Journal of Pediatric Urology (2014) 10, 1181e1186
Evaluation of lower urinary tract dysfunction in Turkish primary schoolchildren: An epidemiological study ¨ksel a,*, Ays‚e C ¸olpan Yurdakul a, Mehmet Zencir b, Selc ¸uk Yu ¨l C ¨k c Nergu ¸¨ ordu a
Department of Pediatric Nephrology, Pamukkale University School of Medicine, Denizli, Turkey Department of Public Health, Pamukkale University School of Medicine, Denizli, Turkey c Department of Pediatric Surgery, Pamukkale University School of Medicine, Denizli, Turkey b
Received 29 January 2014; accepted 7 May 2014
Available online 20 June 2014
KEYWORDS Lower urinary tract dysfunction; Childhood; Prevalence
Abstract Objective: The aim was to determine the prevalence of voiding dysfunction and its related risk factors in Turkish schoolchildren. Materials and methods: A randomly selected, cross-sectional study was conducted using a selfadministered and previously validated questionnaire. The questionnaire consisted of two parts. The first part included personal demographic and familial information, and the second part included the Dysfunctional Voiding and Incontinence Scoring System (DVISS). The questionnaires were given to 4668 children between 6 and 15 years of age, which were completed by the parents and children together. The children with a score of 9 were accepted as having lower urinary tract dysfunction (LUTD). Results: The data were collected from 4016 children (the response rate was 86.0%), including 48.6% boys and 51.4% girls. The mean age was 10.5 2.2 years. The overall frequency of LUTD was 9.3%. While the 6-year-old children had the highest frequency (23.1%) of LUTD, this rate was 7.9% at the age of 10, and the children aged 14 years had the lowest frequency (4.9%), (p < 0.001). Lower urinary tract symptoms were significantly more common in girls (7.6%) than in boys (3.2%) only for the older age group (between 12 and 15 years of age). Compared with normal children, those with LUTD (with a score of 9) had the following risk factors: less educated parents, a parent that had lower urinary tract symptoms when he or she was a child, more persons per room (2 persons), more siblings (4 siblings) at home, past medical history of urinary tract infections, and squatting position (in girls). Conclusions: Lower urinary tract problems are one of the most important and ongoing health problems in childhood. Determining the prevalence of lower urinary tract problems in children
* Corresponding author. Pamukkale Universitesi Tıp Fakultesi, C ¸ ocuk Nefroloji Bilim Dali, Mavi Bina 2. Kat, 20100 Kinikli, Denizli, Turkey. Tel.: þ90 258 444 0728x5410; fax: þ90 258 241 0040. E-mail addresses: [email protected], [email protected] (S. Yu ¨ksel). http://dx.doi.org/10.1016/j.jpurol.2014.05.008 1477-5131/ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
1182
S. Yu ¨ksel et al. and their related risk factors is the first step to managing and reducing the number of children suffering from voiding problems. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Lower urinary tract dysfunction (LUTD) is a common cause of referral to pediatricians, pediatric nephrologists, and urologists. This problem can lead to poor self-esteem, family stress, and social isolation in most children. In addition, they have a higher rate of parent-reported psychological problems than children without LUTD [1]. Although lower urinary tract symptoms (LUTS), appear to have a peak incidence between the ages of 5 and 7 years, the majority of children with LUTS are primary school-aged children [2]. Moreover, children with LUTS, such as urgency and bladderholding maneuvers, may develop recurrent urinary tract infections (UTIs) or persistent vesicoureteral reflux and carry an increased risk of upper urinary tract damage [3]. The diagnosis of LUTD and the examination of these children include both non-invasive (urinalysis, questionnaires, uroflowmetry, and post-voiding residual urine assessment) and invasive (urodynamic studies) tests [4]. However, in the majority of cases, non-invasive tools are sufficient for diagnosis. In recent years, well-designed and validated questionnaires have been developed to confirm diagnoses of lower urinary tract dysfunction, classify their severity, and serve as a monitoring instrument to determine response to treatment [5,6]. Meanwhile, these questionnaires can easily be used for epidemiological studies into the prevalence of LUTD in the community. To date, although large epidemiological studies to estimate and predict worldwide and regional prevalence of LUTD in adults and children, very limited data for Turkish children have been reported [7,8]. The aim of this study was to evaluate the prevalence of LUTD in Turkish elementary schoolchildren with a previously validated questionnaire, and to identify personal or familial risk factors.
