Home About us Current issue Ahead of Print Back issues Submission Instructions Advertise Contact Login   

Search Article 
Advanced search 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 2313 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 

ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 6  |  Page : 1092-1099
Daytime urinary incontinence among kindergarten children in aden governorate, 2003

1 Department of Pediatrics, Faculty of Medicine and Health Sciences, Aden University, Aden, Yemen
2 Department of Community Medicine and Public Health, Faculty of Medicine and Health Sciences, Aden University, Aden, Yemen
3 Department of Community Medicine and Public Health, Amin Nasher Higher Institute of Health Sciences, Aden, Yemen

Click here for correspondence address and email

Date of Web Publication4-Nov-2010


Daytime urinary incontinence is an involuntary or intentional voiding of urine in an awake child who is old enough to have developed control, and has a variable prevalence throughout the world. In Yemen, data regarding this problem are almost absent. In this study from the capital city of Aden, we aimed to: (1) determine the prevalence of daytime incontinence in kindergarten children aged 4-6 years, (2) identify the relation between daytime enuresis with personal and family characte­ristics of the children studied, and (3) describe the severity and characteristics of daytime enuresis in the studied children. A cross-sectional comparative study was undertaken in all kindergarten children aged 4-6 years in Aden Governorate and 1061 responded. Data were obtained by using a precoded self-administered questionnaire completed by the parents. The questionnaire consisted of two parts: personal and family characteristics of the studied children and the presence of daytime incontinence. The second part was responded if there was history of daytime incontinence, and contained information on the severity and possible associated factors. Daytime incontinence was encountered in 34 cases (3.2%); 18 were females. Significant differences between cases and incontinence-free children were encountered in birth order and type of kindergarten (P < 0.05). Majority (85.3%) had severe form of daytime incontinence. Bed wetting and combined day and night wetting were more frequent among males, whereas urinary symptoms (urgency, squatting, dysuria, dribbling) were more frequent among females. Working mother and frightening and emotionally stressful events in the 6 months preceding the study were significantly associated with daytime incontinence, while parents' education, punish­ment for daytime incontinence, and the presence of family history of incontinence were insignificant. In conclusion, this is the first study from Yemen reporting the prevalence of enuresis, similar to pre­vious reports. Further studies are needed to explore this problem in our region to end the misery of the child and the family.

How to cite this article:
Yousef KA, Basaleem HO, Al-Sakkaf KA. Daytime urinary incontinence among kindergarten children in aden governorate, 2003. Saudi J Kidney Dis Transpl 2010;21:1092-9

How to cite this URL:
Yousef KA, Basaleem HO, Al-Sakkaf KA. Daytime urinary incontinence among kindergarten children in aden governorate, 2003. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2021 Oct 26];21:1092-9. Available from: https://www.sjkdt.org/text.asp?2010/21/6/1092/72297

   Introduction Top

Urinary incontinence is a common problem in pediatric practice. [1],[2] Daytime enuresis is de­fined as involuntary or intentional voiding of urine into clothing while awake, in a child old enough to have developed control. [1],[2],[3],[4] It is less common than nighttime incontinence and tends to disappear much earlier than nighttime ver­sion. [1],[2] Daytime enuresis has a prevalence rate of 3-4% in 5-12 year olds [1],[3],[4] and is more co­mmon in girls than it is in boys. [4],[5],[6] Most chil­dren are continent of urine during waking hours by the age of 3-4 years. [2],[4]

Previous studies of the prevalence of daytime wetting have reported varying results, from 1.8 to 19.2%. [7],[8],[9],[10] This variability may be due to selection bias, the nature of population, or the terminology used to define various symptoms. Most children who wet during the day have normal urinary anatomy and nervous system. [1],[2],[3],[6],[11] One possible cause of daytime inconti­nence, either primary or secondary, is an a) over­active bladder with b) abnormal voiding habits,the most common being infrequent voiding. [1],[4],[5],[6],[11]

