Jaka jest rzeczywista częstość występowania nietrzymania moczu u dzieci w wieku szkolnym w Polsce? – badanie ankietowe

Szymon Czajka, Andrzej Grabowski, Paweł Małek, Anna Wyciszczok, Wojciech Korlacki

DEPARTMENT OF CHILDREN DEVELOPMENTAL DEFECTS SURGERY AND TRAUMATOLOGY IN ZABRZE, MEDICAL UNIVERSITY OF SILESIA SCHOOL
OF MEDICINE IN KATOWICE, KATOWICE, POLAND

Abstract

Introduction: Urinary incontinence should be treated as a pathology in patients who are at least 5 years old, a few percent of patients continue to suffer from this disorderin adolescence. It can be qualified as day-time incontinence (DUI) and nocturnal-incontinence (enuresis-NE).

The aim: To assess the incidence of micturition disorders in children aged 7 to 10, to analyze accompanying symptoms and compare the results with previous studies.

Material and methods: Parents of 954 children (491 girls and 463 boys) were surveyed during parent-teacher meetings held in 2017 in 11 randomly selected schools in southern Poland. The questionnaire was based on International Children’s Continence Society guidelines. Study population was divided into subgroups according to demographical data, presence of accompanying symptoms and the type of micturition disorder.

Results: Minor wetting was common in the studied population, however the group of children with clinically significant incontinence becomes smaller after applying current ICCS criteria. ≥1 symptom of urinary bladder malfunction was reported in 18% of cases (17.5% girls and 18.8% boys). Significant (≥1/month) NE was present in 1,7 % of children and significant (≥1/month) DUI in 2,2%. Significant NE combined with significant DUI occurred in 1% of children. Relationships between incontinence and the age at which children stopped wearing diapers, urinary tract infections, soiling and constipation episodes were observed.

Conclusions: Unified and clearly defined terminology should be used in order to correctly describe and compare the scale of this problem. Urinary incontinence should not be underestimated, because if untreated it may lead to physical, psychological and social disorders.

Streszczenie

Wstęp: Nietrzymanie moczu jest dolegliwością często występującą w populacji dzieci szkolnych. W wielu krajach prowadzone były badania epidemiologiczne oceniające częstość zaburzeń mikcji u dzieci w różnych grupach wiekowych. Nietrzymanie moczu traktowane jest jako patologia u dzieci w wieku powyżej 5 lat, z wiekiem częstość występowania zaburzeń zmniejsza się, jednak część pacjentów boryka się z tym problemem także w wieku nastoletnim oraz w dorosłości . Nietrzymanie moczu dzieli się na 2 główne kategorie: moczenie dzienne oraz moczenie nocne. Dostępne prace dotyczące moczenia u dzieci nie dają możliwości oceny częstości występowania tego zjawiska w Polsce.

Cel pracy: Ocena częstości występowania zaburzeń oddawania moczu u dzieci w wieku od 7 do 10 lat w Polsce. Analiza objawów towarzyszących tym zaburzeniom i porównanie wyników z wcześniejszymi publikacjami na ten temat.

Materiał i metody: Badaniem ankietowym objęto rodziców 954 dzieci (491 dziewczynek i 463 chłopców) uczestniczących w zebraniach rodziców w 11 losowo wybranych szkołach na terenie południowej Polski. Kwestionariusz opracowano na podstawie wytycznych ICCS (Międzynarodowe Towarzystwo ds. Kontynencji u Dzieci). Badaną populację podzielono na grupy w zależności od danych demograficznych, obecności lub braku objawów towarzyszących oraz typu zaburzeń mikcji.

Wyniki: Objawy moczenia o niewielkim nasileniu są częste w badanej populacji, jednak grupa pacjentów z klinicznie istotnym nietrzymaniem moczu zmniejsza się po zastosowaniu aktualnych kryteriów ICCS. Przynajmniej 1 objaw dysfunkcji pęcherza moczowego wystąpił w 18% przypadków (17,5% dziewcząt i 18,8% chłopców). Istotne klinicznie moczenie nocne (≥1/miesiąc) występowało u 1,7% dzieci, natomiast istotne klinicznie moczenie dzienne (≥1/ miesięczne) u 2,2%. Oba typy dolegliwości o znaczącym nasileniu były jednocześnie obecne u 1% dzieci. Zaobserwowano związek nietrzymania moczu z: wiekiem w którym dzieci przestawały nosić pieluchy, występowaniem infekcji dróg moczowych, brudzeniem bielizny oraz epizodami zaparć.

