Nocturnal Enuresis in Primary Schools Children (6-12 Years) of Tabuk City, Saudi Arabia

Background: Regardless of the significance and the disturbing magnitudes of NE, this problem remains under-reported in Tabuk, Saudi Arabia and comprehensive studies in this regard are considerably lacking in that region. This study aimed to discuss the prevalence and associated risk factors of NE among children in Saudi Arabia. Methodology: A cross sectional study design was adopted in Tabuk, KSA using a selfadministered questionnaire for data collection distributed online on social media sites to be filled out personally. All data were collected, tabulated, and statistically analyzed using SPSS 23.0 for windows (SPSS Inc., Chicago, IL, USA). Results: The study included 431 participants. (37.4%) of children aged between six and seven years old, (32.7%) between eight and nine years old, and (17.2%) between ten and twelve years old. (58.9%) of children were males and (41.1%) females. Average frequency various from (53.8%) one time to two times per week, (31.3%) three times to four times per week, (14.8% five times to seven times per week. Enuresis was at night only in (77.5%) while (22.5%) at day or night. (64.5%) don’t seek to medical advice, while (35.5%) getting medical advice. (48.5%) of children getting behavioral therapy to treat this condition, (15.8%) exercise to strengthen bladder muscles, (14.6%) getting medical treatment, (10%) getting urination alarm, (0.5%) doing surgical intervention. There Original Research Article Alomani and Khalil; JPRI, 33(54A): 88-103, 2021; Article no.JPRI.77503 89 was a significant relationship between frequency per week of enuresis with mother educational level, number of family member, age of child (6-7) years old, sex of child (female), family history of nocturnal enuresis and delayed growth. Also, there was a significant relation between timing of enuresis during night or day and night with parents suffering from nocturnal enuresis, father’s education level, mother’s education level, and caring of parents to awaken the child. Conclusion: Nocturnal enuresis associated factors and parenteral knowledge of definition and causes of it were among universal reported figures. Referral to a pediatric urologist can be indicated for children with primary enuresis refractory to standard and combination therapies, and for children with some secondary causes of enuresis, including urinary tract malformations, recurrent urinary tract infections, or neurologic disorders.


INTRODUCTION
Nighttime incontinence or nocturnal enuresis is known as nighttime bedwetting in children aged 5 years or older [1]. It is the urological complaint that is most common in pediatric patients. If it happens in a child who is not dry for at least 6 months, the case may be described as nocturnal enuresis, while secondary enuresis develops after a duration of nocturnal dryness of at least 6 months [2,3].
NE is an international problem across all cultures. The incidence of enuresis (≥2 nights per week) in one large British study was 8% at 9.5 years [2]. In a few studies, the overall prevalence rate was reported to be 5%-20% [4].
It is possible to distinguish Enuresis into primary and secondary classes. Primary enuresis occurs when for six or more months in a row a child > 5 years of age has never achieved a period of full dryness. Although secondary enuresis is a condition that develops at least six months or several years after a child has reached a full dryness period [5].
Enuresis etiology is not fully known. Several main pathophysiological, such bladder dysfunction, low functional bladder capacity, abnormal vasopressin levels, nocturnal polyuria, and abnormal sleep patterns, were suggested [6].
For the child and the parents, nocturnal enuresis has serious consequences. A range of cognitive, social and psychological issues can be triggered by nocturnal enuresis, including embarrassment, blushing, loss of self-esteem and aggression [7]. Behavioral changes such as low self-esteem, isolation, reduced ambition, and increased anxiety in many children who suffer from NI. Within the school system, these children are often low-achievers and become a concern for their family and school. It is therefore important to classify children at risk and to perform therapeutic steps [8].
Prevalence of NE in KSA was variable as a study in Taif region by Al-Zahrani (2014) who carried out a cross sectional study on 2701 child. He reported the frequency of nocturnal enuresis was 7.81 %. There were no significant between boys (7.33%) and girls (8.42%) [9].  in Saudi Arabia conducted A cross-sectional descriptive study on 2148 Child, it was stated that, 31.2% of children have nocturnal enuresis. There were no significant correlations between nocturnal enuresis and child gender while it significantly correlated with child's age and having a family history of NE [10].  in Riyadh, Saudi Arabia carried out another cross-sectional survey included 352 families that had children with NE, it was found that, the prevalence of NE was 18.5% among families with a higher prevalence in boys. Prevalence of NE decreased with increasing age with many children found of having stressful events in their life other than parents' divorce [11].
Also,  in Jazan, Saudi Arabia conducted a cross-sectional study on 505 child, reported that, 76.4% of the children had NE. The prevalence of NE in the boys (79.5%) was non-significantly higher than girls (73.3%).There were statistically significant relationships between NE and history of pinworms infestation, no breastfeeding, low school performance, and lower father education [12]. Regardless of the significance and the disturbing magnitudes of NE, this problem remains underreported in Tabuk, Saudi Arabia and omprehensive studies in this regard are considerably lacking in that region.