An overactive bladder often happens as a con­sequence of urinary tract infection and is more common in girls. [1],[4],[7],[9],[12],[13],[14],[15] Infrequent voiding occurs when the child voluntarily holds urine for prolonged intervals and is common in children of 3-5 years, e.g. when a child may not want to interrupt enjoyable activities, or use the school or home toilet, his/her bladder will be overfilled and starts leaking urine. This child is liable to develop urinary tract infection (UTI), [1],[4],[12],[13],[14],[15] leading to an irritable or overactive bladder. These children are recognized by their frequent fidgeting, holding their perineal areas, and squirming. Daytime wetting is often the only symptom of a dysfunctional voiding pro­blem. Frequently, these children suffer from bowel problems such as constipation and enco­poresis. [1],[6],[14],[16] Symptoms of voiding dysfunc­tion may be secondary to UTI or local irritants such as pinworms infestation or bubble bath. [2],[17] Some of the factors which contribute to noc­turnal incontinence may act together with infre­quent voiding to produce daytime incontinence, such as small bladder capacity (maturation de­lay), [1],[3],[6] bladder, urinary structural problems,neurogenic bladder, anxiety-causing events oc­curring in children of age 2-4 years in the pre­ceding six months, [1],[2],[3],[7],[18] ingestion of bladder irritants such as caffeine, overly strenuous toilet training which may make the child unable to relax the sphincter and the pelvic floor to com­pletely empty the bladder and genetic. [1],[3]

Surprisingly, we did not find any comparable literature reviews from our region, estimating the prevalence of voiding problems. Thus, in this study, we aimed to:

  1. determine the prevalence of daytime in­continence in kindergarten children aged 4-6 years from the city of Aden;
  2. identify the relation between daytime enu­resis with personal and family characteristics of the studied children; and
  3. describe the severity and characteristics of daytime enuresis in the children studied.

   Methodology Top

This was a cross-sectional comparative study targeting all the children of 4-6 years, attending kindergartens of area of Aden Governorate, Yemen (n = 1704). All the kindergartens [public (13) and private (11)] were surveyed during February-May 2003 as shown in [Table 1].
Table 1 :Sample characteristics of studied kindergarten children, Aden, 2003.

Click here to view

For the execution of this study, formal re­quest from the Faculty of Medicine and Health Sciences was presented to the Office of Edu­cation, Aden Governorate, to get the necessary information about kindergartens and get per­mission to carry out the study.

Data were obtained by using a precoded self­administered questionnaire, which was com­pleted by the parents. The questionnaire con­sisted of two parts:

1. The first part sought information on demo­graphic characteristics including age, sex, birth weight, birth order, parents' educational level and working status, number of persons living at home with the child and history of daytime enuresis during the last six months preceding the study.

2. In the presence of history of voiding pro­blems, the parents were asked to proceed to the second part of the questionnaire which contained information on possible associated factors (independent variables) such as a family history of daytime enuresis, history of other di­seases, experience of frightening and emotio­nally stressful condition in the last six months, consumption of caffeine containing drinks like tea or coffee, constipation, whether the child was afraid to use kindergarten or home toilets and punishment for daytime incontinence. Other related variables such as frequency and urgency of micturation, squatting (a holding maneuver that children with enuresis adopt to increase resistance to the escape of urine so that they do not wet until they are made to get up and go to the toilet), dribbling, dysuria were also asked. In addition, the severity of daytime enuresis was assessed using a predefined category of daytime enuresis [7] in which the parents were asked to record the frequency at which their children had daytime enuresis in the 6 months preceding the study as follows:

  • severe daytime incontinence: every day to twice or more/week
  • moderate daytime incontinence: twice or more/month to once/month
  • mild: twice or more/6 months preceding the study

Kindergartens were visited several times by the authors to maximize the response. Children positive for day-time incontinence were asked to visit the pediatrician in the study (author) free of charge so as to be subjected to the ne­cessary counseling and investigation and were treated accordingly.

   Statistical Analysis Top

Data were analyzed using SPSS software 14. Chi-squared test (χ2 ) was used to test statistical significance for differences in proportion and was replaced by Fisher exact probability (FEP) in case of small cell frequency. The cut-off va­lue for statistical significance was considered at P < 0.05.

