Complete resolution of urinary incontinence with treatment improved the health-related quality of life of children with functional daytime urinary incontinence: a prospective study.

BACKGROUND: To assess the health-related quality of life (HRQOL) of children with daytime urinary incontinence (DUI) based on pre- and post-treatment self-reports and parent proxy-reports. METHODS: The study population comprised 117 children with at least one episode of DUI per week and their caregivers as well as 999 healthy children (control group). The Pediatric Quality of Life Inventory 4.0 (PedsQL) questionnaire was administered to assess the HRQOL of children. To assess the degree of improvement in HRQOL, we categorized children into two groups: group A achieved complete response (CR) to treatment within 12 months and group B did not achieve CR within 12 months. CR was defined as the complete resolution of symptoms or alleviation of symptoms to < 1 DUI episode/month. RESULTS: Valid responses were collected from 84 children [53 boys and 31 girls; mean age: 7.9 ± 1.5 years (range, 6-12)]. Sixty-two patients (73.8%) were classified into group A and 22 (26.1%) into group B. Based on self-reports, significant post-treatment improvement was observed in the scores of all PedsQL items (mean total score: 82.2 ± 11.3 vs. 87.2 ± 9.8; P = 0.003). Group A showed significant improvement in the scores of all PedsQL items after achievement of CR based on child self-reports; however, this was improvement not observed in group B. CONCLUSIONS: To the best of our knowledge, this is the first study to demonstrate the complete resolution of DUI with treatment for improving the HRQOL of these children.

Incontinence and headache in preschool children.

AIMS: Headaches in preschool children are associated with behavioral and gastrointestinal symptoms. As the co-occurrence with incontinence is not known in young children, the aim of the study was to examine associations of headache, psychological symptoms and nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI) in a population-based sample of preschool children. METHODS: All preschool children of a defined geographical area were examined at school-entry. Parents completed a 22-item questionnaire, including 14 headache, 4 incontinence, and 25 items of the Strength and Difficulties Questionnaire (SDQ). Five hundred eighty-five children (50.4% males) with a mean age of 5.8 years were included. RESULTS: In total, 27.2% of all children had headaches. 15.7% had secondary and 11.3% primary headaches. Five children had migraine and five tension-type headaches, while all others were unclassifiable. 9.4% of children had incontinence (7.7% NE; 2.4% DUI, 1.2% FI) and 4.0% constipation. The rates of incontinence did not differ between children with primary and those without headache for NE (12.9% vs 7.5%), DUI (3.1% vs 2.7%) or FI (3.0% vs 1.0%), but for constipation (12.1% vs 2.6%). Incontinent children had significantly more behavioral and externalizing symptoms, children with headache more internalizing problems. Primary headache was a significant predictor for internalizing, while constipation and FI were predictors for externalizing symptoms. CONCLUSIONS: This population-based study showed that headache is associated with constipation, but not with incontinence in preschool children. Headache and incontinence are common risk factors for specific psychological symptoms and should be assessed in clinical practice.

Does a serious game increase intrinsic motivation in children receiving urotherapy?

