Enuresis in childhood, and urinary and fecal incontinence in adult life: do they share a common cause?

Transcription

1 Original Article ENURESIS AND URINARY AND FECAL INCONTINENCE GURBUZ et al. Enuresis in childhood, and urinary and fecal incontinence in adult life: do they share a common cause? AYSE GURBUZ, ATES KARATEKE and CANAN KABACA Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey Accepted for publication 16 December 2004 OBJECTIVE To investigate whether there is any association between urinary or fecal incontinence and childhood bedwetting, and given such a relationship, to detect which type of urinary incontinence (UI) is associated with childhood bedwetting. PATIENTS AND METHODS In all, 1021 patients who were admitted to the outpatient gynaecology clinics of the authors institution for an annual gynaecological examination were included in this descriptive clinical study. A simple multi-choice screening questionnaire was used to collect data for analysis. RESULTS There was a history of bedwetting in childhood in 181 (21.1%) of women without and in 48 (29.6%) of those with UI; the difference was significant (chi-square, P < 0.05). Women with stress UI had significantly higher rates of enuresis in childhood (35.4%) than those without UI (21.1%; P = 0.003). Of women who had a history of bedwetting in childhood, 12.2% had stress UI, but only 6.4% of those with no such history had stress UI. Fecal incontinence was significantly more common in women with a history of bedwetting in childhood (P < 0.05). CONCLUSION A history of childhood bedwetting seems to increase the risk of having UI, stress UI and fecal incontinence. Being aware of this association may provide an opportunity to avoid exposing these women to additional risk factors for these condition. KEYWORDS enuresis in childhood, nocturnal enuresis, urinary incontinence, fecal incontinence INTRODUCTION Bedwetting among young children is very common; enuresis is defined as the involuntary loss of urine and is a term generally applied only after children reach an age at which full bladder control is expected, typically after the age of 4 or 5 years. The definition of enuresis remains ill-defined and its epidemiology is based on relatively few studies. Its prevalence is thought to be 15 33% at the age of 5 years [1 3]. The prevalence differs among populations; the methodological differences in questionnairebased trials and social norms probably account for such differences in prevalence [1]. With many causes, urinary incontinence (UI) is prevalent in women [4,5]; childbirth, vaginal delivery, genetic and physical factors are all associated with UI. Female stress UI has been considered an anatomical problem, caused by the weakened pelvic muscles as a result of a neurological dysfunction [6]. The cause of bedwetting in childhood is also related to various factors; genetic, ethnic and physical factors, family antecedent, sleeping and dreaming pattern, bladder function and size are some of those associated with bedwetting in childhood [7 11]. Currently the exact nature of the disorder has not been clarified. However, the possibility of a mutual relationship between incontinence and childhood bedwetting led us to investigate whether there is any association between them. Identifying such an association might be helpful in determining the cause of both conditions. To date, only a few studies have investigated this topic, with some authors reporting an association between urge UI and childhood bedwetting [12 15]. Thus we conducted the present study to detect which type of UI might be associated with childhood bedwetting and if there is such a relationship. PATIENTS AND METHODS Between March 2001 and April 2002, 1021 patients who were admitted to the outpatient gynaecology clinics of our hospital for annual gynaecological examination were included in the present descriptive clinical study. A simple multi-choice screening questionnaire was used to collect data; the questionnaire included the patients demographic characteristics, characteristics related to enuresis (i.e. both nocturnal enuresis (NE) in adulthood and any history of bedwetting in childhood), urinary and fecal incontinence (Appendix). During the period of the study, each woman attending the outpatient clinic for the annual examination was asked whether she would be willing to complete a questionnaire about urinary and fecal incontinence and 1021 (92.6%) of 1102 women agreed. The participants were neither examined clinically nor urodynamically. A woman was considered to have UI if she replied positively to the question Do you currently have some involuntary loss of urine?. The prevalence was determined in three subgroups of UI, i.e. stress UI (defined as an involuntary urethral loss of urine associated with laughing, coughing, sneezing, heavy lifting or physical exercise); urge UI (defined as an involuntary urethral loss of urine preceded by a sudden and strong desire for urination or by rapid and uncontrollable voiding with little or no warning); and mixed UI (defined as the association of stress and urge UI) [16 18]. A woman was considered to have fecal BJU INTERNATIONAL 95, doi: /j x x

