Available via license: CC BY 2.0
Content may be subject to copyright.
BioMed Central
Page 1 of 8
(page number not for citation purposes)
BMC Public Health
Open Access
Research article
The epidemiology and factors associated with nocturnal enuresis
among boarding and daytime school children in southeast of
Turkey: a cross sectional study
Ali Gunes
†1
, Gulsen Gunes*
†2
, Yasemin Acik
3
and Adem Akilli
4
Address:
1
Urology Department, Inonu University, Medical School, Malatya, Turkey,
2
Public Health Department, Inonu University, Medical School,
Malatya, Turkey,
3
Public Health Department, Firat University, Madical School, Elazig, Turkey and
4
Bozova Government Hospital, Bozova, Sanli
Urfa, Turkey
Email: Ali Gunes - gunesali@yahoo.com; Gulsen Gunes* - ggunes@inonu.edu.tr; Yasemin Acik - yacik@firat.edu.tr;
Adem Akilli - ggunes@inonu.edu.tr
* Corresponding author †Equal contributors
Abstract
Background: Nocturnal enuresis is an important problem among young children living in Turkey.
The purpose of this study was to determine the possible differences in the prevalence of enuresis
between children in boarding school and daytime school and the association of enuresis with
sociodemographic factors.
Methods: This was a cross-sectional survey. A total of 562 self-administered questionnaires were
distrubuted to parents from two different types of schools. One of them was a day-time school and
the other was a boarding school. To describe enuresis the ICD-10 definition of at least one wet
night per month for three consecutive months was used. Chi-square test and a logistic regression
model was used to identify significant predictive factors for enuresis.
Results: The overall prevalence of nocturnal enuresis was 14.9%. The prevalence of nocturnal
enuresis declined with age. Of the 6 year old children 33.3% still wetted their beds, while the ratio
was 2.6% for 15 years-olds. There was no significant difference in prevalence of nocturnal enuresis
between boys and girls (14.3% versus 16. 8%). Enuresis was reported as 18.5% among children
attending day time school and among those 11.5% attending boarding school (p < 0.05). Prevalence
of enuresis was increased in children living in villages, with low income and with positive family
history (p < 0.05). After multivariate analysis, history of urinary tract infection (OR = 2.02), age
(OR = 1.28), low monthly income (OR = 2.86) and family history of enuresis (OR = 3.64) were
factors associated with enuresis. 46.4% of parents and 57.1% of enuretic children were significantly
concerned about the impact of enuresis.
Conclusion: Enuresis was more frequent among children attending daytime school when
compared to boarding school. Our findings suggest that nocturnal enuresis is a common problem
among school children, especially with low income, smaller age, family history of enuresis and
history of urinary tract infection. Enuresis is a pediatric public health problem and efforts at all levels
should be made such as preventive, etiological and curative.
Published: 22 September 2009
BMC Public Health 2009, 9:357 doi:10.1186/1471-2458-9-357
Received: 19 February 2009
Accepted: 22 September 2009
This article is available from: http://www.biomedcentral.com/1471-2458/9/357
© 2009 Gunes et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
BMC Public Health 2009, 9:357 http://www.biomedcentral.com/1471-2458/9/357
Page 2 of 8
(page number not for citation purposes)
Background
Nocturnal enuresis can be defined as the involuntary pas-
sage of urine during sleep beyond the age of anticipated
nightime bladder control, after 4-6 y of age [1,2]. It is well
known that nocturnal enuresis is a common, genetically
complex and heterogeneous disorder among children [3].
According to International Children's Continence Society
(ICCS),intermittent incontinence is urine leakage in dis-
crete amounts. It can occur during the day and/or at night,
and it is applicable to children who are at least 5 years old.
Enuresis means intermittent incontinence while sleeping.
In contrast to the previous terminology, the terms (inter-
mittent) nocturnal incontinence and enuresis are now
synonymous[4]. Enuresis can be further categorized into
primary nocturnal enuresis or secondary nocturnal enu-
resis. Primary nocturnal enuresis is therefore bedwetting
in a child aged 5 years or more who has never been dry for
extended periods, while secondary nocturnal enuresis is
the onset of wetting after a continuous dry period of more
than 6-12 months[5].
