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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2006  |  Volume : 17  |  Issue : 2  |  Page : 177-182
Survey of Childhood Enuresis in the Ehor Community, the EDO State, Nigeria


Dept of Child Health, University of Benin Teaching Hospital, Benin City, Nigeria

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   Abstract 

A community survey of enuresis was carried out in November/December 2002 among 300 apparently healthy children aged 5-16 years selected systematically from the Ehor Local Government Area in Edo State, Nigeria. This was done with the aim of ascertaining the true prevalence of the disease and the contributions of some organic causative factors. The overall prevalence of enuresis was 21.3%. Of the 64 children who were enuretic, 58 (91%) had only nocturnal enuresis. No strict daytime enuresis was recorded. Combined daytime and night time enuresis accounted for only six (9.4%) cases. Ninety-four percent of cases of enuresis were primary, while only six were secondary. Prevalence of enuresis declined significantly with increasing age ( X 2 = 14 .93, df = 3; p = 002). There was a strong association between enuresis and family history of bed wetting (more so with siblings) ( X 2 = 45.09, p < 0.000). Though not statistically significant, enuresis was more common in males, in children drawn from families of poor socio-economic status, among first order births, and among those with asymptomatic bacteriuria. Also, there was no significant association between enuresis and hemoglobin genotype. Organic conditions played a minimal role in the etiology of enuresis in the study location, but the morbidity occurred frequently enough to warrant health attention. A community approach is advocated because only an insignificant proportion is seen in orthodox health facilities.

Keywords: Community, Survey, Enuresis, Children, Benin-City.

How to cite this article:
Iduoriyekemwen N J, Ibadin M O, Abiodun P O. Survey of Childhood Enuresis in the Ehor Community, the EDO State, Nigeria. Saudi J Kidney Dis Transpl 2006;17:177-82

How to cite this URL:
Iduoriyekemwen N J, Ibadin M O, Abiodun P O. Survey of Childhood Enuresis in the Ehor Community, the EDO State, Nigeria. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2019 Jun 19];17:177-82. Available from: http://www.sjkdt.org/text.asp?2006/17/2/177/35787

   Introduction Top


Enuresis, which is the involuntary passage of urine at ages when bladder control should have been achieved, can be purely nocturnal, diurnal, or combined, as well as primary or secondary.[1],[2] It is a leading cause of childhood morbidity worldwide. Its prevalence is influenced by such factors as gender, [3] age, [2] ethnicity [4] and culture. [3] Though enuresis is widely acknowledged in all cultures and societies, information on its true prevalence, particularly in developing economies, remains sketchy. This is ascribable, in part, to the fact that the disease state is stigmatising. In addition, the age limit beyond which enuresis is defined tends to vary with reports, ethnicity, and geographical locations. [4],[5] The etiology of enuresis is multi-factorial, with maturational delay of the central nervous system (CNS) and psychosocial factors being prominent factors. [1],[2],[6] Outside these, enuresis is also known to accompany organic conditions like sickle cell anemia, [7] diabetes mellitus, [2] urinary tract infection and chronic renal failure.[8]

In Nigeria, there is a paucity of reports on enuresis. The few available ones are essentially hospital-based studies [7],[9] that do not truly reflect the enormity of the problem. Further­more, varying age-defining criteria were adopted in these reports, making it difficult to relate them to figures emanating from outside Nigeria. Furthermore, these reports were essentially dealing with nocturnal enuresis. Thus, the true picture of enuresis in Nigeria remains elusive.

In order to overcome these pitfalls and decipher the contribution of organic conditions to the overall prevalence of the disease, a community-based approach was adopted. In this report, the prevalence of enuresis was evaluated in the Ehor community, a semi-urban/ rural community in the Edo State, Nigeria.


   Materials and Methods Top


The study was conducted in the Uhumwode Local Government Area (LGA) of Edo state between November 20 th and December 19 th , 2002. The Ehor community is both rural and suburban with a projected 2002 population of 7405. The community is made up of Ehor town and eight adjourning villages of Ugbiyaya, Abumuresere, Okemuen, Ugiamwen, Ugbiyokho, Ukpogo, Eko-Ologbosere, and Agor-Ehana. Permission for the study was obtained from the University of Benin Teaching Hospital (UBTH) Ethnical Committee and the Uhumwode local government council.

Study subjects were apparently healthy children aged 5 to 16 years residing in the community whose parents or guardians were willing to participate in the study following due explanation on what the study entailed. On the assumption of an average prevalence of enuresis of 25%, and based on a one sample situation, a minimum sample size of 300 was used, having built in a 5% attrition rate. Each village and the town were taken as cluster. Two of such clusters (Ugiamwen and Ukpogo) were randomly selected. The town was mandatorily selected because of its large population size. Every child of appropriate age within Ukpogo and Ugiamwen villages was enlisted into the study. In Ehor town, the recruitment of children in consecutive houses was continued with the chief's palace serving as a central location for determining the point of commencement. Houses were visited between 4 and 6 in the evening on weekdays. Interviews of parents involved the use of a researcher-administered questionnaire. The questionnaire sought information on subjects' personal and family history of enuresis, type of bed wetting, birth order, gender, medical history, and the family's socio-economic status. A physical examination was then conducted on each child with the intention of ascertaining his clinical state.

