Background:Considering that enuresis is a common health problem among Iranian children, identifying the frequency of enuresis among children with adenoid hypertrophy (AH) and its related factors could help us design appropriate management plans as well as preventative and interventional studies.
Objectives:We aimed to evaluate the prevalence of enuresis among children with AH and its associations with different characteristics of the disease.
Patients and Methods:This study was designed as a cross-sectional study. Children aged 5 - 12 years diagnosed with adenoid hypertrophy and as well as a group of normal children were studied (2010 - 2011 in Shariati hospital). The prevalence of enuresis was determined and compared in the two groups. The frequencies of different symptoms related to AH were compared in AH patients with and without enuresis.
Results:During this study, children with (n = 60) and without (n = 60) adenoid hypertrophy were investigated. The prevalence of enuresis was significantly higher in patients with AH compared with the control group (40% vs. 15%, P = 0.004, OR = 8.19). Enuresis was more prevalent among patients with AH who had a severe form of the disease, the signs of which are obstructive sleep apnea (OSA), growth impairment, and irritability (P < 0.05).
Conclusions:The results of our study indicated that enuresis was a common health problem among children with AH and it is associated with some symptoms of AH such as OSA, growth retardation and irritability. Using these findings as baseline data, we could determine the appropriate treatment approach for improving the course of the disease as well as the quality of the affected patients’ lives.
Adenoid hypertrophy (AH) is one of the common conditions among the pediatric population and the most important cause of impaired nasal airflow and nasopharyngeal obstruction (1). The estimated prevalence rate of AH among children aged between six months to 15 years has been reported to be 19 - 58% (2).
AH on a spectrum of harmful clinical conditions ranges from mouth breathing to obstructive sleep apnea (OSA). Its associations with several health consequences including growth impairment, systemic and pulmonary hypertension, enuresis, behavioral problems, hyperactivity and attention deficit hyperactivity disorder and poor school achievement have been indicated in previous studies (3-5).
Enuresis is one of the AH-related complications which is defined as involuntary urination or urinary incontinence of children above five years of age (6). It is considered as an important multifactorial clinical problem which could have significant adverse effects on the quality of the affected children’s lives and their parents (7). Evidence indicated that complications such as low self-esteem, attention deficit hyperactivity disorder, reading difficulties, reduced fine motor coordination, visuomotor integration abnormalities and migraine are commonly reported in enuretic children (8, 9). Some of the reported complications of both enuresis and AH are overlapped.
The relation of AH and enuresis with OSA, the most important consequence of severe AH, has been demonstrated in several studies (10-12). In addition, findings of some reports regarding improvement of enuresis after appropriate management of AH or adenotonsillectomy support the association between the mentioned two conditions (13, 14).
The suggested mechanism for the association is inappropriate antidiuretic hormone (ADH) secretion due to insufficient or inadequate time of sleeping (15).
However, there are also reports which have not confirmed such a relation (16) and it seems that available data in this field are controversial and not conclusive enough. Therefore, considering that enuresis is a common health problem among Iranian children (17), identifying the frequency of enuresis among children with AH and its related factors could help us design appropriate managements plans as well as preventative and interventional studies.
We aimed to evaluate the prevalence of enuresis among children with AH and its associations with different symptoms of the disease (18).
3. Patients and Methods
3.1. Study Population
This study was designed as a cross-sectional study. Children aged 5 - 12 years who were diagnosed with adenoid hypertrophy and referred to the ear, nose, throat clinic or the pediatric clinic of Shariati hospital, affiliated to Islamic Azad university of Isfahan, were enrolled (2010 - 2011).
The protocol of study was approved by scientific and ethical review board of Najafabad Islamic Azad university, Isfahan, Iran.
Children aged 5 - 12 years with confirmed diagnosis of AH and history of AH-related snoring for at least four months were included as case group. Those with allergic rhinitis, nasal septum deviation, otitis media and asthma were excluded from the study.
Children in the control group were selected from normal children who referred to the pediatrics clinic of the hospital and were age and gender matched. After selection of participants in each group, written informed consent was obtained from each participant or their parents.
After selection of cases with AH, radiologic evaluation for confirming hypertrophy of adenoid and determining the degree of obstruction was performed. A lateral neck postnasal space X-ray was performed for each patient. Considering the A/N ratio on cervical lateral views of plain X-rays, the degree of obstruction was classified as mild (< 25%), moderate (25 - 50%) and severe (> 50%). N is the distance between the posterior superior edge of the hard palate and the anteroinferior edge of the spheno-basioccipital synchondrosis, and A is the distance between the maximum convexity of the adenoid and a line drawn along the basiocciput.
Enuresis was defined as any intermittent incontinence, at least twice per week for three consecutive months, and chronological age of more than 5 years. Primary enuresis is defined as incontinence due to normal bladder development impairment. Secondary enuresis is defined as incontinence reoccurs after at least six months of continence.
Data regarding the demographic characteristics of the studied population, questions related to symptoms of AH including snoring, mouth breathing, OSA, irritability, dismorphic teeth, growth retardation, behavioral problems, method of treatment and degree of AH were obtained using a valid questionnaire completed by a trained nurse.