The etiology of enuresis is not completely understood.
This condition probably has a multifactor etiology. Most
studies have consistently found that the risk factors for
enuresis are male gender, smaller age, family history and
divorced parents [1,3,6-8]. The overall prevalence of noc-
turnal enuresis, as well as prevalence of nocturnal enuresis
in different age groups, is greatly varied in different coun-
tries, ranging from 2.3% to 25% [3] Enuresis is frequently
diagnosed among schoolchildren and is an important
psychosocial problem both for parents and children. [2].
The relationship between enuresis and behavioural prob-
lems has been studied for several decades. Results range
from enuretic children having no marked emotional,
social or behavioural problems, to enuretic children with
a 4.3-times increase in psychological difficulties com-
pared with their non-enuretic peers [9-11].
Although enuretic children seem to have accompanying
psychological problems, it must be investigated whether
these problems are the results of enuresis or aetiological
factors. Nocturnal enuresis is multifactorial, few studies
have clarified the pathophysiology of Nocturnal enuresis.
Several pathophysiological mechanisms have been pro-
posed, including bladder dysfunction, a small functional
bladder capacity, abnormal nyctohemeral vasopressin lev-
els, nocturnal polyuria, and abnormal sleep patterns and
arousability. [12,13]
Nocturnal enuresis may cause secondary emotional and
social problems in children who continue to wet their
bed. A number of etiologic factors have been described to
explain this phenomenon[14].
Reports of differences among schools in emotional and
social climate were related to changes in behavioral and
emotional problems[15]. Social and emotional distur-
bances were found among students in boarding schools in
some studies [16,17]. Our hypothesis was defined as enu-
resis being more commen in boarding schools than in
daytime schools"
Regional Boarding Primary Schools (YIBO) are being
opened in Turkey in scarcely populated areas for provid-
ing primary education services to the age group in villages
and sub-village settlements that do not have schools, and
for students from poor families as well.
The purpose of this study was to determine the prevalence
of nocturnal enuresis and the association of enuresis with
sociodemographic factors in 6 to 16 years old children in
Bozova, Urfa in Turkey. In addition, we investigated pos-
sible differences in the prevalence of enuresis between
children in a Regional Boarding Primary school and a reg-
ular primary daytime school.
Methods
We used a cross-sectional study design to determine the
prevalence of enuresis in Bozova, Urfa in Turkey and to
investigate its relationship to accompanying sociodemo-
graphic factors. This study was carried out in Bozova, Urfa
which is the largest populated province of the South East
Anotolian Region in Turkey.
The permission was obtained from Primary Health Centre
of Bozova considering administrative and clinical govern-
ance issues related to the regional health care organisa-
tion. A written informed consent form was obtained from
the parents, stating the study's objectives.
The schools were selected from two different types. One of
them was a day-time school and the other one was a
boarding school. There is only one Regional Boarding Pri-
mary School in Bozova. One daytime primary school was
chosen randomly. One class was chosen among same
grade classes randomly in each school. Questionnaires
were distributed to all students and they were instructed
by the school teachers to take them home to their parents.
A brief information leaflet was attached to the question-
naire informing the parent of the voluntary nature of
study. The students were instructed to help their to par-
ents. Any parent (mother or father) fill the questionnaires.
Students in boarding school go their homes on weekend.
The teachers collected questionnaires from children after
one week. Those not wishing to participate were recorded
as "not responding". The questionnaires were returned for
562 (70%) children. The number of children included in
the study from these two schools were similar [286 vs. 276
children].
BMC Public Health 2009, 9:357 http://www.biomedcentral.com/1471-2458/9/357
Page 3 of 8
(page number not for citation purposes)
Questionnaires consisted of two sections. The first section
was used to document the background data of the child
such as age, gender, type of school, monthly income,
parental educational level, father's working status, birth
order, family size, presence of other people sleeping in the
child's room, inhabitation [living in village or county
areas], history of urinary tract infection, constipation and
parasitic disease according to their statements. Constipa-
tion definion was defined as fewer than one bowel move-
ment a day. This was followed by a question on the
presence of bedwetting (see Additional file 1).
