from 5th, 6th, 7th and 8th grades and the questionnaire was finalized. The questionnaire including a total of 37 questions was designed to obtain information about sociodemograph- ic characteristics of the students. The questionnaire involves the students’ age, gender, class, parents’ edu- cational level, income level of family, individuals with whom they lived together, number of siblings. In terms of general health; diseases, medications, smoking, con- stipation, fluid intake, the habit of going to the toilet, urinary complaints, and the presence of urinary inconti- nence are asked. The effect of urinary incontinence on daily life is evaluated by the Visual Analogue Scale. During in-depth interviews, semi-structured question- naire was used. The interviews were recorded on tape and then transcribed. This questionnaire involved 5 ba- sic questions. These questions were as follows: what do you feel because of enuresis?, what do you when you recognize leakage of urine ?, what do you do to cope with UI?, Does UI affect the daily life?, and how do the surroundings react to UI? Statistical analysis The data were analyzed by using SPSS 22.0 packaged software. The value of P < .05 was considered as statis- tically significant. Mean, SD, percentage, Pearson's chi- square test, and logistic regression analysis were used for analysis. Audio records of the in-depth interviews were transcribed and coded, and descriptive and content analyses were used. The collected data were divided into two thematic groups. RESULTS The data gathered through the questionnaire The mean age of 2750 children was 12.53 ± 1.12 (range: 11-14), 50.3% were boys and 26.3% were 14 years old. It was found that 43.1 % of the mothers of the children were primary school graduates and 76.9 % were unemployed. 33.8 % of their fathers were prima- Table 1. Distribution of UI Characteristics of children (N=2750). Characteristics n % Urinary incontinence No 2513 91.4 Yes 237 8.6 Time of UI Day time 161 67.9 Nighttime 40 16.9 Day and night 36 15.2 Primer enuresis 29 34.9 Secondary enuresis 54 65.1 Figure 1. Flow diagram of the study Urinary incontinence in school children-Savaser et al. Pediatric Urology 174 ry school graduates and 51.5 % of the families stated that their income status was high. 92.7 % of the stu- dents were living together with their both parents. The most of the students had a high school performance in previous year (67.8 %). It was found that there was no statistically significant difference within the study group in terms of distribution of gender (P = .73) and age (P = .09). Table 1 shows the incidence of urinary incontinence of the participants. It was determined that 8.6% of the children had UI based on their own personal statements. All participants in enuresis group were non-monosymp- tomatic. It was determined that 83.3% of the children with enuresis had secondary enuresis for 1-3 years. Table 2 shows the comparison of urinary incontinence data within the sample group by demographic and other characteristics. As is seen from Table 2, there was a statistically significant decrease in the prevalence of en- uresis with age (P < .001), enuresis was more common among males (P = .01), and the number of enuretic chil- dren was statistically significantly higher than expected in children of mothers (P < .001) and fathers (P < .001) with low educational level, in children whose mother was employed (P < .001), whose school performance was low (P < .001), and whose family income status was low (P < .001). The number of enuretic children was lower in the group of children living with their both parents (P < .001). In addition, it was determined that the prevalence of childhood enuresis was significantly high (P < .001) in the immediate family of children who reported urinary incontinence. As is seen in Table 3, it was determined that enuresis Table 2. Comparison of urinary incontinence data within the sample group by demographic and other characteristics (N = 2750). Characteristics Incontinent Continent *P-value n % n % Age 11 73 30.8 574 22.8 12 63 26.6 654 26 < .001 13 60 25.3 603 24 14 41 17.3 682 27.2 Gender 99 41.8 1267 50.4 .01 Female Male 138 58.2 1246 49.6 Mother’s educational level Illiterate 26 11.2 128 5.1 Literate 15 6.4 76 3.1 Primary school 105 45.1 1079 43.4 < .001 Secondary school 30 12.9 409 16.4 High School 45 19.2 574 23.1 College 12 5.2 221 8.9 Father’s educational level Illiterate 7 3 23 .9 Literate 10 4.3 71 2.9 Primary school 86 36.9 844 34.1 < .001 Secondary school 58 24.9 473 19.1 High School 43 18.5 705 28.5 College 29 12.4 360 14.5 Income status of family High 101 42.6 1314 52.4 Middle 103 43.5 1113 44.4 < .001 Low 33 13.9 79 3.2 Previous year’s school performance High (certificate of merit/achievement) 135 57 1646 65.5 < .001 Medium (pass) 77 32.5 727 29 