2 ENURESIS AND URINARY AND FECAL INCONTINENCE Factors UI, n (%) Yes No Age, years* (59.3) 677 (78.8) (38.9) 174 (20.2) >65 3 (1.8) 8 (1.0) Constipation* No 63 (38.9) 463 (53.9) Sometimes 59 (36.4) 259 (30.2) Always 40 (24.7) 137 (15.9) Smoking Yes 33 (20.4) 214 (24.9) No 129 (79.6) 645 (75.1) Systemic disease No 128 (79.0) 719 (83.7) Diabetes mellitus 10 (6.2) 26 (3.0) Chronic bronchitis 9 (5.5) 26 (3.0) Cardiac diseases 15 (1.7) UTI Other 15 (9.3) 73 (8.6) Gravidity* 0 6 (3.7) 110 (12.8) (21.6) 399 (46.5) (74.7) 350 (40.7) Parity* 0 8 (4.9) 132 (15.4) (48.2) 575 (66.9) 4 76 (46.9) 152 (17.7) Route of delivery* None 9 (5.6) 136 (15.8) Vaginal 148 (91.3) 619 (72.1) Caesarean 3 (1.9) 84 (9.8) Both 2 (1.2) 20 (2.3) Duration of labour, h* <10 51 (34.9) 369 (52.9) >10 95 (65.1) 328 (47.1) Infant birth weight, kg* <4 85 (66.9) 504 (73.7) >4 42 (33.1) 180 (26.3) incontinence if she replied positively to the question Do you accidentally lose stool from the rectum, occurring once a month or more frequently?. The potential risk factors for UI were defined as age, smoking, systemic diseases (diabetes mellitus, chronic lung diseases and UTI), constipation (defined as fewer than three bowel movements per week), and obstetric causes (number of pregnancies and deliveries, previous Caesarean or vaginal delivery, duration of delivery >10 h, and giving birth to a large baby, i.e. >4 kg). Women with neurological diseases were excluded from the study, to eliminate neurological causes of UI. Enuresis in childhood was defined as TABLE 1 Potential risk factors for urinary incontinence (UI) *statistically significant differences between groups with and with no UI. bedwetting after the age of 5 years; the frequency was evaluated as daily, once a week, more than once a week, once a month, and less than once a month. At least one episode of bedwetting during the previous 4 weeks was considered to be NE. To evaluate the risk factors for UI, two populations were defined, i.e. women with or with no UI. The women were assessed in different age groups (18 45, and >65 years) to represent reproductive age, menopause and late menopause groups. The questionnaire was validated in three stages; in the first the content validity was established by submitting the questionnaire to four gynaecologists with a special interest in incontinence. They were asked to critically evaluate the questionnaire for specificity and sensitivity of the questions. Alterations to the questions suggested by these experts were incorporated. In the second stage, before generally distributing the questionnaire, its readability was tested by five randomly selected women who completed it, after which they interviewed about their perception of each question. In the third stage, 3 months after completing the questionnaire, 30 previous responders were asked to complete a second identical questionnaire, and the answers were compared both within women and between groups, to evaluate the short-term reproducibility. The results were assessed statistically using routine statistics (mean, SD), and the chisquare test used to compare groups. A logistic regression analysis was used to identify significant variables of enuresis in childhood and for UI. Differences were considered significant at P < The k reliability test was used to analyse the agreement between the answers when validating the questionnaire. RESULTS The reproducibility of the questionnaire was good (k = 0.8) when comparing the answers to the first and second questionnaire responses. The mean (SD, range) age of the patients was (10.62, 18 69) years. The overall prevalence of UI in the 1021 women was 15.9% (162); 48.7% (79), 30.9% (50) and 20.4% (33) women self-reporting UI were classified as having stress, urge or mixed UI, respectively. The potential risk factors for UI are presented in Table 1. Of these 1021 women, 229 (22.4%) had a history of NE in childhood; in these 229 the frequency of childhood NE in 28 (12.2%) was daily, in 33 (14.4%) once a week, in 21(9.2%) more than once a week, in 51(22.3%) once a month and in 96 (41.9%) less than once a month. The mean age when the NE in childhood resolved was 9.33 (2.39, 6 16) years. The rates of childhood NE in the subgroups of UI are shown in Table 2. There was a significant difference between the women with a history of childhood NE and those without in the distribution of types of UI (P < 0.05). A history of NE in childhood was encountered in 181 (21.1%) of the women 2005 BJU INTERNATIONAL 1 059