Materials and methods We conducted a randomly selected, cross-sectional study using a self-administered and previously validated questionnaire that was developed by Akbal et al. [6] in 20 elementary schools from December 2011 to January 2013. The children and their parents were not informed about normal voiding and urinary tract dysfunction before the study. Parental consent and permission from the local ethics committee and City Directorate of National Education were obtained. The questionnaires were given to 4668 children who were between 6 and 15 years of age (first- to eighth-grade students), which were to be completed by the parents and children together, and collected after 7 days. The questionnaire consisted of two parts. The first part included demographic information, such as age, gender,
school localization (rural or urban), ages of the parents, parents’ education, family income, number of siblings, number of people living at home, type of toilet (seat or squat), history of UTIs, and family history of LUTS (Appendix 1). The second part of the questionnaire included the DVISS, which was developed for Turkish children by Akbal et al. (Appendix 2) [6] and validated by Dogan et al. [4]. We have only added a picture of the holding maneuver for a better understanding of the 11th question. According to this questionnaire, which has 90% sensitivity and specificity, children with a score of 9 or greater were accepted as having LUTD. We used the Statistical Package for Social Sciences (SPSS) 17.0 for Windows to perform statistical analysis. The means are given as mean standard deviation. According to the symptom score, the children were divided into two groups on the basis of the categorical variables of children with and without LUTD. All personal and familial parameters were evaluated for significant risk factors associated with LUTD using chi-square tests. A p-value < 0.05 was considered to be statistically significant.
Results The data were collected from 4016 children (a response rate of 86.0%), which included 1927 boys (48.6%) and 2035 girls (51.4%); 54 children did not report their gender. The mean age was 10.5 2.2 years. According to the data for the 3892 children who had filled out the second part of the (DVISS) questionnaires completely, the prevalence of LUTD was 9.3% (363/3892). While the children aged 6 years had the highest frequency (23.1%) of LUTD, this rate was 7.9% at the age of 10; children aged 14 years had the lowest frequency (4.9%) (p < 0.001). The frequency of LUTD decreased with age (Fig. 1). There was no statistically significant gender difference in terms of LUTS frequency (9.8% in girls vs. 8.6% in boys, p Z 0.18) in all children. However, when the participants were divided into two groups as younger (6e11 year of age) and older (12e15 year of age) children, the frequency of voiding dysfunction in girls was significantly higher than in boys (7.6% vs. 3.2%, p Z 0.001) in the older age group (Fig. 1). According to the demographic data, there was no significant relationship between LUTD and the following parameters: residential area (urban or rural), presence or lack of family health insurance, total number of people living at home, death of one of the parents, and family income. However, the associations of LUTD with the number of persons per room (2 persons) and the number of siblings (4 siblings) were statistically significant (Table 1). We found that children from families with more educated parents had significantly less LUTD (Table 1). There was no
Lower urinary tract dysfunction in Turkish schoolchildren
Figure 1
1183
The prevalence of the children with lower urinary tract dysfunction according to age and gender.
significant relationship between the parents’ ages at the time of their child’s birth and LUTD in children. LUTs were also significantly more frequent in children with past history of UTIs. There was no statistically significant difference between different voiding positions (sitting, squatting, and standing) and LUTD in boys. However, there was a significant relationship between voiding positions (sitting and squatting) and LUTD in girls. Girls who voided in the squatting position suffered from LUTD more frequently than girls who voided in the sitting position (Table 2). LUTs were also significantly more common in children with a family history of LUTD, especially in the participants’ mothers or at least one sibling, than children without a family history (Table 1). The frequency of nocturnal enuresis was found to be 14.5% in all children, and it was more frequently seen in children with daytime wetting than in children without daytime wetting (9% vs. 5.5%, p < 0.001).
Discussion Our study revealed that the overall frequency of LUTD was 9.3% in schoolchildren. Although it was a single-center study, studies including a large number of participants have not previously been reported from Turkey. Dirim et al. [9] reported that the frequency of voiding disorder was 7.2% in 712 healthy schoolchildren (mean age 8.9 1, range 6e12 years old). Recently, Vaz et al. [10] from Brazil, who used modified voiding symptom scores, reported that the frequency of LUTD was 21.8% in 739 healthy schoolchildren. Previous studies about the prevalence of daytime wetting from Turkey and other countries have reported varying results, from 1.8% to 49% [8e16]. This large variability may be due to selection bias, questionnaire method, the nature of different populations, the different age groups surveyed, and the terminology used to define voiding symptoms (which seems to be the most important factor) [11,12]. Thereby, many authors advise using a survey that has been validated for epidemiological studies related to LUTS.
