1. Dr. Majda Abdul Wadood Mohamed Aljenaei (Aljenaei A. Majda, Certificate Arab Board
pediatric) - Corresponding author
Pediatric specialist in Hamad Medical Corporation, West Bay health center -Doha-Qatar
Phone: 4475409
Mobile: 5893763
Email: wadood3@yahoo.com

2. Dr. Mansoura Fawaz S Ismail (Fawaz M, M.Sc., PhD family medicine)
Lecturer Family Medicine, Suez Canal University Egypt and Fulltime Trainer Family
Medicine Department, Hamad Medical Corporation,West Bay health center-Doha-Qatar
Phone: 4931158
Mobile: 5344029
Email: mansoura70@hotmail.com

3. Dr.Asma Amin Abd Alaziz (Abd Alaziz AA, M.Sc., phD psychiatry)
Assistant prof., psychiatry Ain shamas university Egypt
Phone: 4475424
Mobile: 5313445
Email: asmaaamin@yahoo.com

4. Dr. Rasha ElSayed Salama (Salama RE, M.Sc., PhD community medicine)
Lecturer community Medicine, Suez Canal University Egypt and Fulltime Trainer
Community Medicine Department, Hamad Medical Corporation-Doha-Qatar
Phone: 4473215
Mobile: 5973314
Email: rashasalama2004@yahoo.com

INTRODUCTION

Nocturnal enuresis is a common problem that can be troubling for children and their families. Recent studies indicate that nocturnal enuresis is best regarded as a group of conditions with different etiologies.^[1] The American Psychiatric Association has defined bed-wetters as children older than age five who are incontinent of urine at night.^[2] The prevalence of nocturnal enuresis has been difficult to estimate because of variations in its definition and in social standards.^[3,4] It is now generally accepted that 15 to 20 percent of children will have some degree of night-time wetting at five years of age, with a spontaneous resolution rate of approximately 15 percent per year. Therefore, at 15 years of age only 1 to 2 percent of teenagers will still wet the bed. Some studies report that boys wet the bed more frequently than do girls, but this finding has been disputed by other reports.^[5] A study in UAE confirmed the fact that enuresis is a common problem among healthy school children in the UAE and that it is associated with behavioral disturbance.^[6] Bedwetting (nocturnal enuresis) is common. It occurs in up to 20% of 5 year olds and 10% of 10 year olds, with a spontaneous remission rate of 14% per year. Weekly daytime wetting occurs in 5% of children, most of whom (80%) also wet the bed. Bedwetting can have a considerable impact on children and families, affecting a child's self-esteem and interpersonal relationships, and his or her performance at school.^[7] Nocturnal enuresis can take a toll on a child's self-esteem and is a frustrating problem to parents. The parent is typically the one responsible for the clean up after an accident and is also typically charged with finding a cure for the problem. This problem can be stressful for the parents and other family members. Feelings of the parents may range from worried to frustrated, sad to angry, and even tired. Children may be able to sense these feelings in parents. Children may feel responsible for their parents' reactions and for upsetting the household.^[8] The prevalence of nocturnal enuresis has not been studied previously in Qatar. We therefore, conducted this study to determine the prevalence and associated factors of nocturnal enuresis among primary school students in Doha.

Sample size determination was conducted by Epi-info stat-calculator, and was calculated to be 256 subjects after considering a 10% dropout. The subjects of the study were primary school students selected through a multiple-stage sampling procedure. Firstly, one governmental primary school was chosen randomly from the four different regions of Doha city; northern, southern, central and western regions. One class in each of six grades (1st grade to 6th grade) of the participating schools was then randomly selected and students aged 6-12 years were then allocated through a systematic random sample from the selected classes and were invited to participate in the study. In all, 256 students from 48 classes were included and a questionnaire was applied to their parents. A response rate of 98% was achieved in this study. The questionnaire portion of this study was designed to be quick and easy to fill out by the researchers from participants over the phone. The researcher-administered questionnaire was validated before application to ensure its validity through professional review and piloting. It was translated from English to Arabic, and then back translated to ensure language consistency. It included 17 items and was designed for this study to determine the prevalence of nocturnal enuresis, how parents perceive enuresis in children six to twelve years of age, and to determine the parents' knowledge of the causes of nocturnal enuresis. The questionnaire was also a means to measure whether any treatments for enuresis were sought. Nocturnal enuresis was defined as the involuntary voiding of urine once in a great while, monthly in occasion, weekly in occasion, 2-4 times weekly and nightly beyond the age at which bladder control is normally attained (5 years)^[2,9]. Primary enuresis is defined as a child who never gained nocturnal urinary control. Secondary enuresis is where at least a 6 months period of dryness has preceded the onset of bed-wetting.^[4] Questionnaires were prepared for 256 pupils from the selected primary schools, 1st-6th grade. Researchers filled out the questionnaire over the telephone after informing the parents of the purpose of the study, that participation in the study was voluntary and that the participants remained anonymous. Collection of data was over a period of two months from April to May 2008. Parents of children enrolled in study must sign a special consent form which was approved by the Research committee of HMC. Data were analyzed using SPSS for Windows version 10 software program. Frequency tables and descriptive statistics were done. Significance test used included confidence intervals, odds ratio and chi square test. Frequency rates were compared to available data on national averages and trends. The value of p was considered significant if less than 0.05.