3 GURBUZ ET AL. with no UI and in 48 (29.6%) of the women with UI. The difference in the history of childhood NE in women with and with no UI was significant (P < 0.05). The highest prevalence of childhood NE was in women with stress UI, and they had significantly higher rates (35.4%) than women with no UI (21.1%; P = 0.003). However, there were no such differences between women with no UI and those with either urge or mixed UI, respectively, regarding NE in childhood (P < 0.05 for both). The question about NE in adulthood was completed by 1019 patients, of whom 982 (96.4%) reported none, 22 (2.1%) reported sometimes and 15 (1.5%) reported always. Among patients with a history of enuresis in childhood, 218 (95.2%) reported no NE, five (2.2%) reported it sometimes and six (2.6%) always. There were no significant differences between women with a history of childhood NE and those without for NE in adult life. The question about fecal incontinence was completed by 1017 patients; fecal incontinence was significantly more common in women with a history of NE in childhood (P < 0.05; Table 2). There was no significant difference in age distribution between women with and with no such history (P = 0.081; Table 3), nor in women with various types of UI (P = 0.35; Table 3), nor within those women with a history of NE in childhood and in subgroups of UI (P = 0.49; Table 3). In the logistic regression analysis to identify the independent variables related to NE in childhood, the only significant factor was the presence of stress UI (P = 0.001). In the logistic regression for the independent variables in the group with UI, the remaining significant factors were gravidity, parity (both P = 0.001), duration of delivery (P = 0.018), presence of NE (P < 0.001), constipation (P = 0.038) and history of NE in childhood (P = 0.007). DISCUSSION The relationship between childhood NE and UI has been investigated in a few studies; Yarnell et al. [12] reported an increased relative risk of having UI in women with a history of NE after the ages of 5 and 9 years, in a study including 990 women. Kuh et al. [15] reported that women who had a history of NE at the age of 6 years, in the daytime or several nights per week, were more likely to have severe UI and urge symptoms. Foldspang et al. [14] reported NE in childhood TABLE 2 Condition Present Absent Total The association of a history UI 181 (79.0) 678 (85.6) 859 (84.1)* of NE in childhood with the Stress UI 28 (12.2) 51 (6.4) 79 (7.8) other types of incontinence Urge UI 11 (4.9) 39 (5.0) 50 (4.9) Mixed UI 9 (3.9) 24 (3.0) 33 (3.2) Fecal incontinence Yes 13 (5.7) 19 (2.4) 32 (3.1) No 216 (94.3) 769 (97.6) 985 (96.9)* *P < Group Age distribution, years n (%) >65 P NE in childhood Present 186 (81.2) 43 (18.8) Absent 587 (74.1) 194 (24.5) 11 (1.4) UI Stress 49 (62) 28 (35.4) 2 (2.6) Urge 32 (64) 18 (36) Mixed 15 (45.4) 17 (51.6) 1 (3) NE and UI 0.49 stress 20 (58.8) 8 (57.1) urge 7 (20.6) 4 (28.6) mixed 7 (20.6) 2 (14.3) Total an association between childhood NE and urge UI, and adult NE. Moore et al. [13] reported an association with childhood NE and idiopathic detrusor instability, and with adult NE. In the present study, there was also an association between NE in childhood and UI in adult life. In several studies, using clinical examination as a reference, it was reported that questionnaire-based information on UI was reliable [4,18]. The reliability of the information on childhood NE depends on social norms, and the memory of responders is expected to be attenuated by ageing in older patients. Despite these limitations, the incidence of childhood NE in the present study did not seem to be affected by these factors, because the rate of NE in childhood was similar to prevalence reported in many studies [1 3]. The rate of NE in childhood in the present patients was 22.4%, similar to that in many other studies [1 3,19 21]. Also, when the incidence of NE was analysed according to age groups, the distribution was not significantly different. Therefore, the memory impairment associated with age did not seem to affect the data for NE in childhood. The overall incidence of NE is reportedly 8 28% in most studies [2,3,19 21] but in these studies the prevalence of TABLE 3 The age distribution of the patients with a history of NE in childhood, in the subgroups with UI, and in subgroups of UI with a concomitant history of NE in childhood childhood NE was investigated in an age range of, e.g years. Thus, the overall prevalence decreases as the incidence of NE decreases with increasing age. However, the present rate of NE in childhood reflects all women who had had NE in their childhood, and therefore did not indicate a prevalence in a specific age group. Therefore, the rate is very similar to those reported in the youngest groups in other studies [2,3,19]. In the present study, NE in childhood was strongly associated with stress UI; there was no similar association with either with urge or with mixed UI. A history of NE in childhood was an independent variable for female UI. In addition, stress UI was an independent variable for NE in childhood. Of the women who had NE in childhood, 12.2% had stress UI, but of those who had no such history, 6.4% had stress UI. Another notable point is that NE in childhood was also associated with fecal incontinence. According to a Medline review of English publications, the present study is the first to report an association of NE in childhood with fecal incontinence; contrary to the study of Foldspang et al. [14], we found no association between NE in adult life and NE in childhood BJU INTERNATIONAL