INTRODUCTION: Urotherapy is considered the treatment of choice for children suffering daytime urinary incontinence (DUI). Urotherapy intends to improve bladder dysfunction for children with DUI. For children with refractory DUI, an intensive inpatient bladder training program exists, which focuses on relearning, concentration on, and awareness of the bladder. Children's motivation and adherence are key determinants of a successful training outcome. It is hypothesized that motivation endurance throughout the treatment process may be enhanced by a serious game training tool, which could make the training more appealing and rewarding. OBJECTIVE: The study explores intrinsic motivation in children receiving bladder training for DUI and whether using a serious game improves their intrinsic motivation. STUDY DESIGN: In this pragmatic study, 50 children were allowed to choose among receiving bladder training with (intervention group) or without the application of a serious game (control group). At 4, 8, and 12 weeks of training, children and parents were asked to complete the Intrinsic Motivation Inventory (IMI). Children also completed the Pediatric Urinary Incontinence Quality of Life Tool (PinQ) before the start of the training and 6 months thereafter. At 6-month follow-up, patients were ask to participate in two focus groups, wherein the children discussed how they used the serious game and which improvements they would prefer. RESULTS: Children who received standard bladder training with the addition of a serious game did not differ in terms of intrinsic motivation from children who underwent standard bladder training only. Training results were equal in both the groups, with 80% good or improved. Incontinence-related quality of life (QoL) improved accordingly. DISCUSSION: In contrast to the study expectations, this game did not increase intrinsic motivation. Findings on training and QoL results are consistent with those of previous studies in both interventions. Although a randomized design could have yielded more valid results than this preference-based approach, the latter is more congruent with clinical practice. In contrast to existing bladder diary apps, this game offers a combination of child-friendly instructions, explanation of bladder (dys)function, and keeping a bladder diary. Mobile devices are playing an increasingly important role in health care; therefore, an urotherapy app can be a complementary therapeutic tool. CONCLUSION: Most children find it attractive to combine bladder training with a serious game. However, no added value was found regarding intrinsic motivation and training results. All children with persistent DUI in this cohort were highly motivated to complete an intensive bladder training program.

The Prevalence of Diurnal Urinary Incontinence and Enuresis and Quality of Life: Sample of School.

PURPOSE: Enuresis can cause loss of self-esteem in children, change relations with family and friends, and decrease the school success. This study was conducted to determine the prevalence of urinary incontinence (UI) in school children aged between 11-14 years and identify the emotions and social problems of enuretic children. MATERIALS AND METHODS: A mixed methods approach was used on a group of students who reported UI by combining quantitative data from school population-based cross-sectional design with qualitative data using in-depth interview techniques. The data of this descriptive and cross-sectional study were collected from 2750 primary school students aged between 11-14 years in Istanbul. RESULTS: The overall prevalence of UI was 8.6% and decreased with age. Prevalence of the diurnal enuresis in children was 67.9% and all of them had non-monosymptomatic enuresis. 83.3% of the children were identifiedwith secondary enuresis for 1-3 years. UI was significantly more common in boys and those who had frequent urinary infections, whose first degree relatives had urinary incontinence problem in childhood, and who reportedlow socioeconomic level in the family. The emotional and social effects of urinary incontinence were given in the context of children's own expressions. CONCLUSION: Urinary incontinence is an important problem of school-age children. In this study the prevalence of UI was found to be 8.6%, diurnal UI and secondary enuresis were very common, and all of the children werenon-monosymptomatic. Enuresis has negative emotional and social effects on children.

EEG Measurement of Emotion Processing in Children with Daytime Urinary Incontinence.

OBJECTIVE: Daytime urinary incontinence (DUI) is common in childhood. The aim of the study was to neurophysiologically analyse the central emotion processing in children with DUI. METHOD: In 20 children with DUI (mean age 8.1 years, 55 % male) and 20 controls (mean age 9.1 years, 75 % male) visual event-related potentials (ERPs) were recorded after presenting emotionally valent (80 neutral, 40 positive, and 40 negative) pictures from the International Affective Picture System (IAPS) as an oddball-paradigm. All children received a full organic and psychiatric assessment. RESULTS: Children with DUI did not differ significantly from controls regarding responses to emotional pictures in the frontal, central, and parietal regions and in the time intervals 250-450 ms, 450-650 ms, and 650-850 ms after stimulus onset. The patient group had more psychological symptoms and psychiatric comorbidities than the control group. CONCLUSIONS: EEG responses to emotional stimuli are not altered in children with DUI. Central emotion processing does not play a major role in DUI. Further research, including a larger sample size, a more homogeneous patient group (regarding subtype of DUI) or brain imaging techniques, could reveal more about the central processing in DUI.

Voiding school as a treatment of daytime incontinence or enuresis: Children's experiences of the intervention.

