1. Background
As a general term, bladder dysfunctions that lead to voiding dysfunction describe abnormalities in filling and emptying the bladder (1). This is the most common urological condition constituting more than 40% of pediatric urology clinic visits, and is classified as diurnal and nocturnal enuresis (2). In addition, it is classified as primary enuresis, without achievement of dryness, and secondary enuresis, which is dry for at least six months (3). NE has a prevalence of 15% at five years of age, 7% at eight, and 1% at 15. An annual spontaneous remission rate of 15% has been reported (2, 4).
This condition is influenced by different internal and external factors (5). Factors that probably affect the development of urination control include cognitive and physical maturation, cultural norms, socioeconomic status, changes in social status, toilet training, and others (6). Toilet training has a more vital role than other factors (7). Prerequisites for achieving elimination in the toilet include the child’s ability to recognize the urge for urination, to get to the toilet, to understand the sequence of tasks required, to avoid oppositional behavior, and to take pride in achievement (8). Factors that may induce urination dysfunction include the difference in developmental aspects, organic disorders, delayed bladder maturation, psychological distress, genetic factors, low bladder volume, deep sleep, and low level of vasopressin (4). Also, medical problems that may contribute to bedwetting include diabetes, UTIs, constipation, pinworms, kidney failure, seizures, and sleep problems (1, 8).
2. Objectives
As many factors may impact urination control in children, we can reduce these disorders with better control of urination in children by considering these factors. Therefore, this study aimed to evaluate factors that can influence urination control in children in pediatric clinics of Arak city.
3. Methods
3.1. Study Setting
This cross-sectional hospital-based study was conducted in Amirkabir hospital’s pediatric clinic and Imam Reza’s pediatric clinic in Arak city in 2020.
3.2. Inclusion and Exclusion Criteria
Inclusion criteria included children in Amirkabir hospital pediatric clinic and Imam Reza pediatric clinic, 5 to 18 years of age, and consent to participate in the study. The exclusion criterion was a lack of consent to participate in the study.
3.3. Study Population
Sampling was done by the census method. In total, 1252 children (male or female aged over five years) were evaluated, but 82 children were excluded, and information of 1,170 children was recorded. Of these children, 184 were affected by urinary incontinence in the preliminary evaluation, and only UI etiologies were indicated.
3.4. Ethical Considerations
The authors have observed ethical issues (plagiarism, data fabrication, and double publication). In addition, the Ethics Committee of Arak University of Medical Sciences approved the study protocol, with ethical code IR.ARAKMU.REC. 23-166-93.
3.5. Statistical Analysis
Data description was done using mean and standard deviation for quantitative data and frequency and percentage for qualitative data. Data analysis was conducted by the chi-square test for qualitative variables in the SPSS program at a significance level of P < 0.05.
4. Results
The mean age of children was 6.45 ± 1.96 years. There were 436 (44.2) males and 550 (55.8) females. Based on Table 1, anatomic and functional bladder disorder, UTIs, and organic causes were the most common genetic factors, and the neglect of toilet training was the least common etiology factor. Based on Table 2, the association between demographic, epidemiologic, and clinical factors and the urination control time is assessed. Based on this table, some factors significantly affected urination control, including gender, living area, father and mother education, economic condition, consanguineous parents, toilet and nappies status, and growth status of children. Detailed information has been indicated in tables. Other factors in Table 2 that did not significantly differ between the two groups (P > 0.05) are parental status, maternal delivery age, birth weight, delivery type, gestational age, breastfeeding duration, and lactation type.