METHODOLOGY
To discuss the prevalence and associated risk factors of NE among children in Saudi Arabia Study Design: A cross sectional study design was adopted.

Study Area and Setting:
The study was carried out in Tabuk, KSA. It is located in northern Saudi Arabia.

Study Period:
The data was collected during a period of four months from February 1st 2021 to June 31th, 2021.

Study Population:
Mothers of children of primary school age (6-12 years).

Inclusion Criteria:
· Age between 18 and 65 years · Saudi · Able to read and write Exclusion Criteria: · Older than 65 or younger than 18 years · Illiterate · Non-Saudi Sample Size: The sample size of this study is calculated by using the formula: n= P (1-P) * Z α 2 / d 2 , [14] assuming n: Calculated sample size Z: The z-value for the selected level of confidence (1-a) = 1.96. P: An estimated prevalence of having child with nocturnal enuresis as 50% since t.ere is no specific figure for that Q: (1 -0.50) = 50%, i.e., 0.50 D: The maximum acceptable error = 0.05. So, the calculated minimum sample size was: n = (1.96)2 X 0.50 X 0.50/ (0.05) 2 = 384. By adding 10% dropped out cases, the total sample becomes 420 mothers.

Data Collection Tool:
A self-administered online disseminated questionnaire was used for data collection. It composed of two main sections. Section 1 includes socio-demographic characteristics of the child. The second sections was ask history of NE in the family, knowledge of the mothers about NE, risk factors, management and caring about the affected child.

Data Collection Technique:
The researchers distributed the questionnaire online as the questionnaire on social media sites (WhatsApp-Facebook-Twitter) to be filled out personally. The questionnaire had a brief introduction explaining the nature of the research and confidentiality of the information that given to participants.
A Pilot study was conducted on 20 mothers of school students to test the questionnaire's clarity and relevance, the time needed to answer all questions, and test reliability. We carried out all modifications, and they were not included in the analysis.

Data Management and Statistical Analysis:
All data were collected, tabulated, and statistically analyzed using SPSS 23.0 for windows (SPSS Inc., Chicago, IL, USA). Quantitative data were expressed as the mean ± SD & (range), and qualitative data were expressed as absolute frequencies (number) & relative frequencies (percentage). Percent of categorical variables were compared using the Chi-square test or Fisher exact test when appropriate. Mann-Whitney U was used to the compared median of the variable of two groups not normally distributed. All tests were two-sided. P-value < 0.05 was considered statistically significant (S), and p-value ≥ 0.05 was considered statistically insignificant (NS).

RESULTS
In Table (1), illustrated the sociodemographic characters of 431 participants, the mother's education level was (10.9%) of primary school, (18.3%) of high school level, while (70.8%) of fathers have university education or more, (35.3%) of fathers was high school education. monthly family income was (64.3%) enough (20%) is more than enough while (15.8) % isn't enough. Number of family members was (55.9%) five to ten member, (36%) less than five member, (8.1) more than ten member. The marital status of parents was; (82.8%) living together, (10%) divorced, (7.2) one of them deceased. Age of children was n=161 (37.4) % was between six and seven years old, n=141 (32.7%) was between eight and nine years old, n=72 (17.2%) was between ten and twelve years old, n=55 (12.8%) more than twelve years old. Sex of children was (58.9%) male, (41.1%) female. The birth order of children was (63.6%) from first to the third, (18.1%) was from forth to the fifth, (18.3%) upper than fifth.
As In Tables (5, 6); there was a significant relationship between frequency per week of enuresis and mother educational level ,number of family member, divorcing of parents' , age of child ( 6-7) years old, sex of child ( female), birth order from first to third ,timing of enuresis during just night , improvement of fluid taking reduction, awaken children at night to urinate, embarrassment of condition to the child, urination alarm to the child, improvement to the treatment , parents' which suffering from nocturnal enuresis , delayed growth. Also there was a significant relation between timing of enuresis during night or day and night with parents suffering from nocturnal enuresis, type of delivery, embarrassment from condition to the child, average frequency of enuresis, not knowing that nocturnal enuresis is a health problem, parents are divorced, monthly family income, fathers education level, mothers education level, caring of parents to awaken the child.