For nocturnal enuresis the ICD-10 definition of at least
one wet night per month for three consecutive months
was used [5]. The second section was completed only
when wetting was present. Items included in the second
section were the frequency of wetting, family history of
wetting, previous therapies and indicators of parental atti-
tudes towards their enuretic child, and whether the child
was embarrassed by his wetting. The variables of parental
concern and child distress ranged from 1 [a great deal] to
4 [not at all].
Statistical analyses were carried out using the Statistical
Package for Social Sciences Chi-square test was used to
determine the significant predictive factors for nocturnal
enuresis. P-values of < 0.05 were considered to be statisti-
cally significant. Age variable was tested for normal distri-
bution. A logistic regression model was applied to
estimate the odds ratios (OR) of significant predictive fac-
tors for enuresis. Age variable was tested for normal distri-
bution. Variables with p values < 0.05 on univariate
analysis were included in the regression model by back-
ward elimination
Results
A total of 562 children aged between 6 and 16 years were
investigated [mean 11.21 ± 2.48]. The overall prevalence
of nocturnal enuresis was 14.9% and 84 children with
nocturnal enuresis were identified. The prevalence of noc-
turnal enuresis declined with age. [Table 1].
There was no significant difference in prevalence of noc-
turnal enuresis between boys and girls [14.3% versus 16.
8%]. Enuresis was reported as 18.5% among children
attending day time school and 11.5% among those
attending boarding school [p < 0.05]. Nocturnal enuresis
was primary in 60.7% and secondary in 37.2% of the
cases. Secondary enuresis in day time school and boarding
school were 42.4% and 37.3%, respectively [p > 0.05].
There was no association between enuresis and parent's
education, father's working status, presence of other peo-
ple sleeping in the child's room, birth order of the child [p
> 0.05]. Prevalence of enuresis was more in children living
in villages, with low income and with positive family his-
tory [p < 0.05] [Table 2].
Enuresis was more in children with history of urinary tract
infection, with constipation and with history of parasitic
disease [p < 0.05]
After multivariate analysis, history of urinary tract infec-
tion [OR = 2.02], age [OR = 1.28], low monthly income
[OR = 2.86] and family history of enuresis [OR = 3.64]
were factors associated with enuresis.
Overall, 32.1% children with nocturnal enuresis of chil-
dren [27/84] had a positive family history. In most chil-
dren, episodes of enuresis occured less than 2 nights per
week. Parents were asked about the impact of enuresis on
their life and the child's life. 46.4% of parents and 57.1%
of enuretic children were significantly concerned about
the impact of enuresis. Of the enuretic children, only
11.9% (10 children) had visited a physician [Table 3]
Visiting a physician was not associated with any risk fac-
tors such as as gender, age, inhabitation and severity of
wetting [Table 4]
Discussion
Nocturnal enuresis is common among younger school-
children and its frequency decreases with increasing age.
In most countries the prevalence of enuresis among 6-11
year olds is reported as 1.4-28%[1,2]. The prevalence rates
of enuresis differ across countries, ranging from 4.3% in
Chinese children [18] and 52% in Jamaican primary
school children [19]
The overall prevalence of enuresis was found to be
12.95% in children aged 5-16 years from France [20] and
15% in children aged 6-11 years from Saudi Arabia [21].
We found the prevalence of enuresis to be 14.9% in a
county, southeast of Turkey. In previous studies reported
from different Turkish provinces, the prevalence of enu-
resis was reported as 11.5-17.5% [1,2,22-25].