Mid-stream urine was then collected from each child (in females, this followed due pre­paration of the vulva). Also, from each child five mL of venous blood was obtained (2 mL kept in an EDTA bottle for hemoglobin genotype determination and the remainder stored in a lithium heparin bottle for subsequent determination of serum creatinine using the modified Jaffe's method). [10] Urine samples were transported in cold boxes at a temperature of 4 to 8o Celcius. On each urine sample, micro­scopy and culture were done in the research laboratory of the Department of Child Health, UBTH, using a standard biochemical method. [11] Urinalysis was carried out using Combi-10 multi strips (ANALYTICON GmbH). Subjects with significant colony counts were assumed to have urinary tract infection, were commenced on amoxicillin at a dose of 100mg / kg / day in three divided doses for seven days, and were subsequently followed up at the pediatric nephrology unit in UBTH.

Data Analysis

The means, standard deviations, and pro­portions were calculated and cross tabulations were made. The significance of a difference in proportion between groups or classes was determined using the chi-square test. These were done with the aid of SPSS. [10] Statistical significance was set at p <0.05.


   Results Top


Complete data were available for 300 children and 197 caregivers. The mean age of the children was 10.0 ± 3.4 years (range, 5 -16 years) while the modal age bracket was 5-7 years. Of the 300, 143 (47.7%) were males and 157 (52.3%) were females.

Prevalence of Enuresis

Sixty-four of the 300 children had enuresis, thus giving a prevalence of 21.3%. the majority (51.6%) of the enuretic children were aged 5-7 years, with a median age of seven years. The mean age of enuretic children of 8.3 ± 2.8 years did not vary significantly from that of non-enuretic children (10 ± 3.4 years). The prevalence of enuresis declined with increasing age [Table - 1]. Only three (4.7%) of the enuretic children were aged 14-16 years, in comparison with 33 (51.7%) drawn from the age bracket 5-7 years. Age was significantly associated with bedwetting ( X 2 = 14.93; df = 3; p = 0.002). Of the 64 enuretics, 35 (54.7%) were males while 29 (45.3%) were females. Gender specific prevalence of enuresis was 24.5% for males and 18.5% for females.

Types of Enuresis

Fifty-eight of the 64 enuretic children (46.7%) were strictly nocturnal bed wetters, while six (3.3 %) had a combination of diurnal and nocturnal enuresis. Male predilection was observed only in nocturnal enuresis. Of the 64 enuretic children, 60 (98.7%) had primary enuresis, while four (6.3%) had secondary enuresis. Gender predilection was in favour of females (43.3%) in primary enuresis, while it was in favour of males (25.0%) in secondary enuresis. All cases of secondary enuresis had nocturnal enuresis.

Influence of Socio-Demographic Factors

Forty-five (70.3%) of the enuretic children were drawn from families of low socio­economic background while seven (10.9%) came from families of high socio-economic class. There was, however, no significant asso­ciation between family, social class, and prevalence of enuresis. There was a high (45%) incidence of history of enuresis among family members of study subjects that were currently bedwetting.

Over 80% of these had siblings who had a history of bedwetting or were currently enuretic. In three (10.3%) and two (6.9%) cases, uncles and aunts respectively were involved. The association between family history and prevalence of enuresis was stronger with a brother or sister being enuretic than with other forms of relationships ( X 2 = 54.0; df = 10; P = 0.000). Though not statistically significant, enuresis was commoner in first order births and tended to decline with increasing birth order up to the fourth birth order, following which the prevalence increased again [Table - 2].

Role of Organic Diseases in the Prevalence of Childhood Enuresis

None of the study subjects had glycosuria or a deranged specific gravity. One enuretic child (0.3%) and four (1.3%) non-enuretic children had elevated serum creatinine. Six (1.8 %) children had mild proteinuria of whom only one was enuretic. This child also had elevated serum creatinine. Fifty-eight of the 300 children (19.3%) had asymptomatic bacteriuria (ABU). Seventeen (26%) of these were enuretic in comparison with 10 (17.9%) who were non-enuretic. Although ABU was commoner in enuretics, this association was not statistically significant. Urinary pathogens involved were  Escherichia More Details coli in 40 (69.0%), Klebsiella species in 10 (17.2%), and  Proteus mirabilis Scientific Name Search  in eight patients (13.8%). Sixty­five percent, 80%, and 50% of these isolates respectively were recovered from males.

