Enuresis is a common childhood problem. However, it can cause significant distress to the affected individuals and is also associated with sleep disturbances and behavior problems [1-3], thus hampering the overall quality of life. The term ‘lower urinary tract dysfunction (LUTD)’ refers to conditions where children have symptoms related to voiding in the absence of any overt uropathy or neuropathy [4,5], and is a part of the group of conditions known as bladder-bowel dysfunction (BBD) [4]. LUTD is associated with psychological comorbidity, urinary tract infection (UTI), vesicoureteral reflux (VUR) and constipation. The exact prevalence of LUTD in the population is not known but is estimated to be between 2% and 21.8% [6].

Teachers’ awareness of the voiding habits of normal children and decision-making when faced with toilet requests have significant implications in both the evolution and management of LUTD [7,8]. Toilet requests should ideally be honored by teachers [7] but can be a stressor because of interference with teaching schedules and administrative expectations.  However, there is very little data on awareness and stress amongst teachers related to this aspect of childcare.

We planned this study to estimate the prevalence of LUTD and enuresis among student in a single school, and to assess the knowledge of teachers regarding voiding habits of children, record perceptions of teachers regarding toilet use, and measure stress experienced by teachers due to toilet requests.

Methods        

This observational descriptive study was conducted in a secondary school in Visakhapatnam, India after clearance by Institutional ethics committee of the affiliated hospital of the authors, as well as permission from school authorities. The parents of the students in the school have stable employment with the Central Government but are relocated frequently. The school has adequate number of clean toilets. The participants of the study were students aged 5 to 17 years, and all teachers of the school.

Enuresis was defined as passage of urine while sleeping. Non-monosymptomatic enuresis was defined as enuresis and any one of the following (i) passage of urine in the clothes while awake (ii) and any of the following symptoms: straining while passing urine, pain while passing urine, interrupted stream of urine, need to return to pass urine a second time immediately after passing urine, urgency, holding manoeuvres or passing urine in clothes before reaching the toilet. Overactive bladder was defined as presence of any two of the following symptoms: urgency, holding manoeuvres or passing urine in clothes while awake. Dysfunctional voiding syndrome was defined in the presence of any of the following (i) any two of the following symptoms; straining while passing urine, pain while passing urine, interrupted stream of urine and need to return to pass urine a second time immediately after passing urine (ii) passage of urine in clothes while awake and any one of the following symptoms: straining while passing urine, pain while passing urine,  interrupted stream of urine, and need to return to pass urine a second time immediately after passing urine.

To assess the prevalence of LUTD, the Dysfunctional voiding and incontinence symptom score (DVISS) [9] was used as a community-based screening tool, after suitable adaptation with permission of the author. The modified questionnaire was translated into Hindi by forward and reverse translation by five healthcare professionals each of whom were fluent in Hindi and English, with final reconciliation by the authors. Face validation was performed by a team  consisting of a psychologist, a pediatrician and a community medicine specialist. With an estimated prevalence of 9% for LUTD,  as well as enuresis [10,11], the minimum number of participants was estimated to be 1721 at 1% absolute error of margin with a finite correction and 99% confidence interval. 

To assess the knowledge of teachers regarding voiding habits of children and their perceptions regarding toilet use, a questionnaire known as Bathroom behavior scale (BBS) was prepared. To evaluate the stress experienced by teachers due by toilet requests in terms of frequency as well as intensity, a second questionnaire, i.e. the Teachers’ hassle scale for toilet requests (THSTR) was prepared. Both questionnaires were prepared after inputs from 10 teachers from different schools. With an assumed prevalence of 20% regarding awareness of LUTD among teachers, the minimum number of participants required for assessing knowledge of teachers regarding voiding habits was estimated at 136 at 1% absolute error of margin with two finite correction and 99% CI.

Face-validity of the BBS as well as the THSTR was assessed by the expert opinion of three pediatricians and another ten teachers from other schools, with separate feedback forms. Content validity was assessed using feedback forms distributed to these experts.