DISCUSSION
Nocturnal enuresis is a very common problem in children, leading to embarrassment, social isolation, and loss of self-esteem. Because many people do not admit to the problem for fear of embarrassment, the exact incidence remains unknown [15]. Various studies so far have used different criteria resulting in different prevalence being reported. A larger proportion of enuresis is usually the primary type. It has a global incidence of 1.4%-28% among 6-12 years old children [16].
In our study, (82.1%) of participants know that nocturnal enuresis is a health problem, (39.9%) know the reason of nocturnal enuresis. The causes of nocturnal enuresis were identified as (34%) psychological problems, (16.5%) hereditary, (25.3%) weakness of bottoms urinary tract muscles, (15%) urinary tract infection, (2.6%) freedom and patience, (5.8%) problems or nerves that control urinary tracts, (0.7%) reasons of pregnancy and child birth. A study conducted in Saudi Arabia reported that (61.3%) of respondents knew about nocturnal enuresis, and 34.2% of them believed they know its causes while 19% identified causes of nocturnal enuresis as weakness in the muscles of the lower urinary tract, 9.1% as problems or damage of the urinary tract or nerves that control the urinary system, 8.0% as psychological problems, and 2.8% as urinary tract infection [17].
In our study (77.5%) reported enuresis only at night, while (22.5%) at day or night. This was lower than reported in another Saudi study as 40% of the children had enuresis at night only, while 55.1% had it during day and night although [17]. Sherah et al. and Sarici et al. reported that daytime enuresis was seen in only 14.29% and 18% of cases, respectively, of children of schoolage [18,19] Another study reported that all of the children that had NE were wetting their bed during night time with 38.7% frequency every night 11.3% of children were wetting their bed during daytime as well [20]. Lower figures was reported in Iran 0.5% for diurnal enuresis and 0.8% for combined day and night wetting [21]. Higher figures were reported in Iran one year later as (7.5%) had diurnal enuresis and one child (1.6%) had nocturnal and diurnal enuresis [22].
The fluid reduction intake before night improving the enuresis as reported by (91%) of our participants. Another study reported lower numbers as only 78.8% of children improved on decreasing fluid intake before sleeping within 5-7 weeks [17].
Regarding frequency of enuresis, average frequency found to be (53.8%) one time to two times per week, (31.3%) three times to four times per week, and (14.8%) five times to seven times per week. This was inconsistence with a study reported highest frequency of bedwetting was three or more times weekly [20]. In Iran, (50.7%) of the children with nocturnal enuresis had > or =3 wet nights per week [21].
Enuresis has been found to negatively impact the child's and family's quality of life, [8,5] lead to low self-esteem, mood problems, and high levels of stress. The condition also impairs the patient's ability to socialize with peers normally. Additionally, evidence that effective treatment of enuresis leads to improvement in the quality of life of patients [23]. In our sample, (69.4) % of children feeling of embracing of this condition. Another Saudi study reported that the problem caused embarrassment and social shame for 94.3% of children, and 76.4% sought medical advice [17]. A study in Egypt reported that most of studied children with nocturnal enuresis had law self-esteem [23].
According to our results, (7.4%) of children suffer from anemia, (5.3%) suffer from parasitic infection, (2.6%) have diabetes mellitus, (3.5%) suffer from delayed growth, (8%) suffer from recurrent or chronic urinary tract infection, and (9.5%) have psychological illness. Regarding family history, (6.3%) of children had positive family history for enuresis in both children, (13.7%) had family history in fathers and (10.7%) had family history in mothers. Another study reported that 6.5% of studied children had diabetes, 58.1% of the families of those children did not get NE when they were children and 62.9% of these children with NE were circumcised [20]. In Iran, a positive family history in father and mother was seen in 51% and 39% of children with primary nocturnal enuresis respectively [21]. Another study in Iran reported that Urinary infection is detected in one child (1.5%). The incidence of urinary system abnormalities was 10.6% in all enuretic children [22]. Another study reported numbers of the subjects with a history of urinary tract infection and seizures were (7.5%) and (3.5%) children, respectively, out of whom (9.4%) and (20%) children, respectively, had nocturnal enuresis as well (1.8%) had congenital problems (back problems, kidney problems, nervous problems, etc.), out of whom (15.4%) had nocturnal enuresis, while (7.9%) with no congenital problems suffered from nocturnal enuresis [24].
