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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 157-163

Prevalence of enuresis among children and adolescents: A systematic review and meta-analysis


1 Department of Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Surgery, Federal Medical Centre, Nguru, Yobe State, Nigeria
3 Department of Surgery, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
4 Division of Urology, Department of Surgery, Ahmadu Bello University, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
5 Infectious and Tropical Diseases Unit, Department of Internal Medicine, Public Health and Diagnostic Institute, College of Medical Sciences, Northwest University, Kano State, Nigeria

Date of Submission21-Jul-2018
Date of Acceptance08-Jul-2019
Date of Web Publication29-Nov-2019

Correspondence Address:
Dr. Abubakar Abdulkadir
Department of Surgery, Bayero University, Aminu Kano Teaching Hospital, PMB 3452, Kano, Kano State
Nigeria
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DOI: 10.4103/smj.smj_41_18

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  Abstract 


Background: Enuresis is a common dilemma among minors, which is under-documented and under-disclosed. The plight has a negative effect on the quality of life, with an adverse bearing on social and academic development. The recognition of its strains on the family added to the aforementioned necessitated the designation of every last Tuesday of May as annual bedwetting day to create complacent personality among subjects faced with this challenge. Enuresis has worldwide distribution; however, the national prevalence of enuresis is unknown in Nigeria. Objective: The aim of our review is to determine the prevailing prevalence of juvenile enuresis in the country and its regions. Materials and Methods: We used electronic databases to explore reviews and select studies, and then extracted necessary data from the appraisals on prevalence and incidence of enuresis among children and adolescents from Nigerian communities. STATA 12 random effect meta-analysis of observational studies was used to compute the pooled prevalence and other estimates. Results: Twenty-four studies fall within the inclusion criteria. The combined pooled population studied was 15,172 (n = 3567 children and adolescents). The pooled prevalence of enuresis was 28.19% (22.37%–34.00%) (95% confidence interval). Conclusion: This study showed that enuresis is hyperendemic among Nigerian children and adolescents.

Keywords: Enuresis, Nigeria, prevalence


How to cite this article:
Abdulkadir A, Abubakar BM, Tela UM, Ahmed M, Bello A, Ahmad MY. Prevalence of enuresis among children and adolescents: A systematic review and meta-analysis. Sahel Med J 2019;22:157-63

How to cite this URL:
Abdulkadir A, Abubakar BM, Tela UM, Ahmed M, Bello A, Ahmad MY. Prevalence of enuresis among children and adolescents: A systematic review and meta-analysis. Sahel Med J [serial online] 2019 [cited 2019 Dec 7];22:157-63. Available from: http://www.smjonline.org/text.asp?2019/22/4/157/272141




  Introduction Top


Enuresis or bedwetting was specified by the International Children's Continence Society as the situation of urinary incontinence in the course of sleep.[1] Despite under-disclosure and under-documentation, western studies report a prevalence ranging between 5% and 10% among the 5–7 years old; this persists to adulthood in 1% of patients.[1],[2] Enuresis can be monosymptomatic enuresis (MSE) or nonmonosymptomatic; MSE can further be divided into primary or secondary.[3] The strain on the family and parental disapprobation from enuresis may lead to juvenile prejudice plus abuse, which may compound the negative impact on the quality of life of these subjects.[4] The recognition of its sober bearing on the juvenile self-appreciation, innate well-being, and day-to-day effectiveness with an unfavorable impact on subject's academic and social accomplishment necessitated an annual dedication of last Tuesday of May as the world bedwetting day.[5] The essence of the day as projected by the inscription “time to take action” was to inspire all stakeholders, particularly the parents and the caregivers, to see the obligation of doing more in the creation of complacent personality in bedwetting juveniles.

Worldwide, urological and other support bodies have committed time and resources in raising awareness of the pathophysiology and treatment of enuresis. These efforts included those by the International Children's Continence Society plus the bedwetting resource center and the South African guidelines on enuresis among many others.[1],[5],[6],[7] Supplementary to these, there are assorted appraisals on this unpleasant predicament affecting many Nigerian children and adolescents. It is, however, difficult to objectively affirm its epidemiological extent among Nigeria juveniles since the current national prevalence is unknown. For this reason, the aim of our review is to duly determine the prevailing prevalence of juvenile enuresis in the country, including the prevalence in its regions and subregions.


