Review of literature is an essential activity of scientific research project. It helps to familiarise with the practical issue related to the problem and enable the researcher to strengthen the study which helps to reveal the prevailing situation of the similar study. The reviewed literature for this study is presented in the following sections.
2.1 Prevalence and contributing factors of nocturnal enuresis
2.2 Management of nocturnal enuresis
2.1 Prevalence and Contributing Factors of Nocturnal Enuresis:
A cross sectional study was conducted on prevalence and risk factors of mono symptomatic nocturnal enuresis in school children of Ankara. Among 15150 children, 9% children had mono symptomatic nocturnal enuresis.it was found that Frequency was higher in boys than girls. Analysis revealed that gender, toilet training methods , problems of sleep, school performance, and approach of the family members to such children are significant factors. Age, male gender, experience of toilet training with threatening methods, deep sleep, sleep walking,and introverted and shy behavior were significantly increased the risk of nocturnal enuresis (Secil Ozkan, et al., 2010).
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An epidemiological cross sectional study was conducted to determine the prevalence of nocturnal enuresis in children 5-14 years in Sudan, 218 children were involved in the study and out of that 33.5% children were found to have nocturnal enuresis. Frequency was high among girls than boys and the prevalence of bedwetting decrease as the age of the child increased from 13.3% at 5-7 years of age to 2-3% at 12-14 years ( Magdi, A. H., 2010).
A prevalence study was conducted in Eastern Croatia to establish the prevalence of nocturnal enuresis in 6-7 year old child. Factors associated with nocturnal enuresis and parental perception were also evaluated. Parents of 3011 children were included in the study. The prevalence rate is 1.2% and it is significantly more in boys than girls. 68.6% of children had the family history of nocturnal enuresis and only 17.1% of parents expressed some concern about problem on child’s future development(Miskulin, M. et al.,2010).
A cross sectional study conducted in southeast of Turkey to study the epidemiology and factors associated with nocturnal enuresis among boarding and daytime school children revealed that 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% had the problem, while the ratio was 2.6% for 15 years-olds. There was no significant difference in prevalence of nocturnal enuresis between boys and girls. Enuresis was reported as 18.5% among children attending day time school and among those 11.5% attending boarding school .Prevalence of enuresis was increased in children who are living in villages, with low income families and who are having positive family history of nocturnal enuresis. After multivariate analysis, history of urinary tract infection, age, low monthly income and family history of enuresis were factors associated with enuresis. 46.4% of parents and 57.1% of enuretic children were significantly concerned about the impact of enuresis (Ali Gunes, Gulsen Gunes, Yasemin Acik and Adem Akilli, 2009).
A descriptive questionnaire based study was done in Africa to evaluate the quality of life and sleep quality and the association between the parameters in children with mono symptomatic nocturnal enuresis. 71 children in the age group of 6-15 years were included in the study and it was found that as age of the child and the duration of the problem increases, self esteem, physical wellbeing and friend domains worsens (Ertan,P et al, 2009).
A two-stage mental health survey was conducted among 5000 urban children to examine the association between enuresis and psychopathology in urban Ethiopian children. It was found that male sex, younger age and lower achieved were having this problem. Nocturnal enuresis was significantly higher for children in families with significant financial worries and in children from homes where parents were separated. Children with DSM III-R anxiety disorders, mainly simple phobia, or disruptive behaviour disorders were found to have significantly higher rate of enuresis ( Menelik Desta, 2007).
A cross-sectional study was conducted in 2007 at Iran to estimate the prevalence of nocturnal enuresis and determine associated factors revealed the prevalence of 6.8% among 7562 children. A significant relationship was found between the prevalence of enuresis and age, educational status of parents, number of family enuresis, parenting methods, and deep sleep. Prevalence of urinary tract pathology was 2.9% in enuretic children (Mohammed .R. Safarinejad, 2007).
A descriptive study was conducted in India to establish the prevalence of enuresis in school children and to determine contributing factor . Parents of 1473 children aged between 6-10 years were surveyed. The overall prevalence of enuresis was 7.61%. Enuresis was more commonly seen in boys. A positive family history of enuresis was seen in 28.57% children; 14.29% of the children had daytime wetting as well. Only 24.11% of the parents had taken their child to a doctor for the treatment. Family problems,stressors, birth history and lower socioeconomic status were present in the children with enuresis. Poor scholastic performance was also an important factor in this group (Avinash De Sousa, Hema Kapoor, Jyoti Jagtap, Mercilina Sen, 2007).