4 ENURESIS AND URINARY AND FECAL INCONTINENCE In the normal adult, urinary control can be subdivided into bladder filling, urine storage and voiding phases. The bladder and urethra are the most important structures for proper storage and emptying. Other important components include pelvic floor musculature, ligaments and neural control. Both anatomical and neurological factors contribute to UI. There is a correlation between bladder filling and urine storage reflexes. Stretch receptors from the bladder relay information about bladder fullness to the pontine continence centre, the peri-aquaductal grey matter, and the right anterior cingulate cortex, known to be active during tasks requiring attention. Simultaneously, sympathetic efferent activity is increased, promoting increased bladder compliance; parasympathetic activity is inhibited, and fibres projecting from the activated pontine continence centre activate Onuf s nucleus to increase the tone of the external urethral sphincter [22]. These mechanisms are lacking in the newborn. At birth, the bladder stores and then discharges rhythmically, independent of voluntary control. Voluntary control is accomplished some time during the first 5 years of life, and its development probably requires the maturation of various organ systems, the development of sufficient strength and maturity of pelvic musculature, cortical perception of proprioceptive signals of bladder fullness, cortical regulation of somatosensory pathways, and the ability to link the inhibition of voiding to voluntary contraction of external urinary sphincter [23]. With increased intraabdominal pressure, the proximal urethra can be forced to open by shearing forces that separate the anterior and posterior urethral walls, or by the unequal transmission of intraabdominal force to the bladder more than the urethra. If these forces can be resisted by the active closure of the striated sphincter (mediated by the pudendal nerve), by urethral compression against the anterior vagina bolstered by levator ani contraction, and by urethral mucosal coaptation, then continence is maintained [24]. The presence of the history of childhood NE seems to increase the risk of having UI, stress UI and fecal incontinence. This may reflect a congenital dysfunction or impairment of afferent or efferent nerve systems, a deficiency in the proprioceptive afferent signals of bladder fullness resulting in an insufficient response of the external urethral sphincter in inhibiting voiding, and an attenuated response of urethral components to increased abdominal pressure in adult life. Developmental defects in the pelvic muscles and external urethral sphincter or ligaments arising from various factors, e.g. defects or deficiencies in the collagen component, causing both delayed maturation of the levator ani-external urethral sphincter complex in early childhood and weakness and vulnerability to injury of these muscles, may also be present in these patients. Falconer et al. [25] reported that women with stress UI had a significantly lower total innervation of the paraurethral vaginal epithelium than continent controls. In that study the collagen type III content was significantly less in the specimens from patients with stress UI than from those without [26]. These findings suggested that women with stress UI had an altered collagen profile in the skin, the uterosacral and the round ligaments. This finding seemed to be unrelated to secondary damage of the supportive tissues and the degree of pelvic relaxation. In conclusion, determining the causes of both UI and fecal incontinence should help to solve these problems when originating in childhood. An awareness that women with a history of childhood NE have a higher risk of developing stress UI may provide the opportunity to avoid exposing these women to other predisposing factors for stress UI, e.g. a long labour, vacuum or forceps delivery, delivering vaginally, and delivering an infant of >4 kg. CONFLICT OF INTEREST None declared. REFERENCES 1 Bryd RS, Weitzman M, Lanphear NE, Auinger P. Bedwetting in US children. 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