  Materials and Methods Top


We put into use the protocols of systematic review and Meta-analysis Of Observational Studies in Epidemiology for this appraisal.[8] We explored entire appraisals on the incidence and prevalence of enuresis among children and adolescents in Nigeria from the databases; these included African Journal Online, PubMed, Google Scholar, Scopus, and Institute for Scientific Information from 1997 to 2017. We concluded the search on March 25, 2018. To explore for other pieces presumably missed, we surveyed nonindexed Nigerian publications and also communicated with the specialist in the discipline. The keywords for the data search were “prevalence” or “incidence,” “Enuresis” or “bedwetting,” “children or adolescents,” “Nigeria,” or “Africa” (and the subregions with the states were crossed with Nigeria in the search). We minimize the chances of bias by reviewers independently exploring reviews and consolidating singled out studies adopted in the conclusive summary of added articles. The references of the retrieved appraisals were reexamined for more suitable studies. The inclusion criteria comprised analysis in Nigeria, appraisal design been cross-sectional or cohort, and enuresis established in the patients; appraisals were added if published in English between 1997 and 2017. Only children and adolescents' appraisals were pooled. The exclusion criterion was pieces with wordings other than English. Age group grouping was effected as follows; children were those of 12 years of age and less while adolescent aged 13–17 years. The survey quality was evaluated by 10-point modified Downs and Black checklist scoring system.[9] In the next phase, compiled pieces were summarized and integrated for the meta-analysis. The principal outcome estimated was the prevalence of enuresis among Nigerian children and adolescents. The standard error of prevalence was calculated by utilizing binomial probability distribution. Between-study heterogeneity was estimated by applying the Cochran test and I2 test. The level of significance for Cochran test was prescribed as 0.05. I2 values in the vicinity of 25% indicate low heterogeneity, nearly 50% measures mean moderate heterogeneity, and those above 75% hints at high heterogeneity. Random effect model, Der Simonian–Laird version was applied for the estimation of pooled tally by computing the pooled estimation and confidence intervals (CIs) established on the weighted least square (weighting is produced by the reciprocal sum of between and within appraisal variances).[10] Publication bias was assessed by the Begg's funnel plot and Egger's test. All analyses were effected using STATA software (version 12) StataCorp. 2011. Stata Statistical Software, College Station, TX: StataCorp LP.


  Results Top


Our survey generated 178 studies initially. Subsequent to screening and assessment for eligibility, at the end, 23 cross-sectional plus a cohort piece were enrolled and used for the ultimate analysis as displayed in the flow diagram of the pooled studies for the analysis [Figure 1]; the table of summaries of the included studies are presented in [Table 1].[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34] The combined population studied was 15,172 (n = 3567 children and adolescents).
Figure 1: Flow diagram of the studies reviewed

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Table 1: Characteristic of the studies included in the meta-analysis on the prevalence of enuresis among Nigerian children and adolescents during 1997-2017

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Overall prevalence

The prevalence of enuresis among Nigerian children and adolescents in sections of Nigeria as shown in the forest plots differs from 2.29% to 69.35% among the pooled appraisals [Figure 2]. The pooled prevalence estimate for Nigerian children and adolescents was 28.19% (95% CI: 22.37% and 34.00%, respectively). There was a high difference in appraisal outcomes amid studies (heterogeneity: I2 = 95.7%; P < 0.001).
Figure 2: Forest plot studies included from parts of Nigeria

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Subgroup analyses

The stratified sequence showed differences in the prevalence of enuresis among the subgroups. By the age of the participants, the prevalence was highest in children with 30%, followed by an amalgam of children and adolescents with 25.3%; the least in prevalence being adolescents at 15.8%. Enuresis prevalence was highest in the reviews from urban settings (32%), compared to the rural (20%). There were more studies (19 appraisals equivalent to 79%) in the southern region and the prevalence highest with 28.2%–32.8%. There was no review from Northeastern Nigeria while northcentral region has a single (4%). There was no statistically significant difference between primary and secondary plus nocturnal over diurnal enuresis. Further detail on subgroup analysis is as depicted in [Table 2].
Table 2: Estimated prevalence of enuresis by the age of the participants, settings, subregions in the country, timing and as either primary or secondary