Table 1: Prevalence rate of nocturnal enuresis in children
Enuretics Nonuretics
Age n % n %
6-7 16 32.0 34 68.0
8-9 25 23.4 82 76.6
10-11 24 18.9 103 81.1
12-13 16 10.8 132 89.2
14+ 3 2.3 127 97.7
Total 84 14.9 478 85.1
BMC Public Health 2009, 9:357 http://www.biomedcentral.com/1471-2458/9/357
Page 4 of 8
(page number not for citation purposes)
The prevalence of enuresis showed a decreasing trend with
increasing age of children. This trend is also similar to
most reports in the literature [14] Spee-Van der Wekke
stated that the prevalence of nocturnal enuresis was 15%
in the 5-6-year-old group and 1% in the 13-15-year-old
group [14]. Lee et al. showed that prevalence of enuresis
declined with age from 20.4% in 7-year-olds to 5.6% in
12-year-olds [26]. According to our results, of the 6-7 year
olds children, 32% had enuresis, while this ratio was 2.3%
of 14 years and older. Byrd et al. reported that the preva-
lence of enuresis was 33% among children 5 year olds,
18% among 8 year olds and 0.7% among 17 year olds in
North America [27].
Nocturnal enuresis is more common and prolonged in
boys than in girls [28]. According as our findings, gender
did not have a significant effect on the prevalence of enu-
resis. The general principle about gender, enuresis is more
common in boys in the early years but equals out in the
latter years [29]. Turkish families living in eastern of Tur-
key generally enroll to school at an older age. It could be
possible, because the mean age of children was 11.2 in
this study, we did not found gender differences. Some
other studies also showed no gender differences [23,24].
Enuresis was more frequent among children attending the
day-time school than the boarding school, although by
logistic regression analysis no correlation was found. A
Table 2: Social background and some other characteristics in children with and without nocturnal enuresis
Enuretics Nonuretics
n% n % X
2
p
Gender
Boys 59 14.3 354 85.7 0.535
Girls 25 16.8 124 83.2 0.272
School type
Day-time 51 18.5 225 81.5 5.321 0.014
Boarding school 33 11.5 253 88.5
Father's education
≤ 5 years 50 13.9 311 86.1 0.954
> 5 years 34 16.9 167 83.1 0.196
Mother's education
≤ 5 years 79 15.0 446 85.0 0.064
> 5 years 5 13.5 32 86.5 0.514
Father's working status
Yes 63 13.8 393 86.2 2.430
No 21 19.8 85 80.2 0.082
Monthly income
High 8 9.3 78 90.7 9.840
Medium 43 13.0 287 87.0
Low 33 22.6 113 77.4 0.007
Room sharing
None 5 10.6 42 89.4 0.749
2 or more person 79 15.3 436 84.7 0.266
Inhabitation
Village 54 18.7 235 81.3 6.541
County 30 11.0 243 89.0 0.013
Family history of enuresis
Yes 27 42.2 37 57.8 42.150
No 57 11.4 441 88.6 0.000
Birth order
1-3
th
49 16.6 246 83.4 1.506
4-6
th
23 13.8 144 86.2
≥7
th
12 12.0 88 88.0 0.471
History of Urinary Tract infection
Yes 25 21.6 91 78.4 5.016
No 59 13.2 387 86.8 0.021
Constipation
Yes 15 24.2 47 75.8 4.687
No 69 13.8 431 86.2 0.029
Total 84 14.9 478 85.1 562
BMC Public Health 2009, 9:357 http://www.biomedcentral.com/1471-2458/9/357
Page 5 of 8
(page number not for citation purposes)
possible explanation that enuretic children may not want
to attend to boarding school. This is an important popu-
lation of children to study, whether they sleep in open
dormitories or would be more prone to teasing and sham-
ing if enuresis occurred. It might be considered that the
children attending boarding school could arouse from
sleep easy. Nocturnal enuresis has been related to obstruc-
tive sleep-disordered breathing in children. In a commu-
nity sample of children, those with habitual snoring more
often had primary nocturnal enuresis than did those with-
out snoring [30]. A problem noted in children with noc-
turnal enuresis was difficulty in waking during the night
[31]. Many parents complain their bed-wetting children
are difficult to be fully awakened. In the study of Tai et al.,
the ratio of deep sleepers between bedwetting and non-
bed-wetting children showed a significant difference [31].
A recent epidemiological study by Neveus et al. reported
that most of the dry children were relatively easy to arouse
from sleep [32]. It is obvious that waking up is still a prob-
lem in enuretics and that some questions remain to be
answered on this matter.