The total number of participants was 256, comprising an even numbers of boys & girls in different age groups, 6-12 years old (Table 1). Out of the studied participants, sixty-four (25%) had nocturnal enuresis. Twenty eight parents of children with nocturnal enuresis (10.9%) stated that their children struggled with bed wetting once in a great while, while the others dealt with bed wetting on a monthly, weekly and sometimes nightly basis (Table 2). Primary nocturnal enuresis was seen in three quarters of them while secondary nocturnal enuresis in (25%) of them. Near half of parents of children with nocturnal enuresis (46.9%) stated that the laziness of the child might be a cause while thirty of them (26.6%) stated that they did not know what the cause was. Most of the participants (70.3%) stated that their child did not go to physician. Nearly one third (31.2%) of the children's parents reacted to their children's problem by using punishment. All of the respondents perceived that enuresis affected their children's self-esteem. They stated children get embarrassed, shy, emotional, or hesitant to spend the night away from home. More than half of them also perceived that enuresis affected their children's self respect (Table 3). Bedwetting is more common in boys than girls. The prevalence rate among boys and girls was (13.7%) and (11.3%) respectively (Table 4). There is a statistically significant drop of nocturnal enuresis occurrence at increasing age (Table 5).
The current study showed that there is some difference between Nocturnal Enuresis Frequencyand Child Psychological Status but it is not statistically significant (Table 6).

Odds ratio= 0.778
Confidence interval (95%)= lower: 0.441, upper: 1.373

Nocturnal enuresis is common among younger school children and its frequency decreases in conjunction with increasing age; however, the prevalence of enuresis varies with geographical areas, the study population and the criteria used in the studies^[10-12]. The overall prevalence of nocturnal enuresis in Qatari children aged 6-12 years old was 25%, this is higher than the 8-15% reported in the west^[2] and 8.8% in Jordon^[6]. This finding is consistent with a study in Australia, which showed that 18.9% of children in the same age group had enuresis^[13]. The current study showed that the prevalence rate of enuresis decreased at 6-9 years old (14.5%) then (10.5%) at 10-12 years old, which is higher compared to the same age group in the Taiwanese and the Korean studies^[13,14]. However, two studies from Turkey^[15,16] show a prevalence rate of nocturnal enuresis of 11.5% and 13.7% at 6-12 years old and at 7-11 years old, respectively. Our results also show that nocturnal enuresis is more common in boys than girls, which is consistent with other reports^[2,13,14]. These differences arise because the definition of nocturnal enuresis varies from study to another. Marked nocturnal enuresis (more than twice weekly) in this study was 2.8% and considered lower than those reported in Sweden, France and Turkey^[17]. The current study showed that primary nocturnal enuresis was more marked than secondary enuresis and this agreed with a study done in Jordan^[6]. Qatari families of 29.7% of the children with enuresis had sought medical assistance by consulting physicians which is considered lower than the rate of Jordanian families (50%) who showed a greater concern about the problem^[18]. The current study showed that enuresis affects children's self respect and self-esteem (67.2% -100%) respectively. These findings were in concordance with previous studies of parental reports which suggests that children with nocturnal enuresis are reportedly found to be more vulnerable to low self -esteem, general anxiety, social fears and sadness, which worsen with the severity of bed-wetting^[19], while in one study in Stout-university of Wisconsin (55.9%) of participants thought that there was no effect on their children's self-esteem^[20]. In a study conducted in the USA, it showed that the prevalence of enuresis at least once a week was similar among boys and girls (7% v 6%). Parents reported that more than half of the children are distressed by their enuresis, and two thirds of parents expressed concern. Thirty-eight percent of bed-wetters have seen a physician about their condition. More than one third of these children have been treated with a drug. The most commonly recommended regimen in the literature, the bed alarm, was prescribed to only 3% of bed-wetting children who saw a physician.^[21]

Nocturnal enuresis is a frequent condition, being more prevalent in boys than in girls, and its prevalence declines with the child's age. Nocturnal enuresis is a disturbing problem, affects child self respect and affects child's self-esteem in all participants and thus should be seriously considered.

STRENGTHS AND LIMITATIONS
It was assumed that an adult, such as a parent or guardian, responded to the questionnaire in a reliable manner. The strength of this research was that the survey questionnaire is comprehensive, yet manageable for parents to understand and answer. The resulting data closely mirrored national statistics for the younger age groups, which suggests that the group that responded reasonably matches the national population. A limitation to this study was that the adult answering the questionnaire might not have a clear recollection of the child's earlier years. If the parent or guardian was unable to recollect earlier stages of the child's development, the questionnaire may not have been answered in a credible and factual manner. Another limitation is also the small sample size therefore; any results should be used cautiously. Another known limitation, is the collection of data over the phone which can decrease the reliability of data.

COMPETING INTERESTS
The authors declare that of no competing interests.

ACKNOWLEDGEMENTS
We wish to thank parents of the school children for their collaboration. Also we would like to thank the ministry of education for their support and help in this research. The study was accepted by the research committee in Hammed Medical Corporation, which had a big role in study design, data collection, data analysis, data interpretation, and writing of the report.

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