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Meta-regression analysis displayed a decreasing prevalence of enuresis with increasing sample size that was not significant (slope coefficient = −0.01, P = 0.067) [Figure 3]. Although there was an increasing prevalence of enuresis with increasing year of study publication, this was also not statistically significant (slope coefficient = 0.67, P = 0.36). There was no publication bias with Egger's and Begg's test (Begg's P = 0.535 and Egger's P = 0.830). This was portrayed graphically by the excellent symmetry in the plots [Figure 4] and [Figure 6].
Figure 3: Meta-regression analysis showing decreasing prevalence of enuresis with increasing sample size (slope coefficient = −0.01,P = 0.067)

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Figure 4: Meta-regression analysis showing increasing prevalence of enuresis with increasing year of study publication (slope coefficient = 0.67,P = 0.36)

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Figure 5: Begg's funnel plot of the studies on the prevalence of enuresis among Nigerian children and adolescence 1997–2017

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Figure 6: Egger's publication bias plot of the studies on the prevalence of enuresis among Nigerian children and adolescence 1997–2017

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  Discussion Top


This study was conducted on the appraisals among Nigerian children and adolescents that embodied more than 55 million persons (age category 5–18 years)[35] in a country with a land mass of 923,769 km2.[36] Collation and analysis of data directly from this population would be gigantic pursuit in face of limited resources.[37] A recognized replacement against this background is the statistical pooling of all suitable studies on enuresis from this population.[38] This yielded a prevalence of 28.19% [Figure 2]; this was consistent with 26.3% prevalence of nocturnal enuresis reported in the Demographic Republic of Congo.[39] The prevalence was, however, much higher than 9.52% recorded by Sarici in Turkey and higher than 5%–10% in western countries by the International Children's Continence Society and 16.0% in South Africa.[1],[2],[40] The pooled studies in our review were the accessible appraisals mostly from “selected population” of different institutional settings; some of which gave an astonishingly high prevalence.[12],[16],[17],[18],[33] The studies differences added to the significantly high heterogeneity in the forest plot and the high pooled prevalence. All the subjects in the study form a significant segment of our populace and cannot be denied treatment for enuresis, and hence, none was excluded in our count.

Almost 80% of the studies were from the southern part of the country. This region showed a significantly higher prevalence of 28.2%–32.8%. This concurred with the surpassed educational eminence and better socioeconomic attainment, which often parallel a better health-seeking behavior and less of underreporting and stigmatizations.[41] An identical inference seemingly explains the higher prevalence in urban settings. Unfortunately, no study fits into our inclusion from the most resource and educational deprived northeastern part of the country where insurgency had been rife until recent. The same deduction explained a single study from the northcentral region that is second to the northeast in deprivations and uprisings. The single study from northcentral zone reported the least prevalence amid the pooled subregional studies. The study showed a dominance of nocturnal over diurnal likewise primary over secondary enuresis, which concurred with findings in the literature.[40] Meta-regression analysis showed a decreasing prevalence of enuresis with increasing sample size, this was trending toward statistical significance, and the implied community-based appraisal with a greater population size will likely produce prevalence likely different and perhaps lower than inferred in this study. In addition, inequality in the sample size likely subscribes to high heterogeneity. The meta-regression supported increasing prevalence with increasing awareness as communities developed lead to less under-reporting and the under-documentation of enuresis. The Egger's plot and Begg's test show no significant publication bias in the pooled studies.

The limitations of our appraisal owed to inherent bias in the primary studies and diversities in study designs plus parameters.[42] The “file-drawer effects”[43] is a possibility; besides, chances of the clustered higher prevalence of enuresis amid a selected institutionalized population in the primary reviews could raise the overall prevalence. The study was a pool of 20-year reviews that brought together diversified investigators that utilized varied definitions, information gathering modes, and interpretations. However, in spite of these constraints, this appraisal reliably added up the prevalence of enuresis among Nigerian children and adolescence in 20 years. This high prevalence strengthens the necessity for a national treatment protocol and support for these subjects. The precision of our inferred estimations is upheld by the insignificant publication bias (Egger's P = 0.830 and Begg's P = 0.585) as illustrated in the plots [Figure 5] and [Figure 6].


  Conclusion Top


This study showed that enuresis is hyperendemic among the Nigerian children and adolescents. This has implications for their academic and social accomplishment. Nigerian health caregivers and other stakeholders must, therefore, perpetually promote “time to take action” on enuresis as advanced by the enuresis day. The study stressed clamor for further capacity building to meet resultant negating impact on the quality of life and sarcastic self-appreciation. The importance of these to favorable academic and social accomplishment to the population cannot be overemphasized.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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