In our study, there was no relationship between the enu-
resis prevalence and the educational level of the father and
mother. Spee-Van der Wekke found that the educational
level of parents was not significantly related to the
prevalance of nocturnal enuresis [14]. In Turkey, Gumus
et al. showed that the low educational level of parents was
associated with nocturnal enuresis[2]. Ozden et al. also
showed that low education level were significantly associ-
ated with enuresis [1]. In our study, most of the parents
educational level was low. We found that low socio-eco-
nomic status of the family was associated with nocturnal
enuresis. Chiozza et al. found that the prevelance of enu-
resis was higher in families of low socioeconomic class[8].
Low socioeconomic status is also a risk factor for psycho-
pathology[33].
Enuresis was also significantly more common with village
inhabitation than with county inhabitation. This might be
related to poor sanitation, lower educational level of par-
ents, and smaller monthly income for village families as
compared to those for county families. Gumus et al. [2]
Chiozza et al. [8] and Gur et al. [23] also showed that
lower educational levels of the parents and lower socioe-
conomic class were both associated with nocturnal enu-
resis.
Table 3: Possible relationship of different factors in children with
nocturnal enuresis
n%
Frequency of wetting
Every night 27 31.0
2-6 nights per week 21 24.1
< 2 nights per week 39 44.8
Family history
Yes 27 32.1
No 57 67.9
Children who visited a physician 10 11.9
Therapies
Tablets/Drugs 9 10.7
Behavioral therapy 1 1.1
Parental concern
1 (a great deal) 39 46.4
22023.8
378.3
4 (not at all) 18 21.4
Child's concern
1 (a great deal) 48 57.1
21517.9
389.5
4 (not at all) 13 15.5
Table 4: Visiting to a physician and some characteristics in children with nocturnal enuresis
Visit to a physician Not visit to a physician
n% n % X
2
p
Gender
Boys 5 8.2 56 91.8 2.404 0.146
Girls 5 20.0 20 80.0
Severity of wetting
Severe (everynight) 4 14.8 23 85.2 0.389 0.718
Others 6 10.2 53 89.8
Ages of children
6-7 years old 4 23.5 13 76.5 2.921 0.104
Others 6 8.7 63 91.3
Inhabitation
Village 7 12.7 48 87.3 0.179 1.000
County 3 9.7 28 90.3
BMC Public Health 2009, 9:357 http://www.biomedcentral.com/1471-2458/9/357
Page 6 of 8
(page number not for citation purposes)
Family history of enuresis was found in 32.1% of enuretic
children's families in our study. Enuresis history of the
child's mother, father, brothers or sisters has frequently
been reported as an accompanying finding in the litera-
ture. Furthermore, previous studies reported the preva-
lence of family history in enuretic children as 22-48%.
Twin studies also support a genetic basis for enuresis.
[1,2,22]
Rona et al., in their study of the population of England
and Scotland, found that primary nocturnal enuresis was
more likely in a child who was not the first born in the
family [34]. In this study, however, birth order was not a
significant determinant of nocturnal enuresis. Kana-
heswari also showed that birth order was not associated
with enuresis [29]
When the logistic regression analysis was applied to risk
factors for the bed-wetting in the present study, a signifi-
cant positive correlation was revealed for low age, low
income, history of urinary tract infection and family his-
tory of enuresis.
We found association between enuresis and history of uri-
nary tract infections [UTI] and constipation in this study.
Kajiwara et al. also found that children with a history of
cystitis had a significantly higher rate of nocturnal enu-
resis than children without such a history [35]. Ozden et
al found that recurrent UTI were significantly higher in
enuretics when compared to non-enuretics [1]. The rea-
son for this is not clear. However, it has been suggested
that the strong contraction of the proximal urethra and
pelvic floor muscles might cause UTI by leading to ure-
throvesical reflux of bacteria in the proximal urethra [36].
Pelvic floor overactivity and bladder dysfunction are
thought to simultaneously cause overconstriction of the
anal sphincter resulting in constipation [35] Inan et al
also found that constipation was more frequent in enuret-
ics [37].