A randomly selected cross-sectional study was conducted from elementary schools in Changhua County, Taiwan, to investigate the prevalence of nocturnal enuresis among children and to evaluate its associated factors and severity. The overall prevalence of nocturnal enuresis was 6.8%. The ratio of male to female was about 1.5. The prevalence of enuresis according to age group declined from 12.5% at 6 years to 2.0% at 12 years. The prevalence of enuresis in the urban area did not show significant difference from that of rural area .The factors associated with enuresis were gender, age, urinary frequency or urgency, heredity,habit of drinking before sleep and difficulty in waking. They showed significant difference after multiple logistic regression analysis (HuiLung Tai, et al., 2006).
A case control study consisted of 55 children with nocturnal enuresis from a continence centre and 117 matched controls from a general paediatric practice revealed that breastfeeding protects against the development of bedwetting. Bed-wetting was strongly associated with family history. Approximately 45% of children wet the bed if one parent was enuretic and 75% wet the bed if both parents were enuretic. Twenty-one parents (38%) in the study group and 6 parents (5%) in the control group were enuretic as children (Barone, et al., 2006).
An epidemiological study was conducted to investigate the prevalence and characteristics of nocturnal enuresis (NE) and to examine the prevalence of overactive bladder (OAB) symptoms in preadolescent schoolchildren. It was conducted in 6917 school children belonging to 11 primary schools that were randomly enrolled in the survey. They assessed the relationship of nocturnal enuresis with voiding habits, episodes of cystitis and constipation. They found the prevalence of nocturnal enuresis to be 5.9% and inversely related to increasing age. Nocturnal enuresis and overactive bladder were detected in 5.9% and 17.8% of preadolescent and schoolchildren respectively (Kajiwara, et al.,2006).
A community survey of enuresis was carried out in 2002 among 300 apparently healthy children aged 5-16 years in Edo State, Nigeria with the aim of ascertaining the true prevalence of the disease and the contributions of organic causative factors. The overall prevalence of nocturnal enuresis was 21.3%. Of the 64 children who were enuretic, 58 (91%) had only nocturnal enuresis.. Combined daytime and night time enuresis accounted for only six (9.4%) cases. Ninety-four percent of cases of enuresis were having primary nocturnal enuresis and only six were having secondary nocturnal enuresis. Prevalence of enuresis decreases significantly with increasing age .There was a strong association between enuresis and family history of bed wetting. Enuresis was more commonly seen in males, in children from families of poor socio-economic status, among first child in the family, and childrenwith asymptomatic bacteriuria (Iduoriyekemwen,N.J.,2006).
A cohort study was conducted to determine the prevalence of nocturnal enuresis among 13971 children at 7.5 years old, revealed that 1260 children (15.5%) at 7.5 years wet the bed, but most wet once or less a week. A higher prevalence was reported in boys than girls . 266 children had both daytime wetting and bedwetting, with 189 (2.3%) having both daytime soiling and bedwetting. Daytime urgency of urination increased with severity of bedwetting and occurred in 28.9% of children with nocturnal enuresis (Richard .J. Butler, Jean Golding, Kate Northstone, 2005).
A cross sectional population based study was conducted in Turkey to establish the prevalence of enuresis among school children and determine the risk factors associated with this disorder. Among 1576 schoolchildren aged between 6-16 years, the overall prevalence of enuresis was 12.4% and a significant relationship was found between the prevalence of enuresis and age, educational level of father, the family’s monthly income, and number of family members. Mono symptomatic nocturnal enuresis was found to be more common in boys. Both maternal and paternal low educational status were found to be associated with mono symptomatic nocturnal enuresis. It was found to be more common in the children of unemployed mothers. Nocturnal enuresis was found to be more associated with large families (Gur, E. et al., 2004).
Community survey of a stratified sample of 400 children in the age group of 6-12 years in United Arab Emirates to determine the prevalence, associated socio demographic variables and associated psychopathology in children with enuresis was found out that nocturnal enuresis was associated with psychosocial stress in the family and positive family history( Eapen ,V., 2003).