BACKGROUND: Daytime incontinence and enuresis are common problems in otherwise healthy children, and negatively influence their social lives and self-esteem. Motivation for treatment is often a real clinical problem. Children's experiences of their incontinence treatments have not been previously described. OBJECTIVE: The aim of this study was to describe children's experiences of the Voiding School intervention as a treatment for their incontinence. STUDY DESIGN: A qualitative, descriptive focus-group study with a purposive sample was conducted at a Finish university hospital in 2014. Children aged 6-12 years participated in the Voiding School at an outpatient clinic. The intervention included two 1-day group visits 2 months apart. The educational content was based on the International Children Continence Society's standards for urotherapy. The education was delivered with child-oriented teaching methods. At the end of the second visit, 19 children were interviewed in five groups. Data were analysed with inductive content analysis. RESULTS: The children described incontinence as an embarrassing problem, which they had to hide at any cost. They had experienced bullying and social isolation because of it. Normal outpatient visits emphasized adult-to-adult communication, which made the children feel like outsiders. The children perceived the Voiding School as a nice and child-oriented experience. Making new friends was especially important to younger boys who felt that the Voiding School day was too long and issue-oriented. In the Voiding School, videos and 'learning by doing' helped the children to understand the basis of given advice, and they were able to learn new habits, which gave them control over the incontinence; this helped them to become 'the boss of the bladder'. Sharing experiences and improvements in their incontinence with their peers supported the children's self-esteem and encouraged them to do new things, such as staying overnight with friends. These experiences helped them to acquire control over the problem (Summary Figure). DISCUSSION: According to the children's experiences, normal outpatient visits were only appointments for adults, and not very useful for children. In the Voiding School, they were respected as being the main person, and their views were listened to. The results underlined the importance of a child-oriented approach to patient education with regard to children, and provided encouragement to further develop the intervention. CONCLUSION: Child orientation, peer support, learning by doing, and understanding the cause and effect helped children to gain control over their bladders. Based on the children's experiences, this could be achieved by a voiding school.

Effects of urinary incontinence on psychosocial outcomes in adolescence.

To examine whether daytime wetting and bedwetting urinary incontinence (UI) in childhood and adolescence are associated with psychosocial problems in adolescence. We used data from the Avon Longitudinal Study of Parents and Children to examine the association between trajectories of UI from 4 to 9 years and self-reported psychosocial problems in adolescence (13-14 years) including depressive symptoms, peer victimisation, poor self-image and school experiences (negative perception of school and teachers, problems with peer relationships). Sample sizes ranged from 5162 (perception of teachers) to 5887 (self-image). We also examined associations between self-reported UI at 14 years and psychosocial problems. Relative to normative development, adolescents who experienced delayed development of bladder control had poorer self-image [standardised mean difference = 0.18 (95% CI 0.04, 0.32)], more negative perceptions of school [0.18 (0.02, 0.34)] and more problems with peer relationships at school [0.25 (0.10, 0.40)]. Persistent wetting (bedwetting with daytime wetting) in childhood was associated with increased problems with peer relationships in adolescence [0.19 (0.03, 0.34)]. The strongest associations between adolescent UI and psychosocial problems were found for daytime wetting (reference = no UI at 14 years): depressive symptoms [OR = 3.04 (95% CI 1.91-4.84)], peer victimisation [2.14 (1.48-3.10)], poor self-image (t = -8.49, p < 0.001) and problems with peer relationships (t = -4.69, p < 0.001). Children with delayed development of bladder control and persistent wetting have increased psychosocial problems in adolescence. Adolescents with UI reported a range of psychosocial problems and clinicians should be aware that they might require support from psychological services.

Incontinence and psychological problems in children: a common central nervous pathway?

Nocturnal enuresis is caused by a mismatch between the nocturnal bladder capacity and the nocturnal diuresis rate, in the presence of a deficient arousability in the majority of patients, according to the pediatric and urologic literature. Psychiatric and psychologic literature are still concentrating on the potential role of psychological factors and central nervous mechanisms in the pathogenesis, as is reflected in the DMS-5 criteria. However, research has clearly shown several important comorbidities between neuropsychological dysfunctions and nocturnal enuresis. Due to the increased comorbidity of (neuro)psychological problems, sleep problems, circadian rhythms, and enuresis, the question arises as to whether there is a possible common central pathway in the pathogenesis. It is likely that the coexistence of these problems can be attributed to a common central nervous system involvement. The specific role of the central nervous system remains unclear, but several pathways are possible. The high comorbidity between enuresis, sleep, and (neuro)psychological functioning is probably attributable to a common pathogenetic pathway, emphasizing the importance of a multidisciplinary focus in screening and treatment in children with nocturnal enuresis.