There have been few investigations of the severity of bed-
wetting in the literature. In our study, 31.0% of children
wet everynight. Ozden et al defined 33.3% severe enuresis
as bed wetting every night in Turkish children[1]. In
southeast Anatolia, the prevalence of "marked" enuresis
[at least weekly] was 9.8%. [24] In Karachi, 30% of the
children with bed wetting wet every night [38]. Wang et al
found that the prevalence of bed-wetting every night was
24.6%[39]. One- third of the children with enuresis wet
every night in our study. Our result is consistent with
other studies.
In the present study only 11.9% of the children were seen
by a physician. This low rate demonstrates that most of
the children with enuresis were not treated. Oge et al.
from Turkey reported that the families mostly choose the
traditional methods in attempt to treat enuresis [25]. In
the present study 10.7% of the children were treated with
medication provided by physicians. The use of medical
treatment is low when compared to other studies.
[25,26,29] It may be that among parents few know of the
availability of medical treatment.
Parental concern toward the problem of enuresis and the
child's concern were studied. Results indicate that 46.4%
of parents of nocturnal enuretic children and 57.1% of
children consider "it a great deal". Kanaheswari reported
that 73% of parents of nocturnal enuresis consider it a
problem and 76% of children with nocturnal enuresis
embarrassed by their problem [29]. Foxman et al. [40]
also found that two-thirds of American parents worried
about the symptom, and over half the children were dis-
turbed by the problem. Lee et al. reported similar findings
in Korean children [26]. In our study, parental concern
was a little lower from other studies. It may some relation-
ship to the cultural acceptance of enuresis in southeast of
Turkey.
There are some limitations of our study. Questionnaires
were filled in children's homes by their parents. This
might raise questions about objectivity results is not
objectively. Family history of wetting is difficult to esti-
mate. Parents might have given false information their
children's bedwetting, bowel habits, arousability. The
present study was limited to only one boarding school. It
would be desirable to conduct a larger population-based
study throughout in more number boarding schools in
Turkey.
Conclusion
In summary, the prevalence rates for enuresis in Bozova,
Urfa in Southeast of Turkey were similar to other studies
from Turkey and higher than western countries. It may be
cultural differences in the achievement of bladder control,
and in the attitude of parents to their bedwetting child.
Enuresis was more frequent among children attending
daytime school when compared to boarding school. Our
results with enuresis prevalence and associated factors
which were smaller age, low income, family history of
enuresis and history of urinary tract infection. We docu-
mented that most of the children with enuresis in south-
east of Turkey do not have adequate attention about
enuresis and most of the enuretic children do not receive
professional treatment.
Enuresis is a pediatric public health problem and efforts at
all levels should be made such as preventive, etiological
and curative. The misconceptions among the parents
require health education intervention.
BMC Public Health 2009, 9:357 http://www.biomedcentral.com/1471-2458/9/357
Page 7 of 8
(page number not for citation purposes)
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AA; planned to study, participated in its design and coor-
dination; GG; participated in its design and coordination
and writing the article; YA; performed statistical analysis
and literature collection, AAkilli; collected data.
All authors read and approved the final manuscript.
Additional material
Acknowledgements
We would like to acknowledge the encouragement, help and other support
provided by directors and teachers in schools in completing this research.
References
1. Ozden C, Ozdal OL, Altinova S, Oguzulgen I, Urgancioglu G, Memis
A: Prevalence and associated factors of enuresis in Turkish
children. Int Braz J Urol 2007, 33(2):216-22.
2. Gumus B, Vurgun N, Lekili M, Is¸can A, Muezzinoglu T, Buyuksu C:
Prevalence of nocturnal enuresis and accompanying factors
in children aged 7-11 years in Turkey. Acta Paediatr 1999,
88:1369-72.
3. Wen JG, Wang QW, Chen Y, Wen JJ, Liu K: An epidemiological
study of primary nocturnal enuresis in Chinese children and
adolescents. Eur Urol 2006, 49(6):1107-13.
4. Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W,
Jørgensen TM, Rittig S, Walle JV, Yeung CK, Djurhuus JC: The stand-
ardization of terminology of lower urinary tract function in
children and adolescents: report from the Standardisation
Committee of the International Children's Continence Soci-
ety. J Urol 2006, 176(1):314-24.
5. World Health Organization: The ICD-10 Classification of Mental
and Behavioral Disorders: Diagnostic Criteria for Research.