   Results Top

In total, 1061 subjects responded to the ques­tionnaire, with a response rate of 62.3%. Thirty­four cases of daytime wetting were encountered, representing 3.2% of the children studied. The cases consisted of 16 (47.1%) males and 18 (52.9%) females. [Table 2] shows five charac­teristics of the children studied, of which cases and non-cases significantly differed in birth order and the type of kindergarten. More first and second birth orders were present among cases (1.9 ± 1.4) compared to non cases (2.6 ±1.7) (P = 0.02). Regarding the type of kinder­garten, a higher percentage of children from private kindergarten were included in the cases (44.1%) compared to incontinence-free children (27.7%) (P < 0.05).
Table 2 :Daytime incontinence by the personal characteristics of children, Aden, 2003.

Click here to view

Family characteristics of the studied children are given in [Table 3]. The mean family size was 5.6 ± 2 persons and the groups had similar education. However, working mothers were more common among the non cases (P < 0.05). Fathers' profession or job status was not dif­ferent between the two groups. In [Table 4] are presented seven characteristics related to day­time incontinence, comparing males and fe­males, which show similar prevalence (P > 0.05).
Table 3 :Daytime incontinence by the family characteristics of children, Aden, 2003.

Click here to view
Table 4 :Characteristics of daytime incontinence among kindergarten children by sex, Aden, 2003.

Click here to view

Different factors with possible relation to the daytime incontinence are shown in [Table 5].
Table 5 :Daytime incontinence by some related factors among children by sex, Aden, 2003.

Click here to view

   Discussion Top

The overall prevalence of daytime wetting in Aden Governorate's kindergarten children was 3.2%, similar to that reported in the literature, [1],[4],[5],[8],[9],[10],[18],[19] but was much lower than what was found in a similar study done in Australia [7] in which the prevalence of daytime wetting was 19.2%. Previous studies of this common problem have used a variety of definitions of daytime wetting in different populations, [7],[8],[9],[10] and as a result, the prevalence figures reported vary considerably. The majority (85.3%) of the stu­died daytime wetters were troubled frequently, daily or once or twice/week, while the mino­rity had mild-moderate form of daytime incon­tinence (once or twice/month or once or twice/6 months), contrary to findings of a study from Australia, [7] where the majority of children had the mild form of incontinence. In our case, the mothers reporting incontinence might be over­estimating the problem, or the low socioeco­nomic status, inadequate, non-integrated health services in our country may also result in de­lays in seeking help.

The study revealed the mean age of daytime wetters to be 61.4 ± 7.1 months, possibly attri­buted to bladder maturation delay. [3],[6],[12]

Our study, similar to that of others, [4],[5],[6],[7],[8],[15] showed that girls were affected by daytime wetting more than boys (52.9% vs. 47.1%). However, the severity of symptoms was similar in either sex.

Daytime wetting was associated with a cons­tellation of other urinary symptoms. Although the majority of the daytime wetters had ur­gency (70.6%), dribbling (64.7%) and squat­ting (58.8%), only 7 (20.5%) of them had past history of UTI, and none of the cases had re­cent UTI or urinary tract abnormalities, as ve­rified from urine cultures, renal function tests, and abdominal ultrasound that was done as part of the study. Similar prevalence has also been reported by others. [4],[6],[7],[13],[14],[15],[18],[20] The study showed that females appeared more prone to urinary symptoms compared to males, but such differences were not statistically significant.

Bedwetting alone or combined day and night enuresis was found in the majority of cases and in all males com-pared to females (94.4%), similar to that reported earlier. Most often, day­time urinary control is achieved before night­time control, and 20% of enuretics are diurnal, [11] and treatment of nocturnal wetting alone fails if the child has persistent daytime wetting because both have probably detrusor activity. [6]

Regarding the type of kindergarten unexpec­ted results were found. There were more incon­tinent children (44.1%) in the private kinder­gartens compared to the public kindergartens. It may be attributed to the small number chil­dren in the private kindergartens, or may re­present community views of the mothers and teachers of the overcrowded public kinder­gartens, for whom daytime wetting may be normal for 6-year-old children, and/or under­reporting of this problem.