Urinary incontinence in spina bifida: Initial instrument validation.

The purpose of this study was to perform a psychometric assessment of the Incontinence Symptom Index-Pediatric (ISI-P) in a cohort of adolescents with spina bifida (SB) and neuropathic urinary incontinence (UI) to test its validity and reliability. The ISI-P, an 11-item instrument with domains for symptom severity and impairment, was self-administered by subjects 11-17 years old with SB and UI. Controls were 11-17 years old, with nephrolithiasis and no history of UI. Formal psychometric assessment included an evaluation of internal consistency, test re-test reliability and factor analysis. Of 78 study-eligible subjects we attempted to contact, 33 (66.7% female) with a median age of 13.1 years completed the ISI-P (42.3% response rate). 21 control patients also completed the ISI-P. Cronbach's alpha was 0.936 and 0.792 for the severity and bother factors respectively. The delta Chi-square test for the two-factor (vs. one-factor) model was significantly [χ(2)(89) = 107.823, p < 0.05] in favor of the former model with descriptive fit indices being excellent (e.g., comparative fit index = 0.969). Furthermore, category information analysis showed that all categories were associated with different threshold values, namely that each category contributed unique information for the measurement of the latent trait. In conclusion, the ISI-P has desirable psychometric properties for the measurement of UI symptom severity and impairment in adolescents with SB.

Incontinence and parent-reported oppositional defiant disorder symptoms in young children--a population-based study.

BACKGROUND: Oppositional defiant disorder (ODD) and incontinence are common disorders of childhood. We have examined associations between ODD symptoms and incontinence in a representative sample of young children. METHODS: A questionnaire with seven questions referring to incontinence, eight DSM-IV items of ODD, 15 items of the Home Situations Questionnaire and six items regarding eating, drinking or toileting refusal was administered to the parents of 718 children at school-entry from a defined geographical area at school-entry. RESULTS: Of the 718 6-year-old children included in the analysis, 8.2% had nocturnal enuresis (NE), 1.5% had daytime urinary incontinence (DUI) and 1.1% had faecal incontinence (FI). Significantly more boys than girls had NE (12 vs. 4.3%). Overall, 6.7% of children had ODD symptoms. Rates of ODD symptoms were significantly higher in incontinent children (19.5%) than in continent children (5.2%), with the highest rate of ODD symptoms in children with DUI (36.4%). Children with incontinence (mean 6.1 episodes) or ODD symptoms (mean 8.4 episodes) showed non-compliant behaviours in more problem situations than continent children (mean 4.5 episodes) or children without ODD symptoms (mean 4.5 episodes). CONCLUSIONS: Incontinence and ODD are common comorbid disorders at school-entry age. Boys are more affected by both disorders. Children with DUI have the highest rate of ODD symptoms. As ODD symptoms affect many daily family situations, ODD needs to be diagnosed and treated in children with incontinence, as it can negatively affect compliance.

[Enuresis]. / Enuresis.

Enuresis in childhood and adolescence is a common symptom that significantly affects the quality of life of the patients and their social environment. Advanced diagnostic and therapeutic measures have significantly improved the treatment of affected children in the last 10 years in Germany. With the help of an often sufficient non-invasive diagnostic assessment it is possible to assign the symptom to a diagnostic category. This category forms the basis for a successful therapy. A high level of motivation and willingness to cooperate of the children and their families are therapeutic premises. In present-day treatment of functional urinary incontinence urotherapy has the highest priority.

Health-related quality of life and treatment effects on children with functional incontinence, and their parents.