WHO, Geneva; 1993.
6. Bower WF, Moore KH, Shepherd RB, Adams RD: The epidemiol-
ogy of childhood enuresis in Australia. Br J Urol 1996, 78:602-6.
7. Byrd RS, Weitzman M, Lanphear NE, Auinger P: Bedwetting in US
children: pidemiology and related behavior problems. Pediat-
rics 1996, 98:414-9.
8. Chiozza ML, Bernardinelli L, Caione P, Del Gado R, Ferrara P, Giorgi
PL, Montomoli C, Rottoli A, Vertucci P: An Italian epidemiologi-
cal multicentre study of nocturnal enuresis. Br J Urol 1998,
81(Suppl 3):86-9.
9. Liu X, Sun Z, Uchiyama M, Li Y, Okawa M: Attaining nocturnal uri-
nary control, nocturnal enuresis, and behavioral problems in
Chinese children aged 6 through 16 years. J Am Acad Child Ado-
lesc Psychiatry 2000, 39:1557-64.
10. Byrd RS, Weitzman M, Lanphear NE, Auinger P: Bed-wetting in US
children: epidemiology and related behavior problems. Pedi-
atrics 1996, 98:414-19.
11. Chang SSY, Ng CFN, Wong SN: Behavioral problems in children
and parenting stress associated with primary nocturnal enu-
resis in Hong Kong. Acta Paediatr
2002, 91:475-9.
12. Hjalmas K: Nocturnal enuresis: basic facts and new horizons.
Eur Urol 1998, 33(Suppl 3):53-7.
13. Lackgren G, Hjalmas K, van Gool J, von Gontard A, de Gennaro M,
Lottmann H, Terho P: Nocturnal enuresis: a suggestion for a
European treatment strategy. Acta Paediatr 1999, 88:679-90.
14. Spee-van der Wekke J, Hirasing RA, Meulmeester JF, Radder JJ:
Childhood nocturnal enuresis in The Netherlands. Urology
1998, 51(6):1022-6.
15. Kasen S, Johnson J, Cohen P: The impact of school emotional cli-
mate on student psychopathology. J Abnorm Child Psychol 1990,
18:165-77.
16. Kleinfeld J, Bloom J: Boarding schools: effects on the mental
health of Eskimo adolescents. Am J Psychiatry 1977, 134:411-7.
17. Gottlieb RM: Consultation and therapy in the boarding high
school setting. Child Adolesc Psychiatr Clin N Am 2001, 10:139-49.
18. Liu X, Sun Z, Uchiyama M, Li Y, Okawa M: Attaining nocturnal uri-
nary control, nocturnal enuresis, and behavioral problems in
Chinese children aged 6 through 16 years. J Am Acad Child Ado-
lesc Psychiatry 2000, 39:1557-64.
19. Readett DR, Bamigbade T, Serjeant GR: Nocturnal enuresis in
normal Jamaican children: implications for therapy. West
Indian Med J 1991, 40:181-4.
20. Ouedraogo A, Kere M, Ouedraogo TL, Jesu F: Epidemiology of
enuresis in children and adolescents aged 5-16 years in Oua-
gadougou. Arch Pediat 1997, 4:947-50.
21. Kalo BB, Bella H: Enuresis: Prevalence and associated factors
among primary school children in Saudi Arabia. Acta Pediatr
1996, 85:1217-22.
22. Serel TA, Akhan G, Koyuncuoglu HR, Oztürk A, Doğruer K, Unal S,
Celik K: Epidemiology of enuresis in Turkish children. Scand J
Urol Nephrol 1997, 31:537-9.
23. Gur E, Turhan P, Can G, Akkus S, Sever L, Güzelöz S, Cifçili S, Arvas
A: Enuresis: Prevalence, risk factors and urinary pathology
among school children in Istanbul, Turkey. Pediatr Int 2004,
46:58-63.
24. Ozkan KU, Garipardic M, Toktamis A, Karabiber H, Sahinkanat T:
Enuresis prevalence and accompanying factors in schoolchil-
dren: A questionnaire study from southeast Anatolia. Urol Int
2004, 73:149-55.