Table 1.Etiology of Urinary Incontinence in Children (n = 184)
| Causes | No (%) |
|---|---|
| Vesicoureteral reflux | 19 (10.3) |
| Sleep apnea | 16 (8.7) |
| Vasopressin secretion disorder | 8 (4.3) |
| Familial history | 2 (1.1) |
| Psychological factors | 14 (7.6) |
| UTIs | 34 (18.5) |
| Neglect in toilet training | 7 (3.8) |
| Anatomic and functional bladder disorder | 52 (28.3) |
| Organic causes | 32 (17.4) |
Table 2.Demographic, Epidemiologic, and Clinical Factors Related to Urination Control Time (n = 986)
| Variables | Time of Urination Control | P Value | |||
|---|---|---|---|---|---|
| < 3 | 3 - 4 | > 4 | Total | ||
| Gender | 0.0001 | ||||
| Male | 30 (33.3) | 178 (32.4) | 228 (65.6) | 436 (44.2) | |
| Female | 60 (66.7) | 270 (67.6) | 120 (34.4) | 550 (55.8) | |
| Living area | 0.0001 | ||||
| Urban | 90 (100) | 430 (78.5) | 110 (31.6) | 630 (63.9) | |
| Rural | 0 (0) | 118 (21.5) | 238 (68.4) | 356 (36.1) | |
| Father education | 0.0001 | ||||
| Under diploma | 10 (11.1) | 78 (14.2) | 208 (59.7) | 296 (30) | |
| Diploma | 20 (22.2) | 163 (31.1) | 57 (16.1) | 240 (24.3) | |
| Associate’s degree | 10 (11.1) | 157 (27.1) | 33 (9.7) | 200 (20.3) | |
| Bachelor’s degree | 36 (39.4) | 25 (4.5) | 39 (43.2) | 100 (10.1) | |
| Master’s degree or higher | 14 (16.1) | 125 (22.8) | 11 (12.3) | 150 (15.3) | |
| Mother education | 0.0001 | ||||
| Under diploma | 0 (0) | 98 (17.8) | 83 (23.8) | 181 (18.4) | |
| Diploma | 0 (0) | 200 (36.7) | 210 (61.1) | 410 (41.6) | |
| Associate’s degree | 0 (0) | 150 (27.1) | 55 (15) | 205 (20.8) | |
| Bachelor’s degree | 30 (33.3) | 97 (18.2) | 0 (0) | 127 (12.9) | |
| Master’s degree or higher | 60 (66.6) | 3 (0.2) | 0 (0) | 63 (6.3) | |
| Economic condition | 0.0001 | ||||
| Low | 0 (0) | 80 (14.5) | 132 (37.9) | 212 (21.5) | |
| Moderate | 40 (44.4) | 418 (76.2) | 216 (62) | 674 (68.4) | |
| High | 50 (55.5) | 50 (9.1) | 0 (0) | 100 (10.1) | |
| Parental status | 0.2 | ||||
| Death of parents | 0 (0) | 30 (5.4) | 19 (5.4) | 49 (50) | |
| Separation | 20 (22.2) | 60 (10.9) | 8 (2.2) | 88 (8.9) | |
| Consanguineous parents | 0.0001 | ||||
| Yes | 3 (3.3) | 3 (0.5) | 28 (8) | 34 (13.6) | |
| No | 87 (96.7) | 545 (99.5) | 320 (92) | 952 (86.4) | |
| Maternal delivery age | 0.58 | ||||
| < 20 | 10 (11.1) | 88 (16) | 86 (24.7) | 184 (18.7) | |
| 20 - 30 | 80 (88.9) | 410 (74.8) | 206 (59.1) | 694 (70.6) | |
| 30 | 0 (0) | 50 (9.1) | 56 (16) | 106 (10.8) | |
| Birth weight | 0.29 | ||||
| ELBW (< 1000 g) | 0 (0) | 10 (1.8) | 0 (0) | 10 (1) | |
| VLBW (1000 - 1500) | 0 (0) | 0 (0) | 38 (10.9) | 38 (3.9) | |
| LBW (1500 - 2500) | 10 (11.1) | 40 (7.2) | 78 (22.4) | 128 (13) | |
| NBW (2500 - 4000) | 80 (88.9) | 498 (90.8) | 232 (66.6) | 810 (82.2) | |
| Delivery type | 0.76 | ||||
| Natural | 80 (88.8) | 350 (63.8) | 260 (74.7) | 690 (70) | |
| Cesarean | 10 (11.2) | 198 (36.1) | 88 (25.2) | 296 (30) | |
| Gestational age | 0.61 | ||||
| Term | 70 (77.8) | 488 (89) | 303 (87) | 861 (87.3) | |
| Preterm | 20 (22.2) | 40 (7.4) | 29 (8.4) | 89 (9) | |
| Postterm | 0 (0) | 20 (3.6) | 16 (4.6) | 36 (3.7) | |
| Duration of breastfeeding | 0.87 | ||||
| < 12 | 0 (0) | 60 (10.9) | 40 (11.5) | 100 (10.1) | |
| 12 - 18 | 20 (22.2) | 150 (27.4) | 38 (10.9) | 208 (21) | |
| > 18 | 70 (77.8) | 338 (61.7) | 270 (77.6) | 678 (68.9) | |
| Lactation type | 0.39 | ||||
| Breast milk | 70 (77.8) | 390 (71.2) | 174 (50.1) | 634 (64.3) | |
| Milk powder | 10 (11.1) | 48 (8.7) | 60 (17.2) | 118 (12) | |
| Both | 10 (11.1) | 110 (20.1) | 114 (32.7) | 234 (23.7) | |
| Growth status of children | 0.0001 | ||||
| Optimum growth | 90 (100) | 350 (63.8) | 153 (43.9) | 593 (60.1) | |
| Slow growth | 0 (0) | 188 (34.3) | 96 (27.5) | 284 (28.8) | |
| Stop growth | 0 (0) | 0 (0) | 70 (20.1) | 70 (7.1) | |
| Growth failure | 0 (0) | 0 (0) | 29 (8.3) | 39 (4) | |
| Toilet in house | 0.0001 | ||||
| Yes | 90 (100) | 508 (92.7) | 153 (43.9) | 890 (90.3) | |
| No | 0 (0) | 40 (7.3) | 195 (56.1) | 96 (9.7) | |
| Use of reusable nappies | 0.0001 | ||||