OBJECTIVE: To analyze treatment outcomes and the association between treatment effects and health-related quality of life (HRQoL) for incontinent children, and their parents. SUBJECTS AND METHODS: Health-related quality of life in 70 consecutively treated children, and their parents, was assessed with the Pediatric Incontinence Questionnaire and the WHO-Quality-Of-Life-BREF questionnaire. This was assessed before and after three months of standardized treatment. RESULTS: In 44.3% of children, symptoms decreased by 50-89%. After three months of treatment, the HRQoL of children improved significantly. Children with bladder and bowel dysfunction had a significantly lower HRQoL than children with isolated nocturnal enuresis, daytime urinary incontinence or fecal incontinence. Parental HRQoL did not change significantly within three months of treatment. Parents showed a significantly lower mean in the 'psychological' domain of the WHO-QoL-BREF questionnaire compared to norms. CONCLUSION: Children with different subtypes of incontinence can be treated effectively within three months of therapy. After three months, significant improvements of HRQoL were shown. Parents showed no general reduction in their quality of life (QoL). Specific aspects of parental QoL were impaired, but did not improve during the treatment of their children.

Urinary incontinence and quality of life in children.

OBJECTIVE: Urinary incontinence (UI) negatively affects children's quality of life (QOL). It is not known if parents are reliable informants on impact and QOL nor if lower urinary tract symptoms (LUTS) are related to QOL. We wished to determine the association between LUTS measured by the Dysfunctional Voiding Symptom Score (DVSS) and QOL measured by the Pediatric Urinary Incontinence QOL tool (PIN-Q), and to test the relationship between parent and patient's responses. SUBJECTS AND METHOD: Forty children (10 males, 30 females), aged 5-11 years with non-neurogenic daytime wetting, and their parents completed DVSS and PIN-Q as well as responding to open-ended questions about the effect of incontinence. RESULTS: Child DVSS: mean 12.6 (3 (very mild) to 21 (severe)); parent DVSS: mean 12.8 (3-20). Child PIN-Q: mean 37.6 (8 (no effect) to 70 (severe effect)); parent PIN-Q: mean 38.7 (15-61). Parents indicated a major effect of UI on family function and dynamics, as well as on the child. CONCLUSIONS: UI has a major effect on the child and the family. The PIN-Q and DVSS are complementary and provide a clinically appropriate picture of LUTS and impact on QOL. Parents understood the effect of incontinence and could act as proxy for the child.

Elimination disorders in persons with Prader-Willi and Fragile-X syndromes.

AIMS: Elimination disorders are common in typically developing children. Only few studies have addressed elimination disorders in persons with intellectual disability (ID)-and even fewer studies in those with specific syndromes. The aim of the study was to investigate the rates of elimination disorders and behavioral symptoms in persons with Prader-Willi (PWS) and Fragile-X syndromes (FXS) in a large sample. METHODS: Three hundred fifty-seven persons with PWS or FXS were recruited through parent self-help groups. A questionnaire regarding elimination symptoms, as well as the child behavior checklist (CBCL)/young adult behavior checklist (YABCL) were filled out by parents or caregivers. RESULTS: The sample included 191 persons with PWS (54.5% male) with a mean age of 20.0 years and 166 persons with FXS (92.2% male) with a mean age of 15.4 years. Persons with FXS were significantly more often affected by elimination disorders. 29.3% of persons with PWS and 48.8% of persons with FXS had at least one elimination disorder. Persons with FXS also had more often DUI (29.5% vs. 12.0%) and FI (28.9% vs. 12.6%). Rates of NE were similar in both groups (22.0% in PWS vs. 28.9% in FXS). Young adults with PWS had more behavioral symptoms in the clinical range (70.8% vs. 48.3%). Incontinence and behavioral symptoms were significantly associated in persons with FXS. CONCLUSIONS: NE, DUI, and FI are very common in persons with FXS and PWS and are associated with other behavioral symptoms in persons with FXS. They persist into adulthood. Early assessment and treatment are recommended.

Does psychological stress affect LUT function in children? ICI-RS 2011.