The frequency of enuresis was determined and compared in case and control groups. Frequencies of different symptoms related to AH were compared in AH patients with and without enuresis.
3.2. Statistical Analysis
Data were processed by statistical package for the social science (SPSS) version 20 (SPSS Inc. Chicago, IL, USA). Comparisons between continuous and categorical variables were performed using Student’s t-test and chi-squared test, respectively. P values less than 0.05 were considered statistically significant.
During this study, children with (n = 60) and without (n = 60) adenoid hypertrophy were investigated. The characteristics of the studied population are presented in Table 1. The two studied groups were similar regarding age and gender distribution (P > 0.05).
The prevalence of enuresis was significantly higher in patients with AH than the control group (P = 0.004, OR = 8.19, 95% CI: 1.57 - 9.39). The difference between the studied groups was mainly due to secondary enuresis (P = 0.1 for primary enuresis and P = 0.01, OR = 3.857, 95% CI: 1.40 - 10.57 for secondary enuresis).
The frequencies of disease symptoms in AH patients with and without enuresis are presented in Table 2. The mean age of patients with AH and enuresis was lower than those without AH (P < 0.05). The frequencies of OSA, growth impairment and irritability were significantly higher in patients with AH and enuresis (0.05). The severe form of AH was more prevalent in patients with enuresis than those without it (P < 0.05). Enuresis was more prevalent among patients with AH who had a severe form of the disease, OSA, growth impairment and irritability (P < 0.05).
|Patients With Adenoid Hypertrophy and Enuresis (n = 24)||Patients With Adenoid Hypertrophy and Without Enuresis (n = 36)||P Value|
|Age, y||5.96+/-1.65||8.89+/-1.73||< 0.001|
|Snoringa||24 (100)||36 (100)||NA|
|Obstructive sleep apneaa||10 (41.6)||4 (11.11)||0.008|
|Growth retardationa||15 (62.5)||9 (25)||0.004|
|Irritabilitya||16 (66.66)||10 (27.77)||0.003|
|Dismorphic teetha||18 (75)||21 (58.33)||0.14|
|Mouth speakinga||24 (100)||36 (100)||NA|
|Abnormal behaviora||20 (83.33)||26 (72.22)||0.24|
|Grade of adenoid hypertrophya|
|Mild (< 25%)||4 (16.8)||9 (25)||0.04|
|Moderate (25 - 50%)||10 (41.6)||22 (61.1)|
|Severe (> 50%)||10 (41.6)||5 (13.9)|
|Medical||13 (54.17)||25 (69.44)|
|Tonsillectomy||11 (45.83)||11 (30.56)|
In this study, we evaluated the frequency of enuresis among children with AH and its association with different symptoms of AH. The results indicated that enuresis was a common problem among this group of patients and it was more frequent among patients with severe form of the disease and was associated with more adverse consequences of the disease.
The suggested causes of enuresis in AH could be explained as follows; the antidiuretic hormone (ADH) is produced during the fourth stage of sleep. Children with AH, especially those with OSA, due to the unreserved integrity of both rapid eye movement (REM) and non-REM sleep stages and episodes of awakenings never reach the fourth stage of sleep, so ADH could not be released appropriately, resulting in impaired concentration of urine and enuresis (21).
In this study, the prevalence of enuresis among patients with AH was 40%. The reported range for enuresis in different studies was ranged from 22 - 42%. The results of the current study were in the reported range. It was similar to the results of Firoozi et al. (22-24).
In a similar study in Mashhad, Iran, the prevalence of enuresis among patients with AH and control group was 37% and 26%, respectively. The rate of enuresis was not different between the two studied groups, but enuresis was more prevalent among patients with AH who had sleep apnea syndrome (18). Taziki et al. in Gorgan, Iran, reported a lower prevalence rate of enuresis, 9%, in patients with AH (19). Aydin et al. in Turkey did not report any association between AH and enuresis (16).
In this study, most of the cases with enuresis had secondary enuresis. This was not similar to the results of previous studies. Most related studies have shown that primary enuresis has been the most frequent type of enuresis among patients with AH. Taziki et al. reported similar rate of primary and secondary enuresis among children with AH (19). Bakhtiar et al. showed that secondary enuresis was the most frequent type of enuresis in AH, especially in those with sleep apnea and they concluded that an intervention for the management of secondary enuresis could be implemented (17).
In this study, the mean age of patients with enuresis was lower than those without it, because the occurrence of enuresis decreases with increasing age. In this study, enuresis was more prevalent among patients with AH who had a severe form of the disease, OSA, growth impairment and irritability. Results of studies in this field have been different.
Taziki et al. did not indicate any association between enuresis and some complications of AH such as growth retardation, month breathing, hyponasal speech, snoring, and morning stiffness (19). Aydin et al. did not report any relation between frequency of enuresis and symptoms of AH (16), whereas in another study in Turkey, Soylu Ozler et al. showed a higher rate of enuresis in patients with AH who had open mouth sleeping and snoring (23).