Data collection for the study was performed in February - March, 2019.

Both Hindi and English versions of the modified DVISS were sent to parents of all students in grade 1-9 and grade 11, along with a letter of consent explaining the purpose of the survey and clarifying that response to the questionnaire was purely voluntary. Data regarding name, age, sex and class were not collected to ensure anonymity. In case the parents did not return the questionnaire within three days of distribution, a single reminder was sent to them by the teachers to allow collection up to seven days after distribution of the questionnaire. The BBS and THSTR were administered to all teachers of the school.

After collection, the filled modified DVISS questionnaires were interpreted question-wise to elicit history suggestive of enuresis, non-monosymptomatic enuresis, dysfunctional voiding syndrome and overactive bladder. Forms with incomplete information and conflicting responses were rejected.

Statistical analysis: Reliability scores of the Frequency and Intensity subscales of the THSTR were calculated by Cronbach alpha. All statistical analysis was performed using Microsoft Excel 2016.

Results

Of 2518 questionnaires of the modified DVISS distributed to parents, 1911 (75.9%) were returned. On scrutiny, 1790 (93.7%) were valid. The prevalence of individual symptoms is shown in Table I. Symptomato-logy compatible with enuresis was noted in 85 children (4.7%, 95% CI 3.7-5.8%), non-monosymptomatic enuresis in 38 children (2.1%, 95% CI 2.0-3.6%, ),  overactive bladder alone in 46 children (2.6%, 95% CI 1.8-3.3%),   dysfunctional voiding syndrome alone in 14 children (0.8%, 95% CI 0.4-1.2%), Thus, a total of 64 children (3.6%, 95% CI 2.7-4.5%) had at least one form of LUTD, i.e. overactive bladder or dysfunctional voiding syndrome.

Table I Prevalence of Symptoms 

		Symptom

		Prevalence

		Daytime incontinence

		34, 1.9 (1.3-2.5)

		  Damp underwear

		19, 55.9 (53.5-58.2)

		  Damp pants

		10, 29.4 (27.3-31.6)

		  Pants soaking wet

		5, 14.7 (13.0-16.4)

		Bedwetting 

		85, 4.7 (3.7-5.8)

		  Damp bedsheets

		52, 61.2 (58.9-63.5)

		  Bedsheets soaking wet

		33, 38.8 (36.5-41.1)

		Urine passed > 7 times/d

		325, 18.2 (16.3-20.0)

		Straining during micturition

		35,2.0 (1.3-2.6)

		Pain during micturition

		16, 0.9, (0.5-1.3)

		Interrupted stream

		26, 1.5 (0.9-2.0)

		Need to return to void a second time

		27, 1.5 (0.9-2.1)

		Urgency

		98, 5.5 (4.4-6.6)

		Holding manuvres

		106, 5.9 (4.8-7.0)

		Passing urine in pants on the 

		19, 1.1 (0.6-1.6)

		  way to the toilet

		Stools passed less than daily

		222,12.4 (10.8-14.0)%

		*Values in number, % (95% confidence interval).

A total of 138 questionnaires of the BBS and THSTR were distributed to teachers and all were returned. Sixty-eight teachers (49.3%) were unaware of the correct amount of water requirement of a child, 34 (24.6%) were unaware of the number of times that a child voids in a day 43 (31.2%) believed that toilet requests in the middle of a class should be denied, and 93 teachers (67.4%), believed that such requests lead to more requests from other children. A medical cause for frequent toilet requests by a child was considered a likely possibility by 82 teachers (59.4%).

Reliability of the Frequency and Intensity subscales of the THSTR were 0.80 and 0.85, respectively. Of 138 questionnaires of the THSTR that were returned, 108 (78.3%) and 101 (73.2%) were valid on the frequency and intensity subscales, respectively. The results of the responses to the THSTR are shown in Web Table I. At least one aspect of toilet requests was a frequent hassle in 43/108 (39.8%) and an intense hassle for 29/101 (28.7%) teachers with valid responses.  Significant overall stress due to toilet requests in terms of frequency and intensity was noted in six teachers (5.6%) and one teacher (0.7%), respectively.