AIMS: Psychological factors and LUTS are closely associated in children. 20-40% of children with nocturnal enuresis (NE) and 30-40% with daytime urinary incontinence (DUI) have a clinical psychiatric disorder, many more are distressed. The associations are complex and differ for each individual subtype of disorder, as both genetic and environmental factors can interact. The aim of this paper is to provide an overview and discuss possible causal associations. METHODS: Relevant studies are reviewed--preferably with population-based, representative results. RESULTS: Four basic associations are possible. Psychological symptoms and disorders can (1) be a consequence of LUTS and NE/DUI; (2) They can be induced by them; (3) Both can be due to common, shared etiological factors; and (4) They can co-occur by chance without causality. CONCLUSIONS: Due to these complex associations, a descriptive approach is endorsed. Both the subtype of NE/DUI and possible psychological symptoms and disorders need to be identified--possible causal relationships can be analyzed in a second step. Screening for psychological symptoms with parental behavioral questionnaires in all settings is recommended, as well as counselling and treatment if indicated.

Twelve-year experience with Hinman-Allen syndrome at a single center.

OBJECTIVE: To report the long-term follow-up results of patients with Hinman-Allen syndrome (HAS) at our institution. METHODS: The data from 22 children with HAS were retrospectively analyzed. The patients were followed up every 3-6 months with serial physical examinations, voiding charts, urine culture, postvoid residual urine volume determination, serum creatinine measurement, and urinary imaging. The follow-up time was calculated from the day of the first visit to the day of the latest dimercaptosuccinic acid scan. Urotherapy, pharmacotherapy, clean intermittent catheterization, biofeedback therapy, and surgery were performed sequentially and/or combined, depending on the disease course. Renal deterioration was defined as any presence of a new scar or cortical thinning compared with the findings from the first dimercaptosuccinic acid scan. Upper urinary tract deterioration was defined as the persistence or progression of hydronephrosis on ultrasonography. RESULTS: The mean age at referral was 9.18 ± 3.36 years (range 2-14), and the mean follow-up period was 80.90 ± 19.57 months (range 54-144). Conservative therapy resulted in improvement of the bladder function in 14 patients; however, 8 patients required surgery owing to failure of this approach. Asymptomatic bacteriuria developed in one half of the children (n = 11, 50%), and in 6 (22.7%), ≥1 febrile urinary tract infection developed. None of the patients had upper urinary tract deterioration; however, renal deterioration developed in 3 patients (13.6%). The mean creatinine levels had remained stable at the end of the follow-up. CONCLUSION: Close follow-up at a single institution and proactive treatment resulted in successful stabilization of HAS in most of our children with HAS.

Assessment of long-term quality of life in patients with orthotopic neobladder followed for more than 5 years.

INTRODUCTION: We analyzed the general health QOL (GH-GOL), urinary QOL, and sexual QOL in patients with orthotopic neobladder who were followed for more than 5 years. MATERIALS AND METHODS: Eighty-six (male 78, female 8) patients who underwent orthotopic neobladder and followed for more than 5 years were enrolled in this study. QOL regarding general health and urinary function were surveyed by SF-36 and ICSmaleSF, respectively. Sexual function was assessed by International Index of Erectile Function (IIEF-5). Satisfaction with urinary and sexual function was evaluated by visual analogue scale (VAS). RESULTS: On overall analysis by SF-36, 2 categories (role-physical functioning and role-emotional functioning) showed significantly lower scores, although bodily pain showed a better than average score for Japanese people of the same age. While patients who required clean intermittent catheterizaion (CIC) or had daytime incontinence presented worse scores in several categories on SF-36, the presence of enuresis did not affect SF-36 score. ICSmaleSF survey showed that voiding symptoms significantly impaired QOL in patients who required CIC and incontinence symptoms significantly impaired QOL in patients who had daytime incontinence and enuresis. With regard to sexual function, most patients (88%) had lost sexual function. On VAS, satisfaction with urinary function was 5.63, and sexual function was only 0.98. CONCLUSIONS: Although GH-QOL was generally well maintained, the presence of CIC or daytime incontinence impaired GH-QOL. Most were not satisfied with their level of sexual function 5 years after orthotopic neobladder construction.

Daytime urinary incontinence among kindergarten children in Aden Governorate, 2003.