A randomised controlled trial was done to study self image of children with nocturnal enuresis. 50 sample in the age group of 8-12 years were included. It was found out that children with nocturnal enuresis had low self esteem than others (Theunis,et al.,2002).
2.2 Management of Nocturnal Enuresis: A randomised prospective study was performed to evaluate the efficacy of different modes of combined therapy in children with mono symptomatic nocturnal enuresis. One group was treated with primary Desmopressin and another group was treated with primary alarm treatment that was combined with Desmopressin after 3 months. 22(73%) children were dry after combined treatment, consisting of 12boys and 10girls. Combined therapy proved effective in children with mono-symptomatic nocturnal enuresis after 6 months (Vogt, M., 2010).
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A cross sectional study was conducted to investigate the efficacy of alarm treatment in a sample of 84 Brazilian children and adolescents with nocturnal enuresis. During 32 weeks, they were received alarm treatment together with weekly psychological support sessions for individual families or groups of 5 to 10 families. 71% of the participants achieved success, by 14 consecutive dry nights. The result was same as that for children and adolescents and for individual or group support (Pereira, R.F., 2010).
A descriptive study was designed to evaluate the success rates of the enuretic alarm device in patients (6-16 years) with mono-symptomatic nocturnal enuresis in Ankara, Turkey. 40 patients who had significant mono-symptomatic nocturnal enuresis (three or more wet nights per week) were included in the study. They initially used an enuretic alarm for 12 weeks initially. 27 patients became dry at night at the end of three months (Ozgur, B.C., 2009).
A randomised control trial conducted in Netherland to assess the short- and long-term effects of simple behavioural interventions for nocturnal enuresis in young children note that nocturnal enuresis occurs in up to 10% of 10-year-old children and that boys have higher rates of enuresis at older ages than do girls. This study compared the relative effectiveness of 3 treatments with a control group. Parents completed diaries detailing night enuresis episodes for up to 6 months after enrolment. The study enrolled 570 participants and 140 to 147 children were there in each of the 4 groups. Sixty percent of the children were male. Success rates at least 14 nights dry in a row at 6 months after enrolment were 21% in the control group, 27% in the lifting with password group, 37% in the lifting without password group, and 32% in the star chart/reward group (Van Dommelen, P., 2009).
A prospective study was done to evaluate the long-term success of the enuretic alarm device in patients with mono symptomatic primary nocturnal enuresis in Turkey. Sixty-two children who had significant mono symptomatic primary nocturnal enuresis were included in this study. They used an alarm for 3 months. 15 of the patients did not have benefit from the enuretic alarm. 47 patients benefited from the enuretic alarm. Thirty-one of the 62 patients underwent combination treatment (enuretic alarm plus medical therapy) for unsuccessful enuretic alarm treatment. The full response rate for combination therapy was 16.1%. (Tuncel A, et al., 2008).
A randomised controlled trial was conducted to compare alarm interventions with no specific treatment, behavioural interventions, drugs or other treatment for treatment of non-organic nocturnal enuresis in children less than 16 years found that alarms reduced nocturnal enuresis and treatment failure (Glazener, C. M., 2008).
A retrospective analysis was performed on data from 423 children in the age group of 6-12 years to evaluate the combination of enuresis alarm and desmopressin in treating children with enuresis found out that 74% of children treated only with alarm became dry and 26% of children being cured by combination of desmopressin and alarm (Kamperis, K., 2008).
A randomised controlled trial was done in Turkey to evaluate the effectiveness of short term desmopressin to enuritic alarm. 58 children were included in the study. The results showed that addition of short term desmopressin to alarm therapy was more effective only in the treatment time, but it did not change the response to alarm therapy in long term (Aktas, B. K., 2008).
A study was conducted to determine the effect and predictive factors of relapse 1 year after combination therapy of an enuresis alarm, bladder training therapy, motivational therapy and retention control training for nocturnal enuresis. It was done in 77 children at Gasthuisberg. Gender, age, sleep arousal, family-history, bladder capacity, overactive bladder, night-time polyuria, duration of treatment, and psychosocial factors were investigated. The relapse rate during the whole year was 50%, with 33.8% of subjects being dry and 16.2% sometimes wet. The relapse rate after 1 year was 16%. The relapse rate during the treatment year was high, but the relapse rate after 1 year was low.It was found out that psychosocial problems and overactive bladder were the only 2 predictive factors for relapse (Van Kampen M, et al., 2004).