Schneider et al. [17] evaluated three surveys that have been demonstrated to predict the severity of LUTS: Farhat et al. [5], Akbal et al. [6], and Nelson et al. [18]. They found that all three surveys were statistically correlated with the physician’s impression of severity for LUTS. We used Akbal’s questionnaire [6] in our study. We also added pictures of the holding maneuvers, in case the participants did not understand the question about holding maneuvers. Mota et al. [19] reported that, when they used the modified scoring system of Farhat et al. [5], the general prevalence of LUTD was 24.2% (11.2% in boys and 35.8% in girls). However, Chung et al. [16] used a different survey and found that the rate of LUTD (46.4% in all children; 43.8% in boys and 49% in girls) was higher than the previously reported rates. In our study, if we only considered question number 1d“Does your child wet during the day?”das a description of LUTD, we would find the frequency to be 25.4%. This shows that the use of only one question to diagnose LUTD may overestimate the frequency of voiding dysfunction in children. Compared with previous studies, the rate of LUTD that we found in schoolchildren was lower. The cause of the higher rates in many previous studies may be the application of questionnaires that have not been validated and/or standardized. Meanwhile, differing ethnicities, lifestyles, diets, and cultural differences may have also contributed to these differences. We found that the frequency of LUTD in all children did not differ according to gender, location of residency (rural or urban), socioeconomic status, or marital status of the parents. Our results revealed that LUTD in girls was significantly higher than in boys for only older age group (between 12 and 15 years of age). Similarly, studies in schoolchildren have indicated that daytime urinary incontinence occurs more frequently in girls than in boys. The present study also showed that the prevalence of LUTS in girls was stable at the age of 10 years, while in boys it was stable at the age of 11 years (Fig. 1). This difference may result from the timing of the puberty. Higher levels of parental education (high school or university graduation) lead to a decrease in the prevalence of
1184 Table 1
S. Yu ¨ksel et al. Familial risk factors associated with lower urinary tract dysfunction. Symptom score 9
Symptom score < 9
N
(%)
N
(%)
43 305
11.3 9.0
337 3097
88.7 91.0
380 3402
0.08
265 97
10.9 6.8
2175 1326
89.1 93.2
2430 1414
Evaluation of lower urinary tract dysfunction in Turkish primary schoolchildren: An epidemiological study ¨ksel a,*, Ays‚e C ¸olpan Yurdakul a, Mehmet Zencir b, Selc ¸uk Yu ¨l C ¨k c Nergu ¸¨ ordu a
Department of Pediatric Nephrology, Pamukkale University School of Medicine, Denizli, Turkey Department of Public Health, Pamukkale University School of Medicine, Denizli, Turkey c Department of Pediatric Surgery, Pamukkale University School of Medicine, Denizli, Turkey b
Received 29 January 2014; accepted 7 May 2014
Available online 20 June 2014
KEYWORDS Lower urinary tract dysfunction; Childhood; Prevalence
Abstract Objective: The aim was to determine the prevalence of voiding dysfunction and its related risk factors in Turkish schoolchildren. Materials and methods: A randomly selected, cross-sectional study was conducted using a selfadministered and previously validated questionnaire. The questionnaire consisted of two parts. The first part included personal demographic and familial information, and the second part included the Dysfunctional Voiding and Incontinence Scoring System (DVISS). The questionnaires were given to 4668 children between 6 and 15 years of age, which were completed by the parents and children together. The children with a score of 9 were accepted as having lower urinary tract dysfunction (LUTD). Results: The data were collected from 4016 children (the response rate was 86.0%), including 48.6% boys and 51.4% girls. The mean age was 10.5 2.2 years. The overall frequency of LUTD was 9.3%. While the 6-year-old children had the highest frequency (23.1%) of LUTD, this rate was 7.9% at the age of 10, and the children aged 14 years had the lowest frequency (4.9%), (p < 0.001). Lower urinary tract symptoms were significantly more common in girls (7.6%) than in boys (3.2%) only for the older age group (between 12 and 15 years of age). Compared with normal children, those with LUTD (with a score of 9) had the following risk factors: less educated parents, a parent that had lower urinary tract symptoms when he or she was a child, more persons per room (2 persons), more siblings (4 siblings) at home, past medical history of urinary tract infections, and squatting position (in girls). Conclusions: Lower urinary tract problems are one of the most important and ongoing health problems in childhood. Determining the prevalence of lower urinary tract problems in children
* Corresponding author. Pamukkale Universitesi Tıp Fakultesi, C ¸ ocuk Nefroloji Bilim Dali, Mavi Bina 2. Kat, 20100 Kinikli, Denizli, Turkey. Tel.: þ90 258 444 0728x5410; fax: þ90 258 241 0040. E-mail addresses: [email protected], [email protected] (S. Yu ¨ksel). http://dx.doi.org/10.1016/j.jpurol.2014.05.008 1477-5131/ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
1182