Daytime urinary incontinence is an involuntary or intentional voiding of urine in an awake child who is old enough to have developed control, and has a variable prevalence throughout the world. In Yemen, data regarding this problem are almost absent. In this study from the capital city of Aden, we aimed to: (1) determine the prevalence of daytime incontinence in kindergarten children aged 4-6 years, (2) identify the relation between daytime enuresis with personal and family characteristics of the children studied, and (3) describe the severity and characteristics of daytime enuresis in the studied children. A cross-sectional comparative study was undertaken in all kindergarten children aged 4-6 years in Aden Governorate and 1061 responded. Data were obtained by using a precoded self-administered questionnaire completed by the parents. The questionnaire consisted of two parts: personal and family characteristics of the studied children and the presence of daytime incontinence. The second part was responded if there was history of daytime incontinence, and contained information on the severity and possible associated factors. Daytime incontinence was encountered in 34 cases (3.2%); 18 were females. Significant differences between cases and incontinence-free children were encountered in birth order and type of kindergarten (P < 0.05). Majority (85.3%) had severe form of daytime incontinence. Bed wetting and combined day and night wetting were more frequent among males, whereas urinary symptoms (urgency, squatting, dysuria, dribbling) were more frequent among females. Working mother and frightening and emotionally stressful events in the 6 months preceding the study were significantly associated with daytime incontinence, while parents' education, punishment for daytime incontinence, and the presence of family history of incontinence were insignificant. In conclusion, this is the first study from Yemen reporting the prevalence of enuresis, similar to previous reports. Further studies are needed to explore this problem in our region to end the misery of the child and the family.

[Toilet training in mental retardation; approach to diurnal enuresis in a 12-year-old boy with hemiparesis]. / Zindelijkheidstraining bij verstandelijk beperkten; aanpak van broekplassen bij een 12-jarige hemiparetische jongen.

A 12-year-old boy with hemiparesis, severe mental retardation, reduced mobility and behavioural problems was not yet toilet trained. He was successfully trained using a behavioural treatment. The training program was based on gradual prolongation of urine retention, the introduction of behaviour restrictions, rewards for using the toilet and overcorrection using repeated exercises if diurnal enuresis occurred. A third of 4- to 18-year-olds with a cerebral palsy do not have diurnal bladder control at the age of 6, in contrast to 1-3% in the general population. An important cause of this difference is the believe that bladder control is dependent on the time of development of bladder control muscles and that it cannot be affected by external methods. This case study shows that even in a relatively older and severely and multiply disabled boy diurnal enuresis can be solved.

Factors associated with low and high voiding frequency in children with diurnal urinary incontinence.

STUDY TYPE: Prognosis (cohort). LEVEL OF EVIDENCE: 2a. OBJECTIVE: To investigate, in a population-based study, the association of urinary voiding frequency and daytime wetting or diurnal urinary incontinence (UI) in children aged 6.5 years, to test the hypothesis that children with high or low voiding frequency have increased somatic and psychological risks. SUBJECTS AND METHODS: Participants were a cohort of > 8000 children enrolled in the population-based Avon Longitudinal Study of Parents and Children, a prospective longitudinal study of an original birth cohort of nearly 14,000 children. Parents completed postal questionnaires asking about diurnal UI, voiding frequency and associated somatic and behavioural signs and symptoms. RESULTS: In all, 10.4% of children had diurnal UI. Children with diurnal UI had significantly more gastrointestinal, urinary and psychological symptoms than the controls. Of the children with diurnal UI, 35.7% had a voiding frequency of < 5 voids/day, 61.5% 5-9 voids/day and 2.8% > or = 10 voids/day. High voiding frequency was more common in boys, children with frequent diurnal UI and those with combined diurnal and night-time UI, and also in children with nocturia, urgency, hyperactivity and conduct problems. Children with a low voiding frequency needed to be reminded to go to the toilet more often. Fecal incontinence, constipation, stomach 'aches', 'choosy' eating and urinary tract infections were not associated with voiding frequency. CONCLUSIONS: Voiding frequency is an important symptom in children with diurnal UI. The children with high voiding frequencies are especially at risk for associated somatic and behavioural problems.