Low (conditional pass/repeat) 25 10.5 138 5.5 Mother’s employment status Employed 72 30.8 552 22 < .001 Unemployed 162 69.2 1952 78 Lives with Both parents 207 87.3 2341 93.2 One of the parents 18 7.6 112 4.5 < .001 Other family members 12 5.1 58 2.3 Immediate family history Yes 107 45.1 - - < .001* No 130 54.9 2513 100 P = Pearson's chi-squared test * Fisher’s exact test Characteristics Incontinent Continent *P-values n % n % Frequent urinary infection Yes 24 10.1 60 2.4 < .001 No 213 89.9 2453 97.6 Constipation Yes 60 25.3 149 5.9 < .001 No 177 74.7 2364 94.1 The use of school toilet Yes 131 55.3 1572 62.6 .03 No 106 44.7 941 37.4 P = Pearson's chi-square test Table 3. Distribution and comparison of urinary incontinence by some characteristics (N = 2750). Urinary incontinence in school children-Savaser et al. Vol 15 No 04 July-August 2018 175 was more common among children who reported fre- quent urinary infections (P < .001), constipation (P < .001) and school toilet avoidance (P = .03). In the study, a logistic regression model which con- tained risk factors associated with urinary incontinence in children aged between 11-14 years was prepared. Table 4 shows the variables which posed a significant risk in the forward propagation multivariate logistic regression analysis compared to the reference. In the regression analysis, it was determined that enuresis risk was significant for younger children (3.05 times higher at the age of 11 compared to 14), children who reported lower maternal educational level (2.46 times higher compared to high school and college graduates), children of employed mothers (1.55 times higher com- pared to those of unemployed mothers), children with low school performance (2.19 times higher compared to those with high performance), children not living with their parents (1.92 times higher compared to those living with their parents), children from families with low income status (4.27 times higher compared to those from families with high economic status), children re- porting frequent urinary infections (1.83 times higher compared to those not reporting frequent urinary infec- tions), and children reporting constipation (4.66 times higher compared to those not reporting constipation). Mean scores of the students, who reported urinary in- continence to the question “How much does urinary in- continence affect your daily life”, was 2.95 ± 2.73 (Me- dian = 3, Mode = 0) in the Visual Analogue Scale (VAS: 0 to 10 - 0: doesn’t affect al all, 10: affects pretty much). Children were grouped and evaluated as follows; those who marked 0 on the scale were not affected by urinary incontinence in daily life; those who marked 1, 2, and 3 were slightly affected; those who marked 4, 5, and 6 were moderately affected; and those who marked 7, 8, 9, and 10 were considerably affected. It was determined that two thirds of enuretic children stated that their daily life was slightly (36.1%) and moderately (25.8%) af- fected by enuresis. The data on emotional effects of urinary incontinence: During the interviews, almost all of the children an- swered the question “What do you feel when you have leakage of urine?” by using the expressions such as em- barrassment, worry, downheartedness. The data on social effects of urinary incontinence: The majority of the children answered the question “Does your problem of urinary incontinence have any effect on your daily life? How?” by stating that their daily life was affected by this problem and they took some measures including taking a change of clothes with them and avoiding drinking water or tea etc. DISCUSSION Continence problems in children can persist into later childhood and have a serious effect on quality of life. Number of studies on its causes and impact is scarce and useful resources are limited(13). The statistical results obtained due to large size of the sample were thought to be significant in terms of urinary incontinence and the associated factors in the study. The review of the literature showed that data in studies conducted to identify emotions and social prob- lems of enuretic children were usually collected from mothers(10,14). The strength of this study is that it deter- mined the effect of urinary incontinence on emotional and social life of children through in-depth interviews. Limitation of the study is that the data on factors thought to be associated with urinary incontinence were collect- ed only from children. It is thought that this study is significant and original since the data of the study were collected from epidemiologic studies obtained from children, the sample size can be regarded as sufficient and emotions of the children reporting urinary incon- tinence were tried to be determined through in-depth interviews. This study revealed that the prevalence of UI was 