S. Yu ¨ksel et al. and their related risk factors is the first step to managing and reducing the number of children suffering from voiding problems. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Lower urinary tract dysfunction (LUTD) is a common cause of referral to pediatricians, pediatric nephrologists, and urologists. This problem can lead to poor self-esteem, family stress, and social isolation in most children. In addition, they have a higher rate of parent-reported psychological problems than children without LUTD [1]. Although lower urinary tract symptoms (LUTS), appear to have a peak incidence between the ages of 5 and 7 years, the majority of children with LUTS are primary school-aged children [2]. Moreover, children with LUTS, such as urgency and bladderholding maneuvers, may develop recurrent urinary tract infections (UTIs) or persistent vesicoureteral reflux and carry an increased risk of upper urinary tract damage [3]. The diagnosis of LUTD and the examination of these children include both non-invasive (urinalysis, questionnaires, uroflowmetry, and post-voiding residual urine assessment) and invasive (urodynamic studies) tests [4]. However, in the majority of cases, non-invasive tools are sufficient for diagnosis. In recent years, well-designed and validated questionnaires have been developed to confirm diagnoses of lower urinary tract dysfunction, classify their severity, and serve as a monitoring instrument to determine response to treatment [5,6]. Meanwhile, these questionnaires can easily be used for epidemiological studies into the prevalence of LUTD in the community. To date, although large epidemiological studies to estimate and predict worldwide and regional prevalence of LUTD in adults and children, very limited data for Turkish children have been reported [7,8]. The aim of this study was to evaluate the prevalence of LUTD in Turkish elementary schoolchildren with a previously validated questionnaire, and to identify personal or familial risk factors.
Materials and methods We conducted a randomly selected, cross-sectional study using a self-administered and previously validated questionnaire that was developed by Akbal et al. [6] in 20 elementary schools from December 2011 to January 2013. The children and their parents were not informed about normal voiding and urinary tract dysfunction before the study. Parental consent and permission from the local ethics committee and City Directorate of National Education were obtained. The questionnaires were given to 4668 children who were between 6 and 15 years of age (first- to eighth-grade students), which were to be completed by the parents and children together, and collected after 7 days. The questionnaire consisted of two parts. The first part included demographic information, such as age, gender,
school localization (rural or urban), ages of the parents, parents’ education, family income, number of siblings, number of people living at home, type of toilet (seat or squat), history of UTIs, and family history of LUTS (Appendix 1). The second part of the questionnaire included the DVISS, which was developed for Turkish children by Akbal et al. (Appendix 2) [6] and validated by Dogan et al. [4]. We have only added a picture of the holding maneuver for a better understanding of the 11th question. According to this questionnaire, which has 90% sensitivity and specificity, children with a score of 9 or greater were accepted as having LUTD. We used the Statistical Package for Social Sciences (SPSS) 17.0 for Windows to perform statistical analysis. The means are given as mean standard deviation. According to the symptom score, the children were divided into two groups on the basis of the categorical variables of children with and without LUTD. All personal and familial parameters were evaluated for significant risk factors associated with LUTD using chi-square tests. A p-value < 0.05 was considered to be statistically significant.
Results The data were collected from 4016 children (a response rate of 86.0%), which included 1927 boys (48.6%) and 2035 girls (51.4%); 54 children did not report their gender. The mean age was 10.5 2.2 years. According to the data for the 3892 children who had filled out the second part of the (DVISS) questionnaires completely, the prevalence of LUTD was 9.3% (363/3892). While the children aged 6 years had the highest frequency (23.1%) of LUTD, this rate was 7.9% at the age of 10; children aged 14 years had the lowest frequency (4.9%) (p < 0.001). The frequency of LUTD decreased with age (Fig. 1). There was no statistically significant gender difference in terms of LUTS frequency (9.8% in girls vs. 8.6% in boys, p Z 0.18) in all children. However, when the participants were divided into two groups as younger (6e11 year of age) and older (12e15 year of age) children, the frequency of voiding dysfunction in girls was significantly higher than in boys (7.6% vs. 3.2%, p Z 0.001) in the older age group (Fig. 1). According to the demographic data, there was no significant relationship between LUTD and the following parameters: residential area (urban or rural), presence or lack of family health insurance, total number of people living at home, death of one of the parents, and family income. However, the associations of LUTD with the number of persons per room (2 persons) and the number of siblings (4 siblings) were statistically significant (Table 1). We found that children from families with more educated parents had significantly less LUTD (Table 1). There was no
Lower urinary tract dysfunction in Turkish schoolchildren
Figure 1
1183
The prevalence of the children with lower urinary tract dysfunction according to age and gender.