Wnioski: Nieprawidłowa kontrola oddawania moczu jest stosunkowo częstym zaburzeniem w badanej populacji. Aby poprawnie opisać i porównać skalę tego problemu, należy zastosować ujednoliconą i jasno zdefiniowaną terminologię. Nietrzymania moczu nie należy bagatelizować, ponieważ nieleczone może powodować nie tylko narastanie objawów somatycznych, ale także upośledzać funkcjonowanie społeczne dziecka i prowadzić do zaburzeń natury psychicznej.

Wiad Lek 2018, 71, 8, -1581

INTRODUCTION

Urinary incontinence is a common clinical problem in childhood; however, a small percentage of patients continue to suffer from this disorder in adolescence or even adulthood [1–6]. Urinary incontinence is divided into continuous and intermittent incontinence. Continuous incontinence refers to constant urine leakage (day and nighttime), which is usually caused by congenital malformations, external urethral sphincter dysfunction, or iatrogenic causes. Intermittent incontinence includes enuresis (NE − nocturnal enuresis) and daytime urinary incontinence (DUI). Enuresis without other lower urinary tract (LUT) symptoms or bladder dysfunction is defined as monosymptomatic enuresis (MNE). Children with enuresis and any LUT symptoms have non-monosymptomatic enuresis (NMNE). The International Children’s Continence Society (ICCS) guidelines define NE as intermittent incontinence of discrete amounts of urine during sleep in a child aged ≥5years, and DUI is described as incontinence of discrete amounts of urine during the day. NE and DUI should be qualified as a significant condition if >1 episode per month occurs for at least three months. The authors propose to qualify the significance of enuresis as frequent (≥4 per week) or infrequent (<4 per week) [7].

Physiologically, continence should be achieved by the age of 5–6 years. Maturation of the central nervous system (CNS) and adequate social circumstances are both key factors in the development of voluntary bladder control [4]. Urinary incontinence can be treated as primary if no continence has ever been achieved or secondary if it reappears after a six-month period of dryness. Secondary incontinence can have an organic or psychological background [8]. The presence of urinary incontinence can lead to serious psychosocial disorders, including problems with peer relationships, depressive symptoms, and poor self-image [9, 10].

Studies show that the etiology of enuresis and daytime incontinence is multifactorial and not fully confirmed [4,,11, 12]The prevalence of DUI and NE in children was assessed in many epidemiological studies performed over a long period of time; they vary in terms of definitions used, methodology, participant selection, and sample sizes. Therefore, there is considerable variation in the reported prevalence rates. NE prevalence has been studied more often than daytime incontinence, which is poorly described.

There are no statistical data available for Poland concerning urinary incontinence in children at any age. The main aim of our study was to assess the incidence of incontinence in the population of Polish primary school children aged 7 to 10. Another objective was to analyze the accompanying symptoms and social background of this problem.

MATERIAL AND METHODS

A randomly selected cross-sectional study was conducted using a self-administered anonymous questionnaire. Polish children enter primary schools at the age of 7 years. The study was performed in January and February 2017. Parents or legal guardians of children aged 7–10 were asked to fill in an anonymous questionnaire during parent–teacher meetings held in 11 randomly selected primary schools in the south of Poland – Lesser Poland and Silesian voivodships. An information leaflet was attached to the questionnaire informing the parents about the voluntary nature of participation in the study and explaining its purpose. The study authors were present at every one of these meetings to ensure high survey response rates, but they did not affect the questionnaire completion process.

According to the Polish Central Statistical Office (GUS), 60% of children aged 5–14 years inhabiting these regions live in the cities. To maintain this proportion, survey forms were distributed 60% in schools located in the cities and 40% in the rural regions. The school administration’s permission was always obtained before the survey forms were distributed.

The questionnaire was based on the ICCS guidelines (see appendix). The first section was used to document the background data of the child, such as age, school grade, gender, inhabitation (living in a rural or urban area), and the patient’s education level (see APPENDIX). The second section consisted of questions concerning urinary incontinence, its type, prevalence, and accompanying symptoms (constipation, diapering habits, soiling, urinary tract infections [UTIs], urgency).

The study population was divided into subgroups based on age, sex, place of residence, parents’ education level, type of micturition disorder, and accompanying symptoms. Contingency tables were analyzed using the chi-squared test. The T-student test was used to compare continuous variables. The results were considered significant at p<0.05. The data were processed using STATISTICA 12 software (StatSoft, Inc., Tulsa, USA).

RESULTS

A total of 1,250 survey forms were distributed to the parents or legal guardians; 954 parents (response rate = 76.3%) completed and returned a questionnaire that was eligible for analysis. We collected data on 491 girls and 463 boys. The investigated children were aged 7–10 (mean age 8.35 years). One or more symptoms of urinary incontinence was reported in 18% of cases (17.5% of girls and 18.8% of boys). Isolated NE symptoms occurred in 5.2% (4.1% of girls and 6.5% of boys). Isolated daytime incontinence symptoms were present in 9.4% of girls and 7.3% of boys (total of 8.4%) (Tab. 1).