A total of 212 (17.7%) study subjects had hemoglobin genotypes AA while the remainder had AS. None had hemoglobin genotype SS. Enuresis occurred in 22.6% of children with hemoglobin genotype AA as against a prevalence of 18.2% in children with hemoglobin genotype AS. The relationship between enuresis and hemoglobin genotype was, however, not statistically significant.


   Discussion Top


Our finding of an overall prevalence of enuresis of 21.3% further reinforces the widely held view that enuresis is a common childhood morbidity. [2],[12] Similarly, the rarity of strict daytime enuresis, as noted by Bakwin[13] and co-workers, was confirmed by the study. The prevalence of strict night-time bedwetting was slightly high in comparison with figures recorded in Lagos, [7] Sudan, [14] and Burkina Faso.[15] Differences in the age­defining criteria between the studies may explain the variation in prevalence figures.

In tandem with results from other studies[16],[17] was the observed trend that the prevalence of nocturnal enuresis tended to decline with increasing age. However, certain trends in age-specific prevalence were observed which differed from what had been documented in some earlier studies. The prevalence of nocturnal enuresis of 19% at six and seven years was higher than what was observed at the age of five years. This apparent increase may be ascribed to the common tendency amongst parents to give approximate ages of their children to the nearest whole number and the fact that, in the study location, most parents are not too concerned about their children being enuretic at five years but become worried about bedwetting as a problem when the child is about to be enrolled in school. Asuni and Swift [18] also documented this observation in their work on age of attainment of bladder control in Nigeria.

Also observed in this study was a second peak age prevalence, which was observed at 12 years. It is uncertain why there is a second peak at this age. Surprisingly, none of the children aged 12 years, and implicated in this apparent surge, had secondary enuresis, which would have accounted for the rise in pre­valence at this age, as this is the period when children leave home for school, and some changes known to be associated with anxiety could precipitate enuresis. However, Ehor and its environment have witnessed a recent upsurge in immigrants due to the location of a juice processing factory in the town. Some of these immigrants could have children within the age bracket who were maladjusted to the new environment, thus accounting for the apparent increase about that age.

The widely documented view that enuresis is more common in boys than girls [9],[12] was also demonstrated in this study. Reasons for this, as noted by other authors, [9],[12] may include the fact that maturational delay is commoner with males than females. Our finding that enuresis is common in children drawn from families of low socio-economic status is in agreement with the results of most studies [12],[16] but conflicted with those of Obi [9] carried out earlier in the same center, where more children from high socio-economic backgrounds were involved. Moreover, Douglas et al [19] found that enuresis was common with first order birth but the finding differed from what was reported by Delvin among Irish children, [20] where more children from middle class families had enuresis. Delvin had argued that such children were less likely to get needed attention in the area of toilet training. The undue incidence of enuresis among first order birth may be due to a disturbed social relationship between such children and their parents who are either too complacent or too harsh with toilet training.

The risk of enuresis is enhanced by family history of the same morbidity. Almost half of the enuretic children in this study had a family history of bedwetting. Our figures were comparable with those of Guiterez et al [21] but much lower than those reported by Gummus et al. [22] In most reports, parents largely contributed the family history. The role of parents was, however, insignificant in this study, perhaps as a result of the stigmatising nature of the disease.

Akinyaju et al [7] and Kwat et al [23] , working respectively in Nigeria and the USA, noted a high prevalence of enuresis among children with hemoglobin genotype SS as compared to hemoglobin genotype AA. Children with hemoglobin genotype SS were not seen in the current study. Nonetheless, prevalence of enuresis was lower in children with hemoglobin genotype AS, as compared to those with AA. The exact relationship between hemoglobin genotype and the prevalence of enuresis requires further elucidation

A high prevalence of ABU among enuretic children has been reported from Australia. [24] This was also observed in this study. In the reports by Dodge et al, [12] ABU was observed to be commoner in girls. However, in this study the prevalence of ABU was commoner in males. Though more males than females were enuretic in this study, this may not entirely explain the gender predilection as observed with ABU. Reasons for the enhanced prevalence of ABU in male enuretics, as found in this study, are not readily apparent.

In conclusion, a community-based study offers the best approach to evaluating childhood enuresis as the morbidity is largely stigmatising, making hospital attendance unpopular.


   Acknowledgement Top


We acknowledge with thanks the contributions of the resident doctor in the Department of Child Health UBTH, who assisted with data collection. Mr. Oladipo was involved in the Laboratory analysis of samples. To him also we are grateful.