25. Oge O, Kocak I, Gemalmaz H: Enuresis: point prevalence and
associated factors among Turkish children. Turk J Pediatr 2001,
43:38-43.
26. Lee SD, Sohn DW, Lee JZ, Park NC, Chung MK: An epidemiolog-
ical study of enuresis in Korean children. BJU Int 2000,
85:869-73.
27. Byrd RS, Weitzman M, Lanphear NE, Auinger P: Bed-wetting in US
children: epidemiology and related behavior problems. Pedi-
atrics 1996, 98(3 Pt 1):414-9.
28. Wen JG, Wang QW, Chen Y, Wen JJ, Liu K: An epidemiological
study of primary nocturnal enuresis in Chinese children and
adolescents. Eur Urol 2006, 49(6):1107-13. Epub 2005 Dec 27
29. Kanaheswari Y: Epidemiology of childhood nocturnal enuresis
in Malaysia. J Paediatr Child Health 2003, 39(2):118-23.
30. Alexopoulos EI, Kostadima E, Pagonari I, Zintzaras E, Gourgoulianis
K, Kaditis AG: Association between primary nocturnal enu-
resis and habitual snoring in children. Urology 2006,
68(2):406-9.
31. Tai HL, Chang YJ, Chang SC, Chen GD, Chang CP, Chou MC: The
epidemiology and factors associated with nocturnal enuresis
and its severity in primary school children in Taiwan. Acta
Paediatr 2007, 96(2):242-5.
32. Neveus T, Hetta J, Cnattingius S, Tuvemo T, Lackgren G, Olsson U,
Stenberg A: Depth of sleep and sleep habits among enuretic
and incontinent children. Acta Paediatr 1999, 88(7):748-52.
33. Van Hoecke E, Baeyens D, Walle J Vande, Hoebeke P, Roeyers H:
Socioeconomic status as a common factor underlying the
association between enuresis and psychopathology.
J Dev
Behav Pediatr 2003, 24:109-14.
34. Rona RJ, Li L, Chinn S: Determinants of nocturnal enuresis in
England and Scotland in the 90s. Dev Med Child Neurol 1997,
39:677-81.
35. Kajiwara M, Inoue K, Kato M, Usui A, Kurihara M, Usui T: Nocturnal
enuresis and overactive bladder in children. an epidemiolog-
ical study. Int J Urol 2006, 13(1):36-41.
36. Kalo BB, Bella H: prevalence and associated factors among pri-
mary school children in Saudi Arabia. Acta Paediatr 1996,
85:1217-22.
Additional file 1
Appendix. Survey Questionnaire.
Click here for file
[http://www.biomedcentral.com/content/supplementary/1471-
2458-9-357-S1.DOC]
Publish with Bio Med Central and every
scientist can read your work free of charge
"BioMed Central will be the most significant development for
disseminating the results of biomedical research in our lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central
yours — you keep the copyright
Submit your manuscript here:
http://www.biomedcentral.com/info/publishing_adv.asp
BioMedcentral
BMC Public Health 2009, 9:357 http://www.biomedcentral.com/1471-2458/9/357
Page 8 of 8
(page number not for citation purposes)
37. Inan M, Tokuc B, Aydiner CY, Aksu B, Oner N, Basaran UN: Per-
sonal characteristics of enuretic children: an epidemiological
study from South-East Europe. Urol Int 2008, 81(1):47-53.
38. Mithani S, Zaidi Z: Bed wetting in school children of Karachi. J
Pak Med Assoc 2005, 55:2-5.
39. Wang QW, Wen JG, Song DK, Su J, Zhu QH, Liu K, Che YY, Du AM,
Wei JX: Bed-wetting in Chinese children: epidemiology and
predictive factors. Neurourol Urodyn 2007, 26(4):512-7.
40. Foxman B, Valdez RB, Brook RH: Childhood enuresis. Preva-
lence, perceived impact and prescribed treatments. Pediatrics
1986, 77:482-7.
Pre-publication history
The pre-publication history for this paper can be accessed
here:
http://www.biomedcentral.com/1471-2458/9/357/pre
pub