Significant (≥1/month) NE was present in 1.7 % of children and significant (≥1/month) DUI in 2.2% of the study group. Significant NE combined with significant DUI occurred in 1% of children (5 boys and 5 girls). Only in 0.4% of patients (3 boys and 1 girl) the condition could be qualified as frequent using the latest ICCS guidelines (Tab. 2). The prevalence of urinary incontinence significantly decreased with age, from 27.13% at the age of 7 to 6.81% in children aged 10 years (Fig. 1). The frequency of urgency episodes (sudden and unexpected experience of an immediate and compelling need to void) was associated with the presence of incontinence symptoms (Tab. 4).

There was a statistically significant correlation observed between the age at which children stopped wearing diapers and the incidence of incontinence at the age of 7–10 years (Fig. 2). Incontinence was present in 27.6% of students with a positive history of UTIs and in 16.3% of patients without episodes of UTI (Fig. 3). The prevalence of incontinence was 6.2% higher in the group of children with episodes of constipation (Fig. 4). Children who had problems with soiling were also more likely to have micturition disorders (Fig. 5). The incidence of incontinence was higher in children living in a city than in children from rural areas, but differences were statistically insignificant (Fig. 6). There was no relationship observed between the level of the parents’ education and the incidence of urinary incontinence of any type. Of 173 patients who developed incontinence symptoms, 16.7% were treated before the study was performed and 17.2% were under treatment at the time of survey.

DISCUSSION

In our study, the overall prevalence of urinary incontinence symptoms reached 18%. However, after applying the criteria proposed in the ICCS standardisation report from 2006 (updated in 2014), [7], the condition could be qualified as clinically significant in only 4.9% of children and as frequent in 0.4% (Tab. 2). There is considerable variation in the prevalence of micturition disorders reported in studies published worldwide. These differences are probably caused mainly by the use of different definitions of urinary incontinence; in some of the studies the definitions used were not given. Predictably, reported prevalence rates should be significantly higher if a lenient definition of incontinence is employed, but this assumption did not work in all cases (Tab. 5). According to an Australian bibliometric study, approximately 25% of studies published after the introduction of ICCS terminology in 2006 (in the period from 2007 to 2010) contained misleading nomenclature [13]. Prevalence rates variation may also be due to differences in the age group, genetic predisposition, psychosocial or environmental conditions, and cultural and traditional background. A number of studies have investigated which medical conditions as well as sociological and economic factors might be correlated with the prevalence of urinary incontinence. The majority of these studies analyzed age, gender, behavioural problems, family history of incontinence and genetic factors, the number of siblings, birth sequence, family’s education and economic status, number of individuals in the family, constipation, and previous history of UTI [5, 12, 14–23]..

In the current study, significant isolated NE (≥1x/month) was present in 1.7% of children, and episodes of isolated bed-wetting were frequent in only one case (≥4x/week). Isolated NE was reported in 1.43% of cases in a study of 4,332 Belgian schoolchildren aged between 10 and 14 years [15]. In this study, 42 children (<1%) wet the bed with a frequency of more than once a month. This research was conducted in an older age group than the current study, which might be the cause of a slightly lower percentage of enuretic children and is in accordance with previous reports, and also with our study, stating that the prevalence of urinary incontinence diminishes with age [3, 6, 11,24–26]. In a Finnish study by Kyrklund et al. [1] published in 2012, 1.37% of children aged 4–12 years had isolated nighttime incontinence; this number matches our results, although the study also included younger children and a different frequency classification was used. Butler et al. [27] reported a bedwetting frequency of 1.6% in children aged 9.5 years using a DSM-IV definition (≥2 episodes/week). In a 2016 study conducted in Egypt, [20], the prevalence of isolated NE in children aged 6–12 years reached 15%, whereas in a Turkish study published in 2014 [19]isolated NE was present in 16.6% of students aged 7–15 years (mean age 10.35). In both studies, no clear frequency criterion was used. The Egyptian study uses the term monosymptomatic nocturnal enuresis (MNE) to define enuresis in general; both of those incontinence types have been described in ICCS reports from 2006 [28] and 2014 [7]. Furthermore, some of the questionnaires in this study were completed only by the children themselves.