| Yes | 10 (11.1) | 30 (5.4) | 65 (18.6) | 105 (10.6) | |
| No | 80 (88.9) | 518 (94.6) | 283 (81.4) | 899 (89.4) | |
| Time of toilet training | 0.0001 | ||||
| < 2 | 90 (100) | 120 (21.8) | 0 (0) | 210 (21.3) | |
| 2 - 4 | 0 (0) | 428 (78.2) | 292 (84) | 720 (73) | |
| > 4 | 0 (0) | 0 (0) | 56 (16) | 56 (5.7) | |
| Correct approach to toilet training | 0.0001 | ||||
| Yes | 90 (100) | 358 (65.3) | 0 (0) | 448 (45.4) | |
| No | 0 (0) | 190 (34.7) | 348 (100) | 538 (54.6) | |
5. Discussion
Based on the present study, proper and timely urination regarding personal, familial, and environmental factors plays a vital role in urination control in children. Also, factors such as gender, living area, father, and mother education significantly differed between the two groups. Firoozi et al., in a study about the resolution of enuresis after adenotonsillectomy, considered 86 children, 40 girls and 46 boys, who underwent adenotonsillectomy. Adenotonsillar was graded from 1 to 4, and enuresis was evaluated by questionnaires. They concluded that the obstruction of the upper airway system in children is associated with a high rate of NE (9). In the present study, apnea, as respiratory system dysfunction, was observed in 16 (8.7%) children, which was different from our study because of the difference in the evaluated cases in the two studies. Hägglöf et al. studied self-esteem before and after enuresis treatment in children. They considered children with enuresis and healthy children as the case and control groups. The children’s evaluation was based on a self-answering questionnaire about psychometric properties within six months of follow-up. They concluded that lower socioeconomic children had lower self-esteem than higher socioeconomic groups, and girls had higher self-esteem than boys (10). Nevertheless, in the present study, many other related factors were evaluated, and most of these factors statistically correlate with the enuresis control time, which clarifies the reason for the difference in the two evaluations.
In addition, Yang et al., in a case-control study, evaluated children with and without habitual snoring as the case and control groups. They included 1,821 children and concluded that children with habitual snoring had PMNE more than children without snoring (7). However, the present study only evaluated sleep apnea regarding respiratory system dysfunction and found a statistically significant difference in it, which was different from the mentioned study, possibly because of the difference in evaluated cases. Duel et al. investigated the correlation between ADHD and urination control. They evaluated 23 boys and five girls as the case group and 10 boys and 12 girls as the control groups by 10 questionnaire sets. They concluded that healthy children had significantly lower rates of constipation, incontinence, infrequent voiding, urgency, dysuria, and NE than children with ADHD (11). However, we did not evaluate this condition in children. Kaerts et al. evaluated toilet training in healthy children. They evaluated 256 children by questionnaires distributed to the parents of healthy children aged 15 to 35 months. They concluded that the toilet training approach is fundamental (4), which aligns with the present study. The limitation of our study was the noncompliance of parents, who were convinced by explaining the importance of this issue. However, because few clinical studies have been carried out regarding the impact of different factors on urination control, further studies will be needed for the reception of this correlation. In addition, several studies in different geographical locations are required.
5.1. Conclusions
Anatomic and functional bladder disorder, UTIs, and organic causes are the most common genetic factors, and toilet training neglect was the least common etiology factor. Also, factors such as gender, living area, father, and mother education significantly differed between the two groups. Proper and timely urination plays a vital role in children.