In our study, (64.5%) don't seek to medical advice, while (35.5%) getting medical advice. (48.5%) of children getting behavioral therapy to treat this condition, (15.8%) exercise to strengthen bladder muscles, (14.6%) getting medical treatment, (10%) getting urination alarm, (0.5%) doing surgical intervention. (71.5%) improved by these methods of treatment, (17.9) % did not improve, and (10.7%) did not use treatment. A study in Saudi Arabia also reported different practices in terms of modalities of treatment provided where behavioral modification was the most commonly used modality by 31.6%, followed by pharmacological treatment (29.6%), bedwetting alarm (6.8%), exercises to strengthen the bladder muscles (6.2%) and surgery reported by 1.5% only. Improvement of nocturnal enuresis on different types of treatment occurred in 43.6% of cases studied [17]. In contrast to these results, Sherah et al. reported using medical treatment in 76% of case and Al-Zahrani et al. reported the treatment methods used to be: enuresis alarm, water restriction, medication, and awaking for voiding in 56.9%, 14.7%, 5.7% and 5.7% of cases, respectively [18,25]. Schlomer et al. reported that parents used some behavioral modifications like voiding prior to sleep (77%), limiting fluid intake at night (71%), and using bedwetting alarm (6%) [26]. Another study reported that (29%) of families tried to treat their children for bedwetting, (6%) families justified their answer of not treating their children that they found their children were improving with time, (12%) families who tried to treat their children used fluid restriction and frequently waked up their children at night to urinate, (6.1%) families who tried to treat their children used medical consultation in addition to fluid restriction as their mode of treatment and (29%) families reported that their children responded to treatment [20]. This was comparable to findings of another study as 17.45% of the children consumed medicinal plants, 31.57% used chemical treatments, 24.65% used behavioral treatments including limiting fluid intake, and 26.3% expected age increase and spontaneous resolution of nocturnal enuresis [24]. In Ramírez-Backhaus's et al.'s study, 17% of the parents did not have any treatments for nocturnal enuresis in their children, and 20% used drug treatments [27]. In the study conducted in Tehran by Safarinejad, 78.6% of the parents applied drug treatments, and this difference can be attributed to cultural differences and more parental sensitivity to the treatment of nocturnal enuresis [28]. The rates of applying treatments in Australia and New Zealand were 4.7% and 28%, respectively [29]. In Turkey, 19.8% of children were seen by a physician similar to that of 17.2% in Turkey. In our study, the most commonly used methods for treatment were medication (64.5%) [30]. Also in Turkey [31] the most preferred treatment was medication (59.5%). In contrast, these results were not supported by studies from northwest Turkey [32].
In our study, there was a significant relationship between frequency per week of enuresis with mother educational level, number of family member, age of child (6-7) years old, sex of child (female), family history of nocturnal enuresis and delayed growth. Also, there was a significant relation between timing of enuresis during night or day and night with parents suffering from nocturnal enuresis, father's education level, mother's education level, and caring of parents to awaken the child. A study in Saudi Arabia has shown significant relationship between enuresis and child's age (P = 0.05) and gestational age (in months) at birth (P = 0.013), type of delivery, hospital admission after delivery, sibling suffering from the same condition, birth order of the child, parents' history of NE, diabetes, urinary tract infection, psychological problems and delayed milestones (P < 0.05) [17]. This was also reported in Iran as younger age (p < 0.002), gender (p < 0.0001) and low level of education of mother (p < 0.028) were significant predictors of enuresis. Positive history of enuresis in father was a significant predictor of primary nocturnal enuresis (p < 0.012) [21]. Another study concerning the relationship between the frequency (intensity) of nocturnal enuresis and the variables reported significant relationships were found for gender, shared bedroom, deep sleep, punishment at school, history of respiratory infections, seizures, anal itching, and dominant right-handedness (P < 0.05). Also, diurnal enuresis was significantly associated with deep sleep, overnight nightmare, seizures, and right-handedness in the children (P < 0.05) [24].

CONCLUSION
Nocturnal enuresis associated factors and parenteral knowledge of definition and causes of it were among universal reported figures. Referral to a pediatric urologist can be indicated for children with primary enuresis refractory to standard and combination therapies, and for children with some secondary causes of enuresis, including urinary tract malformations, recurrent urinary tract infections, or neurologic disorders. We recommend health education about the causes and risk factors in addition to encouraging prompt treatment and close followup to prevent associated self-shame and family stress. Further studies are needed to look indepth into details of the modalities of treatment and how they are conducted and followed in addition to their effectiveness in Saudi children.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
Data was anonymous for patient confidentiality and all filled questionnaires data was kept safely. Participants was assured them that the Confidentiality of their data would be maintained during the study.

ETHICAL APPROVAL
Approval to carry out the study was obtained from the Research Ethics Committee of the King Salman Armed Forces Hospital in Tabuk, KSA.