DUI in children is thought to be one of the most common developmental disorders and also one of the most bothersome problems among affected children and their parents [25]. The issue of daytime wetting has not been studied as often as enuresis; DUI has been frequently analyzed only as an accompanying symptom of NE. A British study published in 2010 [3] estimated the population prevalence of daytime urinary incontinence using DSM-IV criteria, where infrequent DUI (<2x /week) was present in 13.6% of children at the age of 4.5 years, decreasing to 4.4% at the age of 9.5 years. Frequent DUI (≥2x /week) was much less common: 1.9% at 4.5 years decreasing to 0.5% at 9.5 years. While a 2015 German study [18] of 718 children aged 4.6–7.9 years reports a DUI incidence rate of 1.5%, Hellström et al. [14] reported a DUI incidence of 2.7% in children aged 7 years. Results of the above-mentioned studies are comparable in the aspect of DUI prevalence with the current study. On the other hand, different DUI definitions were also used in those studies, as in the case of NE, they ranged from “≥2 episodes/week” [3] to “≥1 wet night over a 6-month period” [29].

Patients with associated daytime wetting (mixed disorder) are regarded as more clinically complex cases than children with isolated bedwetting [27]. Studies suggest that enuretic children with co-existing daytime incontinence probably have a greater chance of persistent wetting in adult life.[5, 17]. In our study, only 1% of the surveyed parents reported mixed urinary incontinence in their children. Exactly the same prevalence was reported in a study by Wen et al. [17]. In studies in which the same definition of incontinence was used, the incidence of NE combined with DUI ranged from 1% to 1.7% [12, 17, 25].

As presented in Table 1, there was no significant difference in the prevalence of any incontinence type between girls and boys in our data series. Most of the studies report higher prevalence of NE in boys, which is often attributed to later development of successful toilet training.[1, 15, 17, 30].
For daytime wetting, the situation is reversed; many authors conclude that girls develop DUI more often [2, 14, 15, 24]. It is important to note that in some papers, as in our study, there were no gender-specific differences in the incontinence prevalence rates [3, 20, 25].

Another important finding is that the percentage of all incontinence symptoms decreased with age from 27.1% in the first grade to 6.8% at the age of 10 years (Fig. 1). This observation suggests that bladder control continues to develop up to adolescence and is supported by data from previous studies.[3, 6, 11, 24–26]. Higher prevalence of incontinence episodes in first-grade students can also be triggered by a strong emotional stressor, which clearly is the first period in a new school [29]. In the studied population, the incidence of isolated enuresis decreased over time; however, the difference was not statistically significant (Tab. 3).

As presented in Table 4, the presence of urinary incontinence symptoms correlated with the prevalence of urgency defined as sudden and unexpected experience of an immediate and compelling need to void. Urgency is often a sign of bladder overactivity, which is one of the causes of wetting. A relationship was observed between the age at which children stopped wearing diapers and the presence of urinary incontinence episodes at the age of 7–10 years (Fig. 2). Wetting could be enhanced by habitual use of diapers, and early potty training can prevent future problems with incontinence. Children are mature enough for such training already in the first year of life [4].

In children with episodes of constipation, a significantly higher prevalence of incontinence symptoms was found (Fig. 4). The association between constipation and incontinence is well described in the literature [31]. The theory behind this connection is that an accumulation of faecal mass in the rectum can lead to compression of the bladder, which induces detrusor instability and thereby causes incontinence. Furthermore, dysfunctional voiding causes overtraining of the pelvic floor as a defense against urine loss. The resulting high pelvic floor muscle tone can lead to dysfunctional elimination of faeces, which, in turn, leads to accumulation of faecal mass in the rectum and soiling.[22, 26, 32–34]. In this context, another key finding in our study, which matches previously published results, is that if a child had experienced soiling, he or she was two times more likely to develop incontinence symptoms (Fig. 5).

There was also a relationship observed between a history of UTIs and the prevalence of wetting episodes (Fig. 3). The presence of this relationship was already described in different publications [4, 15, 20, 26, 31, 35–37]. In our survey, there was no question concerning age at the first UTI or whether the bladder symptoms were primary or secondary to the first UTI, so we are unable to evaluate a cause-and-effect relationship between UTI and the incidence of incontinence. According to a paper published by Loening-Baucke [31] soiling and constipation carry a higher risk of UTIs, which, in turn, can result in daytime wetting. Another study by the same author demonstrated that treatment of constipation can improve urinary symptoms, and, therefore, in constipated children with voiding, dysfunction recurrence of UTIs is prevented [35]. A paper published in Denmark noted that inflammation in the urinary tract may result in disturbed function of the bladder and increased susceptibility to bacterial colonisation. On the other hand, researchers state that incontinence may be the first event. External urethral sphincter malfunction increases the risk of bacterial ascendancy into the urinary tract, and the presence of residual urine increases the risk of bacterial growth [36].