Discussion

In this study, we report prevalence of enuresis in 4.7%, non-monosymptomatic enuresis in 2.1%, overactive bladder in 2.6% and dysfunctional voiding syndrome in 0.8% children, respectively. We also report that a significant minority of teachers are unaware of the physiological basis of the toileting behaviour of children and that a significant proportion of teachers feel that at least one aspect of toilet requests constitutes a stressor.

There is a wide variation in the estimated prevalence of enuresis in developing countries, Indian studies report values between 7-12%. [3,12,13]. A Nigerian study reported figures as high as 37.0% [1]. The estimated prevalence of enuresis in our study, is lower than these studies.  This may be due to absence of traditionally reported risk factors such as crowded families, low educational level of parents, jobless father, working mother and single parent [14], as well as inclusion of older children in our cohort, in whom enuresis has a tendency to resolve [15].

The exact prevalence of non-monosymptomatic enuresis and LUTD in the general population is not known, probably because of a lack of population-based studies. Hellström, et al. [16] in a survey of 7-year old Swedish school entrants reported a prevalence of 2.3% and 2.0% of non-monosymptomatic enuresis among boys and girls, respectively as compared to 2.1% overall prevalence in the present study. They also reported daytime incontinence in 6.0% girls and 3.8% boys as compared to overall prevalence of  1.9% in the present study [16]. Sampaio, et al. [11], in a population-based study based in Brazil, reported a 9.1% prevalence of LUTD as compared to 3.6% overall prevalence in the present study [11]. Lower prevalence in the present study may again have been due to inclusion of older children, a high representation of middle-class families with access to free medical care by the majority.

In our study, a sizeable proportion of teachers were unaware of fluid requirements and toilet requirements of children. Lack of awareness regarding elimination habits of children has been reported previously among schoolteachers [17], and among school nurses [18]. Resistance or conflicting rules regarding toilet requests have been reported as an area of concern for children and adolescents with bladder problems in qualitative studies by in Sweden [19] as well as in the UK [20]. In our study, we report that toilet requests are a stressor for a significant minority of teachers. Instructions to teachers regarding the toilet habits of children may help in mitigating these concerns. Healthcare providers and parents should also be encouraged to involve the school authorities while planning and prescribing urotherapy because individualized health plans with involvement of teachers are reported to improve continence [8].

Anonymous response from parents did not allow analysis of the age-or gender-wise distribution of symptoms. The study was conducted in a population from the middle- and upper-middle class with access to free medical care and its generalizability is therefore limited to such populations. We did not collect data related to presence of uropathies or urinary tract infection. We also did not collect data related to comorbidities of enuresis and LUTD such as screen-time, obesity, scholastic performance, sleep disturbances and behavior disorders.

To conclude, we report the prevalence of enuresis and LUTD in a sub-group of Indian schoolchildren from a single center, and provide data on teachers’ perceptions about toilet requests of school children.  Incorporating information on these aspects during teacher-training may address related stress among teachers.

Ethical clearance: IEC of INHS Kalyani.

Acknowledgements: Dr Parul Kumar, Principal and all staff of Navy Children School, Visakhapatnam. Prof. Pankaj Hari, Nephrology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi for reading the draft manuscript and recommending corrections.

Contributors: RWT: conceptualized the students’ aspect of the study, designed the study, modified the DVISS questionnaire, analyzed data, and prepared the manuscript; NT: conceptualized the teachers’ aspect of the study, prepared and performed validation of the BBS and THSTI questionnaires, analyzed questionnaires and was involved in preparing ,the manuscript; SKS: revised the study design, calculated sample size, conducted the survey, analysed the DVISS questionnaires, conducted, biostatistical analysis, revised the manuscript.

Funding: None; Competing interest: None stated.

References

1. Anyanwu O, Ibekwe R, Orji M. Nocturnal enuresis among Nigerian children and its association with sleep, behavior and school performance. Indian Pediatr. 2015;52:587-9.