8.6%, significantly higher in boys, and decreased with age. In the study conducted by Dirim et al., with school children, they identified urine problems at the rate of 7.2%(15). In the several studies, diurnal UI frequencies showed a difference between 1.8% and 49%(5). The wide range of frequencies is associated with difference in UI definition criteria and difference in data collection Table 4. Risk factors associated with urinary incontinence based on the logistic regression analysis (N = 2750). Associated factors 95% Cl (OR) B S.E. df. Sig. (P) Exp. (B) Lower Upper Age 14 (reference) 13 .72 .22 1 < .001 2 .06 1.33 3.19 12 .76 .23 1 < .001 2.13 1.36 3.35 11 1.12 .23 1 < .001 3 .05 1.96 4.75 Mother’s educational level High school and ↑ (ref.) Primary .25 .18 1 .16 1.29 .90 1.83 L or IL* .90 .25 1 < .001 2.46 1.51 3.99 Mother’s employment status Unemployed (ref.) Employed .44 .16 1 < .001 1.55 1.13 2.14 School performance High (ref.) Medium .23 .17 1 .17 1.26 .91 1.75 Low .78 .27 1 <.001 2.19 1.29 3.70 Household Parents together (ref.) Either parent or other .65 .23 1 < .001 1.92 1.23 2.99 relatives Income status of family High (ref.) Medium .08 .16 1 .61 1.08 .80 1.47 Low 1.45 .26 1 < .001 4.27 2.57 7.07 Frequent urinary i No (ref.) nfections Yes .61 .29 1 .04 1.83 1.03 3.25 Constipation No (ref.) Yes 1.54 .19 1 < .001 4.66 3.21 6.77 Constant -.50 .19 1 < .001 .61 * L = Literate, IL = Illiterate Urinary incontinence in school children-Savaser et al. Pediatric Urology 176 methods with different samples(16). Studies indicate a wide range between 3.1-24.4% for the prevalence of enuresis. Its prevalence usually seems to decrease with age and enuresis is more common among boys in early school years compared to girls (17,18). Prevalence of enuresis was determined to be 10.5- 17.5% in Turkey(8,12). Diurnal UI was more frequent in the present study, as well. Enuresis is a clinical condition of multifactorial etiol- ogy that leads to difficulties in social interaction of the child(19). Many studies report that enuretic children have a family history of enuresis at a high rate (EC)(6,20,21), and the rate of positive family history is between 40.7-76.5 in Turkey(22). The enuresis rate was found to be 45.1% among immediate family members in this study, which is compatible with associated literature. In the study conducted by Fagundes on treatment of 82 patients with enuresis, 91.1% had a family history of enuresis in first-/second-degree relatives, 89.3% had constipation and 40.7% had mild-to-moderate apnea(23). Role of sleep disorders is controversial in enuresis(21, 23). Wille et al.,(24) reported that 60% of EC experienced the problem of deep sleep and 75% of children with noctur- nal enuresis had difficulty in waking up. Akbaba(25) de- termined that the prevalence of enuresis was 1.8 times greater in sound sleepers than light and moderate sleep- ers. One thirds (32.9%) of children who reported UI in this study stated that they wetted their bed because they were sound sleepers. Zaffanello et al., expressed that the symptoms of snoring, sleep apnea, and restless sleep were examined for the children with enuresis in their systematic review study. In the same systematic review, Zaffanello et al., suggested immediate treatment for ob- structive sleep and irregular breathing(26). It was determined that the prevalence of enuresis was 4.27 times greater in children with a low socioeconomic status than children with a higher socioeconomic sta- tus(12). In addition to trials showing a higher prevalence among children of families with lower maternal educa- tional level, there are trials which confirm the inexist- ence of such relation(6,12). The incidence of enuresis was higher among mothers’ educational levels in this study. The studies in the literature have shown that envi- ronmental factors including poor living conditions to which the child is exposed, suffered traumas, etc. are among psychosocial risk factors(13) contributing to enu- resis and enuresis is more common particularly among children of broken families(4,17). In the present study, the prevalence of enuresis is higher among EC living with either parent/relatives compared to EC living with both parents. It is reported that the presence of enuresis in a child creates a vicious circle of decreased self-confidence, social avoidance, and lower school performance(9). In their studies involving 2984 children aged between 6-18 years, Gorur et al.,(21) determined that problems in friend relationships and low school performance were significantly common in the enuretic group. Although it was reported that enuresis was accompanied by uri- nary tract infections and constipation(21), such accom- paniment was not fully clear. One study revealed that the rate of coexistence of enuresis and constipation was 31% (27), and