Living in a rural region is described as one of the risk factors associated with the incidence of wetting [17, 37, 38]. It must be stated that this dependence has a socio-economic basis (medical care, toilet facilities, living conditions), which is not relevant in our area. In this data series, more children who suffered from urinary incontinence lived in the cities than in the rural regions; however, the difference was statistically non-significant (Fig. 6). We observed no relationship between the parents’ education level and the incidence of incontinence in their children.

Regarding the question concerning the primary and secondary character of incontinence, the response rate was too low, and thus the data were ineligible for analysis. Problems appeared after a period of dryness in 24 cases, and eight cases of primary incontinence were reported. We did not study other potential risk factors that might be associated with incontinence, including stressful events, lifestyle, family history, number of siblings, birth sequence, and number of individuals in the family. We did not use a scoring system, which is one of the limitations in the present study. A larger sample would have increased the strength of our results; therefore, we would like our research to be treated as a pilot study in the Polish population.

CONCLUSIONS

In our opinion, the data obtained show that incontinence that should be treated by specialists is relatively common in the study group. Minor wetting is a common problem in the studied population; however, the group of children with clinically significant urinary incontinence becomes smaller after applying more strict criteria developed by the ICCS. It was observed that the prevalence of urinary incontinence decreases with age and is associated with the presence of urgency episodes, positive history of UTIs, constipation, and soiling. The later that the children in the study population stopped wearing diapers, the greater was the incidence of incontinence at the age of 7–10 years.

The use of different definitions of urinary incontinence is the main cause of difficulties in comparing the studies published worldwide. There is a strong need to implement unified and clearly defined terminology in order to correctly describe the scale of these disorders. The problem of urinary incontinence should not be underestimated, because if untreated it may lead not only to physical but also serious psychological and social disorders.

References

1. Kyrklund K, Taskinen S, Rintala RJ, Pakarinen MP. Lower urinary tract symptoms from childhood to adulthood: a population based study of 594 Finnish individuals 4 to 26 years old. J Urol [Internet]. 2012;188(2):588–93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22704114

2. Heron J, Grzeda MT, von Gontard A, Wright A, Joinson C. Trajectories of urinary incontinence in childhood and bladder and bowel symptoms in adolescence: prospective cohort study. BMJ Open [Internet]. 2017;7(3):e014238. Available from: http://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2016-014238

3. Swithinbank LV, Heron J, von Gontard A, Abrams P. The natural history of daytime urinary incontinence in children: a large British cohort. Acta Paediatr [Internet]. 2010;99(7):1031–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20199496

4. Nevéus T, Sillén U. Lower urinary tract function in childhood; normal development and common functional disturbances. Acta Physiol (Oxf) [Internet]. 2013;207(1):85–92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23088436

5. Yeung CK, Sreedhar B, Sihoe JDY, Sit FKY, Lau J. Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int [Internet]. 2006;97(5):1069–73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16643494

6. Hellström A, Hanson E, Hansson S, Hjälmäs K, Jodal U. Micturition habits and incontinence at age 17–reinvestigation ofa cohort studied at age 7. Br J Urol [Internet]. 1995;76(2):231–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7663917

7. Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P 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. J Urol [Internet]. 2014;191(6):1863–1865.e13. Available from: http://doi.wiley.com/10.1002/nau.22751

8. Hodge-Gray E, Caldamone AA. Primary nocturnal enuresis: a review. J Sch Nurs [Internet]. 1998;14(3):38–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9883144

9. Grzeda MT, Heron J, von Gontard A, Joinson C. Effects of urinary incontinence on psychosocial outcomes in adolescence. Eur Child Adolesc Psychiatry [Internet]. 2017;26(6):649–58. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27943057

10. Jönson Ring I, Nevéus T, Markström A, Arnrup K, Bazargani F. Nocturnal enuresis impaired children’s quality of life and friendships. Acta Paediatr [Internet]. 2017;106(5):806–11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28199734

11. Sureshkumar P, Jones M, Cumming R, Craig J. A population based study of 2,856 school-age children with urinary incontinence. J Urol [Internet]. 2009;1(2):808-15; discussion 815-6. Available from: http://dx.doi.org/10.1016/j.juro.2008.10.044

12. Sarici H, Telli O, Ozgur BC, Demirbas A, Ozgur S, Karagoz MA. Prevalence of nocturnal enuresis and its influence on quality of life in school-aged children. J Pediatr Urol [Internet]. 2016;12(3):159.e1-6. Available from: http://dx.doi.org/10.1016/j.jpurol.2015.11.011