significant relationship between the parents’ ages at the time of their child’s birth and LUTD in children. LUTs were also significantly more frequent in children with past history of UTIs. There was no statistically significant difference between different voiding positions (sitting, squatting, and standing) and LUTD in boys. However, there was a significant relationship between voiding positions (sitting and squatting) and LUTD in girls. Girls who voided in the squatting position suffered from LUTD more frequently than girls who voided in the sitting position (Table 2). LUTs were also significantly more common in children with a family history of LUTD, especially in the participants’ mothers or at least one sibling, than children without a family history (Table 1). The frequency of nocturnal enuresis was found to be 14.5% in all children, and it was more frequently seen in children with daytime wetting than in children without daytime wetting (9% vs. 5.5%, p < 0.001).
Discussion Our study revealed that the overall frequency of LUTD was 9.3% in schoolchildren. Although it was a single-center study, studies including a large number of participants have not previously been reported from Turkey. Dirim et al. [9] reported that the frequency of voiding disorder was 7.2% in 712 healthy schoolchildren (mean age 8.9 1, range 6e12 years old). Recently, Vaz et al. [10] from Brazil, who used modified voiding symptom scores, reported that the frequency of LUTD was 21.8% in 739 healthy schoolchildren. Previous studies about the prevalence of daytime wetting from Turkey and other countries have reported varying results, from 1.8% to 49% [8e16]. This large variability may be due to selection bias, questionnaire method, the nature of different populations, the different age groups surveyed, and the terminology used to define voiding symptoms (which seems to be the most important factor) [11,12]. Thereby, many authors advise using a survey that has been validated for epidemiological studies related to LUTS.
Schneider et al. [17] evaluated three surveys that have been demonstrated to predict the severity of LUTS: Farhat et al. [5], Akbal et al. [6], and Nelson et al. [18]. They found that all three surveys were statistically correlated with the physician’s impression of severity for LUTS. We used Akbal’s questionnaire [6] in our study. We also added pictures of the holding maneuvers, in case the participants did not understand the question about holding maneuvers. Mota et al. [19] reported that, when they used the modified scoring system of Farhat et al. [5], the general prevalence of LUTD was 24.2% (11.2% in boys and 35.8% in girls). However, Chung et al. [16] used a different survey and found that the rate of LUTD (46.4% in all children; 43.8% in boys and 49% in girls) was higher than the previously reported rates. In our study, if we only considered question number 1d“Does your child wet during the day?”das a description of LUTD, we would find the frequency to be 25.4%. This shows that the use of only one question to diagnose LUTD may overestimate the frequency of voiding dysfunction in children. Compared with previous studies, the rate of LUTD that we found in schoolchildren was lower. The cause of the higher rates in many previous studies may be the application of questionnaires that have not been validated and/or standardized. Meanwhile, differing ethnicities, lifestyles, diets, and cultural differences may have also contributed to these differences. We found that the frequency of LUTD in all children did not differ according to gender, location of residency (rural or urban), socioeconomic status, or marital status of the parents. Our results revealed that LUTD in girls was significantly higher than in boys for only older age group (between 12 and 15 years of age). Similarly, studies in schoolchildren have indicated that daytime urinary incontinence occurs more frequently in girls than in boys. The present study also showed that the prevalence of LUTS in girls was stable at the age of 10 years, while in boys it was stable at the age of 11 years (Fig. 1). This difference may result from the timing of the puberty. Higher levels of parental education (high school or university graduation) lead to a decrease in the prevalence of
1184 Table 1
S. Yu ¨ksel et al. Familial risk factors associated with lower urinary tract dysfunction. Symptom score 9
Symptom score < 9
N
(%)
N
(%)
43 305
11.3 9.0
337 3097
88.7 91.0
380 3402
0.08
265 97
10.9 6.8
2175 1326
89.1 93.2
2430 1414