another study determined a relationship between enuresis and urinary tract infections(25). The present study revealed higher enuresis rates in children reporting constipation and in children reporting fre- quent urinary infections. It is stated that EC may experience lack of self-confi- dence and self-esteem if they are not treated until school age when social circle widens(23). In this study, the result indicating that low percentage of subjects seeking med- ical treatment for enuresis among those who reported UI is compatible with the literature. When taking high rate of family history into consideration, this result may be interpreted as parents’ being inured to and ignoring the problem. Discussion of the data collected with in-depth in- terviews Bower(28) revealed that children with UI symptoms experienced the feelings of inferiority, irritability and embarrassment more frequently, the quality of life im- paired with failed treatment, and the aspects in which children are affected the most are self-confidence, inde- pendence, and mental health, respectively. In a previous study, it was showed that 65% of EC were unhappy(29). Morison(30) identified that the majority of bedwetting children were embarrassed and worried be- cause of their bedwetting problem, and especially those with perceived hopelessness were less engaged in treat- ment and lost heart in a short time. When associated studies are reviewed, it is seen that bedwetting children develop more negative feelings than those not bedwet- ting(20), level of self-esteem in bedwetting children are lower than the general population(9), and psychological problems slightly increase in the case of EC(17,29), where- as a study comparing EC with healthy children showed no psychological difference between the enuretic and non-enuretic groups(29). During in-depth interviews made in the present study, all of EC expressed embarrassment, sadness, inconven- ience, fear of being exposed to peers; and almost all of them expressed dispiritedness/unhappiness and fear of being mocked and teased. In addition, there were chil- dren who expressed anger, guilt, fear of drawing peers away / being left alone, smelling of urine and staining their clothes, and negative feelings arising from this problem. Children stated that they did not accept sleepover in- vitations because of enuresis, they experienced prob- lems and fear of wetting themselves during school trips, vacations or travels, and, therefore, their participation in overnight activities was limited, and, if they partici- pated, they would change underwear and clothes, they would not drink water, tea, etc. at night, they would visit the bathroom frequently, and they would not sleep well. It is reported that parents are concerned about the ef- fect of enuresis on their child’s social and emotional development(7,14), however, most children are frustrated in response to attending to one’s hygiene and do more laundry(23,29). Parents need to be reassured that bedwetting is not due to a child’s laziness but beyond his/her control(3,30). It is argued that a child’s management of bedwetting must be individually addressed(20,23,26). CONCLUSIONS In the present study, it is suggested that urinary incon- tinence is very important health problem in school-age child. To reduce the complaints of this multi-factor problem, the first option can be description and well management of risk factors. In this study, the prevalence Urinary incontinence in school children-Savaser et al. Vol 15 No 04 July-August 2018 177 of UI was found to be 8.6%, diurnal UI and second- ary enuresis were very common and all children were non-monosymptomatic. UI became less common with age, and considerably high in boys and those who re- ported frequent urinary infections, history of childhood enuresis among their immediate family members and a low socio-economic status. Enuresis have negative emotional and social effects in school children. School and field screening programs should be conducted with school-age children and information should be gathered from children and parents for diagnosing undisclosed UI in the society, and guidance should be provided about the optimal treatment of children with UI. ACKNOWLEDGEMENT This study was supported by The Support Program for Scientific and Technological Research Projects of TU- BITAK (Program Code: 1001 Project No: 107S062). CONFLICTS OF INTEREST The authors declare no conflict of interest. REFERENCES 1. Austin PF, Bauer SB, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society. Neurourol Urodyn. 2016; 35: 471-1. 2. Butler RJ, Heron J. The prevalence of infrequent bedwetting and nocturnal enuresis in childhood: a large British cohort. Scand J Urol Nephrol. 2007; 42: 1-8. 3. Ball JW, Bindler RC. 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