13. Dannaway J, Ng H, Deshpande AV. Adherence to ICCS nomenclature guidelines in subsequent literature: a bibliometric study. Neurourol Urodyn [Internet]. 2013;32(7):952–6. Available from: http://doi.wiley.com/10.1002/nau.20889

14. Hellström AL, Hanson E, Hansson S, Hjälmås K, Jodal U. Micturition habits and incontinence in 7-year-old Swedish school entrants. Eur J Pediatr [Internet]. 1990;149(6):434–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2332015

15. Bakker E, van Sprundel M, van der Auwera JC, van Gool JD, Wyndaele JJ. Voiding habits and wetting in a population of 4,332 Belgian schoolchildren aged between 10 and 14 years. Scand J Urol Nephrol [Internet]. 2002;36(5):354–62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12487740

16. Joinson C, Sullivan S, von Gontard A, Heron J. Stressful Events in Early Childhood and Developmental Trajectories of Bedwetting at School Age. J Pediatr Psychol [Internet]. 2016;41(9):1002–10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27072719

17. Wen JG, Wang QW, Chen Y, Wen JJ, Liu K. An epidemiological study of primary nocturnal enuresis in Chinese children and adolescents. Eur Urol [Internet]. 2006;49(6):1107–13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16406243

18. von Gontard A, Niemczyk J, Thomé-Granz S, Nowack J, Moritz A-M, Equit M. Incontinence and parent-reported oppositional defiant disorder symptoms in young children–a population-based study. Pediatr Nephrol [Internet]. 2015;30(7):1147–55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25588521

19. Akil IO, Ozmen D, Cetinkaya AC. Prevalence of urinary incontinence and lower urinary tract symptoms in school-age children. Urol J [Internet]. 2014;11(3):1602–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25015605

20. Hamed A, Yousf F, Hussein MM. Prevalence of nocturnal enuresis and related risk factors in school-age children in Egypt: an epidemiological study. World J Urol [Internet]. 2017 Mar;35(3):459–65. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27306687

21. Deshpande A V., Craig JC, Smith GHH, Caldwell PHY. Factors influencing quality of life in children with urinary incontinence. J Urol [Internet]. 2011;186(3):1048–52. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0022534711038857

22. Sampaio C, Sousa AS, Fraga LGA, Veiga ML, Bastos Netto JM, Barroso U. Constipation and Lower Urinary Tract Dysfunction in Children and Adolescents: A Population-Based Study. Front Pediatr [Internet]. 2016;4(1):101. Available from: http://journal.frontiersin.org/article/10.3389/fped.2016.00101

23. Nurko S, Scott SM. Coexistence of constipation and incontinence in children and adults. Best Pract Res Clin Gastroenterol [Internet]. 2011;25(1):29–41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21382577

24. Heron J, Joinson C, Croudace T, von Gontard A. Trajectories of daytime wetting and soiling in a United kingdom 4 to 9-year-old population birth cohort study. J Urol [Internet]. 2008;179(5):1970–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18355863

25. Kajiwara M, Inoue K, Usui A, Kurihara M, Usui T. The micturition habits and prevalence of daytime urinary incontinence in Japanese primary school children. J Urol [Internet]. 2004;171(1):403–7. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0022534705627668

26. Chung JM, Lee SD, Kang DI, Kwon DD, Kim KS, Kim SY et al. An epidemiologic study of voiding and bowel habits in Korean children: a nationwide multicenter study. Urology [Internet]. 2010;76(1):215–9. Available from: http://dx.doi.org/10.1016/j.urology.2009.12.022

27. Butler RJ, Heron J. The prevalence of infrequent bedwetting and nocturnal enuresis in childhood. A large British cohort. Scand J Urol Nephrol [Internet]. 2008;42(3):257–64. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18432533

28. Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children’s Continence Society. J Urol [Internet]. 2006;176(1):314–24. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16753432

29. Sureshkumar P, Craig JC, Roy LP, Knight JF. Daytime urinary incontinence in primary school children: a population-based survey. J Pediatr [Internet]. 2000 Dec;137(6):814–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11113838

30. Largo RH, Molinari L, von Siebenthal K, Wolfensberger U. Development of bladder and bowel control: significance of prematurity, perinatal risk factors, psychomotor development and gender. Eur J Pediatr [Internet]. 1999;158(2):115–22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10048607

31. Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics [Internet]. 1997 Aug;100(2 Pt 1):228–32. Available from: http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.100.2.228

32. Ferrara P, Ianniello F, Romani L, Fabrizio GC, Gatto A, Chiaretti A. Five years of experience in nocturnal enuresis and urinary incontinence in children: where we are and where we are going. Urol Int [Internet]. 2014;92(2):223–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24246887

