Elsevier

Journal of Pediatric Urology

Volume 13, Issue 1, February 2017, Pages 36.e1-36.e6
Journal of Pediatric Urology

Importance of neuropsychiatric evaluation in children with primary monosymptomatic enuresis

https://doi.org/10.1016/j.jpurol.2016.10.019Get rights and content

Summary

Background

Nocturnal enuresis (NE) is an involuntary voiding during sleep. It is a very common disorder in school-age children. Comorbid psychopathologies are common in patients affected by enuresis. According to the ICCS, the rate of behavioral and emotional disorders in children with enuresis is doubled compared with healthy control (HC) children.

Objective

The aim of the present study was to investigate the prevalence of neuropsychiatric comorbidities in children affected by NE.

Study design

Two hundred children with a diagnosis of enuresis were recruited from the Neuropsychiatric Unit of Catania University and 200 age-matched neurologically intact HC children were recruited from local schools. The inclusion criteria were a normal IQ and the absence of other pathological clinical conditions such as diabetes or kidney malformation. The exclusion criteria were failure to complete the initial evaluation or clinical/diagnostic procedures, inability (because of young age) to complete study questionnaires, and severe neurological or physical impairment.

Results

Age and gender proportions were not significantly different between the groups. In the NE group, 138 subjects (69%) had a familial history of NE, compared with 24 subjects (12%) in the HC group (p < 0.01). The NE group demonstrated significantly higher scores in the Child Behavior Check List, Conners' Multidimensional Anxiety Scale for Children, and the Child Depression Inventory compared than the HC group as well as the Yale Global Tic Severity Score and Child-Yale–Brown Obsessive Compulsive Scale scores (p < 0.01). Quality of life scores were significantly lower in the NE group than in the HCs group; specifically, between-group differences were significant in the relationship and self domains (p > 0.01 for both comparisons) (Figure).

Discussion

The present case-control study evaluates the prevalence of different neuropsychiatric comorbidities in children with NE as diagnosed according to the new ICCS criteria. An important finding was that neuropsychiatric conditions were more prevalent in NE patients than in age-matched HC subjects. To the best of our knowledge, this is the first study to report associations between enuresis and obsessive compulsive disorder as well as tic disorder, and is the first to describe the comparative psychopathological profiles of 200 children with enuresis and 200 matched HC children.

Conclusion

The results suggest that clinicians should not underestimate the effects of enuresis on psychosocial development. Childhood NE should be managed carefully and comprehensively in order to prevent the development of more serious behavioral problems in the future.

Figure
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Figure. Comparison between nocturnal enuresis patients and healthy control children (p ≤ 0.000). CDI = Child Depression Inventory; MASC = Multidimensional Anxiety Scale for Children; YGTSS = Yale Global Tic Severity Score; C-YBOCS = Children-Yale–Brown Obsessive Compulsive Scale; CBCL = Child Behavior Check-List; QoL = Quality of life; Rel = relationship.

Introduction

Nocturnal enuresis (NE) is an involuntary voiding that occurs in subjects who have not yet achieved bladder control. NE is a very common disorder in school-age children, occurring in 10% of 6-year-olds and in 5% of 10-year-olds [1]. Recently the Children's Continence Society (ICCS) [2] defined enuresis as intermittent (i.e., not continuous) wetting during sleep in children 5 years and older, where the term nocturnal can be added for clarity (i.e., enuresis and NE are synonyms).

Growing interest in the pathophysiology and etiology of enuresis has spurred the publication of more than 570 studies since 2009. This body of work uncovered subclinical behavioral symptoms such as sadness, embarrassment, and humiliation in children with enuresis that could not be technically classified as a disorder [3]. However, some studies suggest that comorbid psychopathologies are common in enuresis patients. In the general population, 10–15% of children have a behavioral disorder. According to the ICCS, the rate of behavioral disorders in children with enuresis is doubled [4]. Enuresis has been previously associated with attention deficit hyperactivity disorder (ADHD) [5], [6], oppositional defiant disorder [7], and conduct disorders [8]. Moreover, patients and family members of patients with enuresis demonstrated lower quality of life global ratings in comparison with healthy control (HC) children [9], [10], similar to observations in patients with chronic diseases such as epilepsy or asthma [11].

Therefore, we conducted the present exploratory case-control study to investigate the prevalence of neuropsychiatric comorbidities in children affected by NE.

Section snippets

Study population

Subjects (patients and controls) were prospectively enrolled between October 2013 and September 2015. In total, 200 children with a diagnosis of primary monosymptomatic enuresis were recruited from the Neuropsychiatric Unit of Catania University and 200 age-matched neurologically intact HC children were recruited from local schools. Diagnoses of enuresis and other clinical conditions were made in accordance with the ICSS criteria by an experienced child neurologist. The inclusion criteria were

Participant demographics

Demographic information is summarized in Table 1. A total of 200 NE patients (122 males and 78 females; mean age, 11.5 ± 3.9 years; age range, 8–15 years) and 200 HC subjects (131 males and 69 females; mean age, 11.9 ± 2.5 years; age range, 8–15 years) were included in the final analysis. Age and gender proportions were not significantly between groups. In the NE group, 138 subjects (69%) had a familial history of NE, compared to 24 subjects (12%) in the HC group (p < 0.01).

CBCL scores

The NE group

Discussion

The present study is the first to evaluate the presence of different neuropsychiatric comorbidities in children with primary monosymptomatic NE as diagnosed according to the new ICCS criteria. An important finding was that neuropsychiatric conditions were more prevalent in NE patients than in age-matched HC children. Females are more affected by mood and anxiety problems and males by tic disorders and ADHD, as largely reported in previous studies [21], [22], [23]. In agreement with our data,

Conclusion

In conclusion, our results are in agreement with the practical consensus guidelines for the management of enuresis [12]: clinicians should not underestimate the effects of enuresis on psychosocial development. Childhood NE should be managed carefully and comprehensively to identify behavioral problems in the future that could be associated to the disorder.

Conflicts of interest

None.

Funding

None.

Acknowledgments

A.A. acknowledges Ferring S.p.A for the collaboration.

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