 
   References Top

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2.Novello AC, Novello RC. Enuresis. Pediatr Clin North Am 1987;34:719-33.  Back to cited text no. 2    
3.Oppel WC, Harper PA, Rider RV. The age of attaining bladder control. Pediatrics 1968;42:614-26.  Back to cited text no. 3  [PUBMED]  
4.Rappaport LA. Enuresis. In: Levine MD, Carey W, Crocker A, (eds) Developmental Behavioural Paediatrics. Saunders Co (Publishers) Philadelphia 1992:384-89.  Back to cited text no. 4    
5.Famyuyiwa OO. Enuresis. Nig Med Pract 1985;10:97-102.  Back to cited text no. 5    
6.Marc C. Primary nocturnal enuresis: current concepts. Am Fam Physician 1999;59: 1205-14,1219-20.  Back to cited text no. 6    
7.Akinyanju O, Agbato O, Ogunmekan AO, Okoye JU. Enuresis in sickle cell disease I: prevalence studies. J Trop Pediatr 1989; 35:24-6.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Winberg J, Bergstrom T, Jakobsson B. Morbidity, age and sex distribution, recur­rences and renal scarring in symptomatic urinary tract infection in childhood. Kidney Int (suppl) 1975;Suppl 4:101-6.  Back to cited text no. 8    
9.Obi JO. Enuresis in Nigerian children as seen in Benin City. Afr J Psychiatr 1977;2:65-8.  Back to cited text no. 9    
10.Spierto FW, MacNeil ML, Burtis CA. The effect of temperature and wavelength on the measurement of creatinine with the Jaffe Procedure. Biochem 1979;12:18-21.  Back to cited text no. 10    
11.Matsen J M, Barrt A L. Susceptibility testing, diffusion test procedures. In: Lennette E H, Spaulding E M, Truant J P (eds). Manual of Clinical Microbiology. American Society of Microbiology (Publisher) Washington DC; 1976;418-27.  Back to cited text no. 11    
12.Dodge WF, West EF, Bridgforth EB, Travis LB. Nocturnal enuresis in 6 to10 years old children. Correlation with bacteriuria, protenuria and dysuria. Am J Dis Child 1970;120:32-5.  Back to cited text no. 12    
13.Bakwin H. The genetics of enuresis. In: Kolvin I, Mackeith RC and Meadow SC (eds) Bladder Control and Enuresis. Heineman (Publishers) London 1993;73-7.  Back to cited text no. 13    
14.Rahim SI, Cederbland M. Epidemiology of nocturnal enuresis in part of Khartoum, Sudan II. The intensive study. Acta Peadiatr Scand 1986;75:1017-20.  Back to cited text no. 14    
15.Ouedraogo A, Kere M. Ouedraogo TL, Jesu F. Epidemiology of enuresis in children and adolescents aged 5-16 years in Ouagadougou (Burkina Faso) Arch Pediatr 1997;4:947-51.  Back to cited text no. 15    
16.Hallgren B. Enuresis. 1. A study with reference to the morbidity risk and symptomatology. Acta Psychiatr Neurol Scand 1956;31:379-403.  Back to cited text no. 16    
17.Gross RT, Dornhusch SM. Enuresis. In: Levin MO, Carey B, Crocker AC (eds) Developmental Behavioural Paediatrics. WB. Saunders (Publishers) Philadelphia; 1983:757-86.  Back to cited text no. 17    
18.Swift CR, Asuni T. Personality develop­ment and life cycle. In: Mental Health and Diseases in Africa. Churchill Livingston (Publishers) Edinburgh; 1975:11-26.  Back to cited text no. 18    
19.Douglas JW. Early disturbing events and later enuresis. In: Kolvin I, Mackeith RC, Meadow SR (eds). Bladder Control and Enuresis. JB Lippincott (Publisher) Philadelphia; 1973:p 109.  Back to cited text no. 19    
20.Devlin JB. Prevalence and risk factors for childhood nocturnal enuresis. Irish Med J 1992;84:118-20.  Back to cited text no. 20    
21.Gutierrez SC, Hidalyo PO. Importance of family history in enuresis. Actra Urol Esp 1993;20:437-42.  Back to cited text no. 21    
22.Gumus B, Vurgun N, Lekili M, Iscan A, Muezzinogliue T, Zbaguksu C. Prevalence of nocturnal enuresis and accompanying factors in children aged 7 - 11 years in Turkey. Acta Paediatr 1999;88:1369-72.  Back to cited text no. 22    
23.Kwat KJ, Scott RB, Ferguson AD. Studies in sickle cell anaemia XXXIV. Observations on enuresis in childhood and nocturia in adults. Clin Pediatr 1969;8:344-6.  Back to cited text no. 23    
24.Cohen MW. Symposium on behavioural pediatrics. Enuresis. Pediatr Clin North Am 1975;22:545-60.  Back to cited text no. 24    

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Correspondence Address:
M O Ibadin
Dept of Child Health, University of Benin Teaching Hospital, Benin City
Nigeria
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    Tables

  [Table - 1], [Table - 2]

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