33. Averbeck MA, Madersbacher H. Constipation and LUTS – how do they affect each other? Int Braz J Urol [Internet]. 2011;37(1):16–28. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21385476

34. De Paepe H, Renson C, Van Laecke E, Raes A, Vande Walle J, Hoebeke P. Pelvic-floor therapy and toilet training in young children with dysfunctional voiding and obstipation. BJU Int [Internet]. 2000;85(7):889–93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10792172

35. Loening-Baucke V. Prevalence rates for constipation and faecal and urinary incontinence. Arch Dis Child [Internet]. 2007;92(6):486–9. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2066162&tool=pmcentrez&rendertype=abstract

36. De Paepe H, Renson C, Van Laecke E, Raes A, Vande Walle J, Hoebeke P. Pelvic-floor therapy and toilet training in young children with dysfunctional voiding and obstipation. BJU Int [Internet]. 2000;85(7):889–93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10792172

37. Bolat D, Acar IC, Zumrutbas AE, Eskicorapci S, Sancak EB, Zencir M et al. Prevalence of Daytime Urinary Incontinence and Related Risk Factors in Primary School Children in Turkey. Korean J Urol [Internet]. 2014;55(3):213. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24648878

38. Bhargava M, Solanki J, Mehta A. Lower urinary tract dysfunction symptoms by Modified Dysfunctional Voiding Scoring System in school age (6-12 years) children. Sch J Appl Med Sci [Internet]. 2016;4(6):2167–72. Available from: http://saspublisher.com/wp-content/uploads/2016/07/SJAMS-46E-2167-2172.pdf

39. Söderstrom U, Hoelcke M, Alenius L, Söderling AC, Hjern A. Urinary and faecal incontinence: a population-based study. Acta Paediatr [Internet]. 2004;93(3):386–9. Available from: http://doi.wiley.com/10.1080/08035250310021109

Conflict of interest:

The Authors declare no conflict of interest

Corresponding author

Szymon Czajka

Department of Children Developmental Defects Surgery and Traumatology in Zabrze,

Medical University of Silesia School of Medicine in Katowice,
Katowice, Poland

e-mail: szymon_czajka@wp.pl

Received: 09.11.2018

Accepted: 28.11.2018

Fig. 1. Incidence of incontinence by age.

Fig. 2. Incidence of incontinence by age of stopping wearing diapers.

Fig. 3. Incidence of incontinence among children with and without UTI

Fig. 4. Incidence of incontinence in children with and without episodes of constipation

Fig. 5. Incidence of incontinence in children with and without episodes of soiling

Fig. 6. Relation between incontinence type and the place of residence

Gender

P Value

Girls

Boys

Type of incontinence

No incontinence

405

376

0,61

DUI (isolated)

46 (9,36%)

34 (7,34%)

0,26

Monosymptomatic enuresis (MNE)

20 (4,07%)

30 (6,48%)

0,10

DUI + NE
(non-monosymptomatic enuresis)

20 (4,07%)

23 (4,97%)

0,78

TOTAL – CHILDREN WITH EPISODES OF INCONTINENCE

86 (17,50%)

87 (18,79%)

IN TOTAL

491

463

Table 1. Distribution of incontinence types by gender.

Type of incontinence

MNE

DUI (isolated)

NE + DUI
(NMNE)

F R EQUENC Y

NO INCONTINENCE

904 (94,76%)

874 (91,61%)

911 (95,49%)

< 1 / month

34 (3,56%)

59 (6,18%)

33 (3,46%)

SIGNIFICANT

1-4x / MONTH

13 (1,36%)

17 (1,78%)

10 (1,05%)

2–3x / WEEK

2 (0,21%)

3 (0,31%)

4-7x / WEEK (frequent)

1 (0,10%)

1 (0,10%)

IN TOTAL (incontinent)

50 (5,24%)

80 (8,39%)

43 (4,51%)

Table 2. Prevalence and frequency of MNE, DUI and NMNE episodes in the study group.

Table 3. Distribution of incontinence types by age.

AGE (years)

NO INCONTINENCE (%)

PRESENCE
OF INCONTINENCE (%)

P Value

TYPE OF INCONTINENCE

MNE

7Y

240 (93,02%)

18 (6,98%)

0,14

8Y

278 (94,56%)

16 (5,44%)

9Y

199 (94,31%)

12 (5,69%)

10Y

187 (97,91%)

4 (2,09%)

DUI (isolated)

7Y

229 (88,76%)

29 (11,24%)

0,045

8Y

266 (90,48%)

28 (9,52%)

9Y

196 (92,89%)

15 (7,11%)

10Y

183 (95,81%)

8 (4,19%)

DUI + NE (NMNE)

7Y

235 (91,09%)

23  (8,91%)

0,002

8Y

282 (95,92%)

12 (4,08%)

9Y

204 (96,68%)

7 (3,32%)

10Y

190 (99,48%)

1 (0,52%)

Table 4. Presence of incontinence by frequency of urgency episodes.