2. Jain S, Bhatt GC, Goya A, Gupta V, Dhingra B. Obstructive sleep apnea in children with nocturnal enuresis. Indian Pediatr. 2018;55:433-4.

3. Nakate DP, Vaidya SS, Gaikwad SY, Patil RS, Ghogare MS. Prevalence and determinants of nocturnal enuresis in school going children in Southern Maharashtra, India. International Journal of Contemporary Pediatrics. 2019;6:564-8.

4. Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, et al. The standardization of Terminology of Lower Urinary tract Function in Children and Adolescents: Update Report from the Standardization Committee of the International Children’s Continence Society. Neurourol Urodyn. 2016;35:471-81.

5. Silay MS, Aslan AR, Erdem E, Tandogdu Z, Tekgul S. Evaluation of functional lower urinary tract dysfunction in children: Are the physicians complying with the current guidelines? [Internet]. The Scientific World Journal. 2013. Available from: https://www.hindawi.com/journals/tswj/2013/341606/. Accessed  August 11, 2019.

6. Vaz GT, Vasconcelos MM, Oliveira EA, Ferreira AL, Magalhães PG, Silva FM, et al. Prevalence of lower urinary tract symptoms in school-age children. Pediatr Nephrol. 2012;27:597-603.

7. Kistner M. Dysfunctional elimination behaviors and associated complications in school-age children. J Sch Nurs. 2009;25:108-16.

8. Boisclair-Fahey A. Can individualized health care plans help increase continence in children with dysfunctional elimination syndrome? J Sch Nurs. 2009;25:333-41.

9. Akbal C, Genc Y, Burgu B, Ozden E, Tekgul S. Dysfunctional voiding and incontinence scoring system: quantitative evaluation of incontinence symptoms in pediatric population. J Urol. 2005;173:969-73.

10. de Jong TPVM, Klijn AJ, Vijverberg MAW. Lower urinary tract dysfunction in children. Eur Urol. 2012;11:10-5.

11. Sampaio C, Sousa AS, Fraga LGA, Veiga ML, Bastos Netto JM, Barroso UJ. Constipation and lower urinary tract dysfunction in children and adolescents: A population-based study. Front Pediatr [Internet]. 2016. Available from: https://www.frontiersin.org/articles/10.3389/fped.2016. 00101/full#B11. Accessed June 10, 2019.

12. De Sousa A, Kapoor H, Jagtap J, Sen M. Prevalence and factors affecting enuresis amongst primary school children. Ind J Urol. 2007;23:354-7.

13. Srivastava S, Srivastava KL, Shingla S. Prevalence of monosymptomatic nocturnal enuresis and its correlates in school going children of Lucknow. Ind J Pediatr. 2013;80:488-91.

14. Hashem M, Morteza A, Mohammad K, Ahmad-Ali N. Prevalence of nocturnal enuresis in school aged children: The role of personal and parents related socio-economic and educational factors. Iran J Pediatr. 2013;23:59-64.

15. Jain S, Bhatt GC. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatr Int Child Health. 2016;36:7-14.

16. Hellström A-L, Hanson E, Hansson S, Hjälmås K, Jodal U. Micturition habits and incontinence in 7-year-old Swedish school entrants. Eur J Pediatr. 1990; 149:434-7.

17. Cooper CS, Abousally CT, Austin JC, Boyt MA, Hawtrey CE. Do public schools teach voiding dysfunction? Results of an elementary school teacher survey. J Urol. 2003; 170:956-8.

18. Arlen AM, Boyt MA, Cooper CS. School nurse perceptions and knowledge of pediatric toileting. J Pediatr Urol. 2012; 8:205-8.

19. Lundblad B, Hellström A-L. Perceptions of school toilets as a cause for irregular toilet habits among schoolchildren aged 6 to 16 years. J Sch Health. 2005;75:125-8.

20. Whale K, Cramer H, Joinson C. Left behind and left out: The impact of the school environment on young people with continence problems. Br J Health Psychol. 2018;23:253-77.