The great variability seen in different studies may be due to differences in diagnostic criteria, methods of studies, and ethnic or genetic background. Though, the rate of tonsillectomy was high in AH patients with enuresis, but the difference was not statistically significant. It may be due to small sample size or the cross-sectional design of the study. Some studies indicated that tonsillectomy of patients with AH resulted in significant improvement in enuresis and some of them recommended that in AH cases with enuresis, for better management of the disease tonsillectomy is favorable (13, 14).
The main limitation of this study was its cross-sectional design. It seems that designing prospective studies in this field would help us to achieve more conclusive results. Other limitations were the small sample size of the studied population and clinical diagnosis of OSA. A multicenter study with larger sample size and polysomnographic evaluation of OSA would be a more appropriate approach in this regard.
The results of our study indicated that enuresis was a common health problem among children with AH and it was associated with some symptoms of AH such as its severity, OSA, growth retardation and irritability. Using these findings as baseline data, we could determine the appropriate treatment approach for improving the course of the disease as well as the quality of life of the affected patients.
Major MP, Saltaji H, El-Hakim H, Witmans M, Major P, Flores-Mir C. The accuracy of diagnostic tests for adenoid hypertrophy: a systematic review. J Am Dent Assoc. 2014; 145 (3) : 247 -54 [DOI][PubMed]
Izu SC, Itamoto CH, Pradella-Hallinan M, Pizarro GU, Tufik S, Pignatari S, et al. Obstructive sleep apnea syndrome (OSAS) in mouth breathing children. Braz J Otorhinolaryngol. 2010; 76 (5) : 552 -6 [PubMed]
Alrashed KM, Bataineh HA. Frequency of Enuresis in (5-10) Year Old Children in Tafila, Jordan. Shiraz E-Med J. 2007; 8 (1) : 1 -5
Neveus T, von Gontard A, Hoebeke P, Hjalmas 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. 2006; 176 (1) : 314 -24 [DOI][PubMed]
Hagglof B, Andren O, Bergstrom E, Marklund L, Wendelius M. Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scand J Urol Nephrol Suppl. 1997; 183 : 79 -82 [PubMed]
Hashem M, Morteza A, Mohammad K, Ahmad-Ali N. Prevalence of nocturnal enuresis in school aged children: the role of personal and parents related socio-economic and educational factors. Iran J Pediatr. 2013; 23 (1) : 59 -64 [PubMed]
Kovacevic L, Jurewicz M, Dabaja A, Thomas R, Diaz M, Madgy DN, et al. Enuretic children with obstructive sleep apnea syndrome: should they see otolaryngology first? J Pediatr Urol. 2013; 9 (2) : 145 -50 [DOI][PubMed]
Weider DJ, Sateia MJ, West RP. Nocturnal enuresis in children with upper airway obstruction. Otolaryngol Head Neck Surg. 1991; 105 (3) : 427 -32 [PubMed]
Ahmadi MS, Amirhassani S, Poorolajal J. The effect of adenotonsillectomy on pediatric nocturnal enuresis: a prospective cohort study. Iran J Otorhinolaryngol. 2013; 25 (70) : 37 -40 [PubMed]
Elnabil L, Helmy H. Effect of adenotonsillectomy on nocturnal enuresis in children with obstructive sleep apnea. Sleep Med. 2013; 14 [DOI]
Aydin S, Sanli A, Celebi O, Tasdemir O, Paksoy M, Eken M, et al. Prevalence of adenoid hypertrophy and nocturnal enuresis in primary school children in Istanbul, Turkey. Int J Pediatr Otorhinolaryngol. 2008; 72 (5) : 665 -8 [DOI][PubMed]
Bakhtiar K, Pournia Y, Ebrahimzadeh F, Farhadi A, Shafizadeh F, Hosseinabadi R. Prevalence of nocturnal enuresis and its associated factors in primary school and preschool children of khorramabad in 2013. Int J Pediatr. 2014; 2014 : 120686 [DOI][PubMed]
Omid F, Adami Dehkordi MA. Prevalence of enuresis in 4-12 years old children w with adenoid hypertrophy. Med Sci J Islam Azad Unive-Mashhad Branch. 2005; 2 : 69 -75
Taziki MH, Tajri HR, Borghei A, Khorashadizadeh H. Factors Associated with Enuresis in Adenotonsillar Hypertrophy and the Effect of Surgery on it. J Guilan Unive Med Sci. 2011; 20 (79) : 62 -7
Cetin DY, Umit A, Tabinda A, Serhat B, Oktay S, Bayram K, et al. Enuresis Nocturna and the Symptoms of Upper Airway Obstruction in Primary School age Children: Is there a Relationship? Middle East J Family Med. 2014; 12 (7) : 4
Mohamadzadeh Rezaei M, Aslzare M. Evaluation of relationship between adenotonsilar hypertrophy and enuresis in children. Urology. 2006; 68 : 17 [DOI]
Soylu Ozler G, Ozler S. Coexistence of Upper Airway Obstruction and Primary and Secondary Enuresis Nocturna in Children and the Effect of Surgical Treatment for the Resolution of Enuresis Nocturna. Adv Med. 2014; 2014 : 656431 [DOI][PubMed]