NO INCONTINENCE

PRESENCE
OF INCONTINENCE SYMPTOMS

p Value

NO URGENCY

391 (40,99%)

49 (5,14%)

<0,001

< 1 / month

214 (22,43%)

61 (6,39%)

≥ 1 / month to 3 / week

154 (16,14%)

54 (5,66%)

4-7 / week

22 (2,31%)

9 (0,94%)

total

781 (81,87%)

173 (18,13%)

Table 5. Published surveys of urinary incontinence prevalence in children.

Study authors

YEAR

study methods

Study population
(country)

Study group (n)

Age group
(years)

Presence of NE

Presence of DUI

Presence of DUI combined with NE

Hellström et al(14)

1990

survey completed by parents

Sweden

3556

7

7,42%
(n=264)
A isolated

2,7%

(N=97) A

ISOLATED

2,1%

(N=76) A

Sureshkumar et al(29)

2000

survey completed by parents

Australia

1419

~5,9

11% (N=155) E

19,2% (N=273) E

2,7% (N=38) D

4,3% (N=61) E

Bakker et al(15)

2002

survey completed by parents

Belgium

4332

10-14

1,4 % (n=62) B
isolated

4% (N=192) B
ISOLATED

3,5%
(n=151) B

Söderstrom et al.(39)

2004

survey completed by parents

Sweden

1478

7,3-10,4

7,1% – 2,7% (N=70) C

6,3% – 4,3% (N=77) C

________

Kajivara et al.(25)

2004

survey completed by parents

Japan

5282

7-12

3,6% C

ISOLATED

4,6% C

ISOLATED

1,6% C

Wen et al.(17)

2005

survey completed by parents

China

6365

5 – 12

4,6%

(N=292) c

isolated

_________

1%

(N=68) c

Butler et al.(27)

2008

survey completed by parents

United Kingdom

10 818

4,5 – 9,5

8,5% D
for children aged 4,5Y
TO 1,6% D

for children aged 9,5Y

_________

_________

Sureshkumar et al.(11)

2009

survey completed by parents

Australia

2856

4,8 – 12,8

__________

10% (N=286) B
ISOLATED

6,5%
(N=186) b

Swithinbank et al. (3)

2010

survey completed by parents

United Kingdom

10 819

4,5 – 9,5

__________

15,5% (1,9% D)
for children aged 4,5Y
TO 4,9% (0,5%
D)

for children aged 9,5Y

________

Chung et al.(26)

2010

survey completed by parents

Korea

16 516

5-13

5,6% (N=919) B

11,2% (N=1854) B

________

Kyrklund et al. (1)

2012

survey completed by parents

Finland

292

4-12

1,9% (N=4)B isolated

20,7% (N=33)B
ISOLATED

3,1% (N=5)B

Akil et al(19)

2014

survey completed by parents

Turkey

416

7 – 15

16,6%

(N=69) b
isolated

6,7% (N=28) B

ISOLATED

4.1% (N=17) b

von Gontard et al(18)

2015

survey completed by parents

Germany

718

4.6 – 7.9

8,2% b

Isolated

1,5% B

_______

Sarici et al. (12)

2015

survey completed by parents

Turkey

1984

6-13

7,8%
(N=155) c Isolated

1,3%

(N=26)B
ISOLATED

1,7%

(N=34) c

Hamed et al(20)

2016

survey completed by parents

Egypt

4652

6-12

15%

(N=701) b

Isolated

_________

2,8%
(N=133)
b

Our study

2017

survey completed by parents

Poland

954

7-10

1,7 % C (isolated)

2,2 % C

ISOLATED

1%C

A INCONTINENCE DEFINED AS AT LEAST 1 EPISODE EVERY 3 MONTHS

B DATA REGARDING ANY INCONTINENCE SYMPTOMS – NO FREQUENCY CRITERION OR DEFINITION UNCLEAR

C AT LEAST ONE EPISODE OF INCONTINENCE PER MONTH

D CLINICALLY SIGNIFICANT AS PER DSM IV CLASSIFICATION – FREQUENCY OF TWICE A WEEK FOR AT LEAST 3 CONSECUTIVE MONTHS

E DEFINED AS 1 EPISODE OF DUI IN LAST 6 MONTHS / 1 EPISODE OF NE PER WEEK