Birth order of the index child seemed to be a significant associated factor. The study revealed that more wetting children were of first (52.9%) and second birth order (29.4%) compared to latter birth orders. This may be due to less experienced mothering and early strenuous toilet training of the earlier birth orders by their mothers. [20],[21]

The association between family history of nocturnal enuresis and subsequent risk to fa­mily members is well established, [1],[3],[7],[22],[23],[24],[25] and family history of daytime wetting, particularly in the paternal side, was an important risk fac­tor as was revealed in other studies. [3],[7],[23] In this study, though a family history of enuresis was present in 67.6%, it had no significant associa­tion with daytime wetters.

Of the acquired potential risk factors, family size and parents' education were less impor­tant for day wetting, though higher percentage of professional fathers were found among con­tinent children than incontinent ones (22.3% and 8.8%, respectively). Our results are similar to the results of the Australian study [7] and dif­ferent from a study done in Turkey [24],[25] where the family size, father's unemployment and pa­rents' education had significant association with daytime wetting. Mothers' working status in this study, however, had a significant associa­tion similar to ours where working mothers had less diurnal affected children.

Parent-reported history of any frightening or emotional events in the past 6 months was a strong independent risk factor for day wetting. Given the cross-sectional nature of this study, we could not determine whether daytime wet­ting was a cause or a result of emotional stress. However, this study and most other studies [2],[3],[4],[7],[21],[25],[26],[27] had demonstrated a strong relation­ship between stressful life events and daytime wetting.

During our survey, we acknowledged that daytime wetting is a vague or "a low level of concern" problem, both to teachers and pa­rents, and this can explain the lower response rate (62.3%). During our visits, some parents were worried only about nocturnal enuresis and wanted medical solutions. This may have introduced response bias that led to some pa­rents not responding to the questionnaire, re­sulting in underestimation of the true preva­lence of daytime wetting. We were unable to contact non-responders due to social and cul­tural issues and lack of a social worker in most kindergartens.

In conclusion, daytime voiding problem was studied for the first time in Yemen, suggesting that prevalence rate for day wetting was simi­lar to those reported in Turkey and other Euro­pean countries. Majority of the affected children had severe form of disease, and predictive fac­tors associated with daytime wetting included the youngest birth order, private kindergartens, housewife mothers, frightening and emotional events. More extended studies are needed in the future to explore this problem and provide medical and social support for the child and fa­milies disturbed with voiding problems.