A retrospective study was conducted to find out the effectiveness of behavioural therapy for primary nocturnal enuresis.250 children in the age group of 5-17 years were selected for the study it was found out that behavioral therapy is effective than desmopressin (Marcopennes, et al., 2004).
In a case-based study, on a 6 year 6 month old child with complaints of bedwetting twice a week, a complete physical examination and history collection was performed. Child was treated with motivational therapy and was recommended parents of the child to be supportive of the patient’s dry nights avoid criticism of wet nights, avoid excessive fluid intake 2 hours before bedtime and emptying his bladder at bedtime. After 1 month it was found that bedwetting problem had improved significantly (Paredes, 2002).
A controlled trial was undertaken to evaluate the practicability and efficacy of treating enuretic children in residential Children’s Homes by using enuresis alarm. An experimental design was employed with 19 and 20 subjects in the treatment and control groups respectively. Eighteen of the nineteen treatment group children achieved initial arrest of enuresis in a mean of 11.9 weeks of treatment (range 5-28 weeks). After a follow-up period of 20 months, 17, out of the 19 children were known to be dry. It was concluded that alarm treatment was effective and practicable in Children’s Homes as in family situations (Jehu, D., 2002).
A randomised controlled trial was conducted at Canada to determine the self concept and behaviour change after 6 months of treatment with conditioning alarm. 182 children of age more than 7 years were included and it was found that there is improvement in the children’s self concept after alarm treatment (Longstaff, S., 2000).
A randomised prospective study was done in France to compare the effectiveness of desmopressin and alarm treatment. 135 children were included in the study from the age group of 6-16 years. The study results showed that desmopressin was effective only for short term and enuresis alarm was effective for long term (Faraj, G. et al., 1999)
A study conducted to find out the effectiveness of star charts among127 children who were referred to an enuresis clinic. The average age of the children who were included in the study was 8.8 years old. Most of them had severe enuresis, which was already unsuccessfully treated. Of the 127 children, 22 became dry when star charts were used to reward their behaviour. Eighty-one of the remaining 96 children had an initial success of 42 consecutive dry nights. Failure to achieve dryness for six months was strongly associated with psychiatric disorders of the children, family stress, and the absence of concern by child and parents (Hanafin, 1998).
An experimental study was conducted in United Kingdom to assess the efficacy of alarm mono therapy with combination of alarm and desmopressin. 35 children in the age group of 6-12 years were included in the study. Study showed that children receiving combination therapy had more dry nights per week (Bradburry, M., 1997).
A retrospective study among 541 children at children’s Hospital of Florence University revealed that motivational therapy is effective. All the patients have been initially helped only with motivational counseling and 76 among them became dry at nights permanently . The remaining 250 children were treated with the conditioning alarm system, always associated with motivation, urine control exercises and other psychological support like token economy. After a follow-up of 6 months of this kind of treatment ,permanent recovery were there in 211 children (84%).No significant difference was noted in relation to sex. These positive results for the conditioning devices shows that the etiology of primary enuresis is mainly biologic. The bell alarm treatment is the most effective treatment for nocturnal enuresis (Bartolozzi, G., 1991).
A study conducted to identify family factors, and with emotional stress factors related to nocturnal enuresis, 127 children who were referred to an enuresis clinic in Sydney were studied. The average age of the children was 8.8 years old. Most of them had severe enuresis and had been already treated unsuccessfully. One-third of the children’s fathers and 70 percent of mothers were unemployed. 41 % of parents acknowledged environmental stresses such as financial or marital disharmony , or serious illness or death in the family.Out of 127 children, 22 became dry when star charts were used to reward their behaviour. Eighty-one of the remaining children had an initial success of 42 consecutive dry nights. The study suggests that the high success rate in these children is related to close supervision by clinical personnel, encouragement by the family, and by giving the child almost complete responsibility for continuing the program. The study suggests that careful identification of associated factors like medical illness, familial stress, and other problems such as housing must be addressed as part of an effective enuresis program (Devlin, J.B., 1990).
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