   References Top

1.Elder JS. Voiding dysfunction. In: Kliegman RM (ed). Nelson Textbook of Paediatrics. 18 th edition. Philadelphia. Saunders, 2007. 2249-52.  Back to cited text no. 1
2.Shella G. Behavioral Disorders. In: Kliegman RM, Marcdante KJ, Jenson HB, Behrman RE (eds). Nelson Essentials of Pediatrics. 5 th edition. http://www.studentconsult.com/content/default.cfm?ISBN=141600159X&ID = Copyright © 2007 Elsevier Inc. Section 3: 68-70.  Back to cited text no. 2
3.Schmitt BD. Nocturnal enuresis. Pediatr Rev 1997;18(6):183-91.  Back to cited text no. 3
4.Robson WL. Diurnal Enuresis. Pediatr Rev 1997;18(12):407-12.  Back to cited text no. 4
5.Hjalmas K. Functional daytime enuresis: Defi-nition and epidemiology. Scand J Urol Nephrol Suppl 1992;141:39-44.  Back to cited text no. 5
6.Casale AJ. Daytime wetting: Getting to the bottom of the issue. Contemp Pediatr 2000;2: 107.  Back to cited text no. 6
7.Sureshkumar P, Craig JC, Roy LP, Knight JF. Daytime urinary incontinence in primary school children: A population-based survey. J Pediatr 2000;137(6):814-8.  Back to cited text no. 7
8.Bloom DA, Seeley WW, Ritchey ML, McGuire EJ. Toilet habits and continence in children: An opportunity sampling in search of normal parameters. J Urol 1993;149(5):1087-90.  Back to cited text no. 8
9.Hansen A, Hansen B, Dahm TM. Urinary tract infection, day wetting and other voiding symp-toms in seven to eight year old Danish children. Acta Pediatr 1997;86(12):1345-9.  Back to cited text no. 9
10.Mattsson S. Urinary incontinence and nocturia in healthy school children. Acta Pediatr 1994; 83(9):950-4.  Back to cited text no. 10
11.Wan J, Greenfield S. Enuresis and common voiding abnormalities. Pediatr Clin North Am 1997;44(5):1117-31.  Back to cited text no. 11
12.Kajiwara M, Inoue K, Usui A, Kurihara M, Usul T. The micturition habits and prevalence of daytime urinary incontinence in Japanese primary school children. J Urol 2004;171(1): 403-7.  Back to cited text no. 12
13.Hellerstein S, Zuguta AA. Outcome of over-active bladder children. Clin Pediatr 2003;42 (6):553-6.  Back to cited text no. 13
14.Von Gontard A, Hollmann E. Comorbidity of functional urinary incontinence and enco-poresis: Somatic and behavioral associations. J Urol 2004;171(6 Pt 2):2644-7.  Back to cited text no. 14
15.Mattsson S, Gladh G. Urinary vaginal reflux: A common cause of daytime enuresis in girls. Pediatrics 2003 Jan;111(1):136-9.  Back to cited text no. 15
16.Soderstrom U, Hoelcke M, Alenius L, Soderling AC, Hjern A. Urinary and fecal incontinence: A population based study. Acta Pediatr 2004; 93(3):386-9.  Back to cited text no. 16
17.Hellerstein S. Urinary tract infection in chil-dren: Why they occur and how to prevent them. Am Fam Physician 1998;57(10):2440-6.  Back to cited text no. 17
18.Sureshkumar P, Craig JC, Cummings R. Urinary tract infection and persistent daytime enuresis in children: A population based cohort study. Conference presentation. From Cell to Society 3, Research conference 2002. College of Health Sciences, University of Sydney, 2002;18-19 Sept, Leura, NSW, Australia.  Back to cited text no. 18
19.Bower WF, Moore KH, Shepherd RB, Adams RD. The epidemiology of childhood enuresis in Australia. Br J Urol 1996;78(4):602-6.  Back to cited text no. 19
20.Bakker E, van Gool J, van Sprundel M, van der Auwera JC, Wyndaele JJ. Risk factors for recurrent urinary tract infection in 4332B Elgian school; children aged between 10-14 years. Eur J Pediatr 2004;163(4-5):234-8.  Back to cited text no. 20
21.National Institute of Health and Urological Diseases Information Clearinghouse. Urinary incontinence in children. Digital Urinary J 2004(04-4095).  Back to cited text no. 21
22.Cendron M. Primary nocturnal enuresis: Current concepts. J Am Fam Phys 1999;59(5):1219-20.  Back to cited text no. 22
23.Azhir A, Frajzadegan Z, Adibi A, Hedayatpoor B, Frazel A, Divband A. An epidemiological study of enuresis among primary school children in Isfahan, Iran. Saudi Med J 2006;27 (10):1572-7.  Back to cited text no. 23
24.Gur E, Tuhan P, Can G, et al. Enuresis: Pre-valence, risk factors and urinary pathology among school Children, Istanbul Turkey. Pediatr Int 2004;46(1):58-63.  Back to cited text no. 24
25.Ozden C, Ozdal OL, Altinova S, Oguzulgen I, Urgancioglu G, Memis A. Prevalence and associated factors of enuresis in Turkish children. Int Braz J Urol 2007;33(2):216-22.  Back to cited text no. 25
26.De Sousa A, Kapoor H, Jagtap J, Sen M. Prevalence and factors affecting enuresis amongst primary school children. Indian J Urol 2007;23(4):354-7.  Back to cited text no. 26
27.Bernard-Bonnin AC. Diurnal enuresis in child-hood. Can Fam Physician 2000;46:1109-15.  Back to cited text no. 27

Correspondence Address:
Huda Omer Basaleem
Department of Community Medicine and Public Health, Faculty of Medicine and Health Sciences, Aden University
Login to access the Email id

PMID: 21060179

Rights and Permissions


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  

    Statistical Analysis
    Article Tables

 Article Access Statistics
    PDF Downloaded365    
    Comments [Add]    

Recommend this journal