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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 36-39

Spina bifida occulta in children with nocturnal enuresis


1 Department of Pediatric, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
2 Department of Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission18-May-2018
Date of Decision16-Mar-2019
Date of Acceptance15-Apr-2019
Date of Web Publication26-Mar-2020

Correspondence Address:
Ebrahim A Elkashlan
Alnakheel 2 District, Building A1, Flat 1, Yanbu Alsenaeiah, 41912, Saudi Arabia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_45_18

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  Abstract 


Background Enuresis is defined as the voluntary or involuntary wetting of clothes or bedding with urine for a period of at least three consecutive months in children older than 5 years of age. It is a common disorder in children affecting about 15–20% of 5-year-old children. Enuretic children have a higher incidence of spina bifida occulta (SBO). Presence of SBO can affect the response of enuretic children to the management.
Objective The aim of this study was to detect the incidence of SBO in children with nocturnal enuresis and the response to treatment of these enuretic children with SBO compared with enuretics without SBO.
Patients and methods From January 2014 to June 2015, we prospectively reviewed 100 patients who visited Al-Hussain University Hospital in Cairo, Egypt, with nocturnal enuresis as the chief complaint to determine the relationship between the SBO and enuresis and also the response to the treatment of children with and without SBO.
Results The overall incidence of SBO in enuretic children was 33% and the presence of SBO could affect the treatment results.
Conclusion The incidence of SBO is higher in enuretic children and its presence may adversely affect the response to treatment. The cause-and-effect relationship between SBO and nocturnal enuresis (NE) should not be overlooked and should be further elucidated.

Keywords: children, nocturnal enuresis, spina bifida


How to cite this article:
Elkashlan EA, Shaaban MM, AlShreif AM, Ghanem M. Spina bifida occulta in children with nocturnal enuresis. Al-Azhar Assiut Med J 2020;18:36-9

How to cite this URL:
Elkashlan EA, Shaaban MM, AlShreif AM, Ghanem M. Spina bifida occulta in children with nocturnal enuresis. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Jul 10];18:36-9. Available from: http://www.azmj.eg.net/text.asp?2020/18/1/36/281355




  Introduction Top


Enuresis is defined as the voluntary or involuntary wetting of clothes or bedding with urine for a period of at least three consecutive months in children older than 5 years of age [1]. It is a common disorder in children affecting about 15–20% of 5-year-old children [2]. Enuresis may be a symptom of many disorders including spinal dysraphism. Spina bifida occulta (SBO) is a subtle form of dysraphism with failure of fusion of the posterior arch of the lumbosacral spines [2].

SBO has been linked with many urodynamic abnormalities [3]. SBO has a wide range of prevalence rates of between 1.2 and 21% [4],[5]. Few reports suggested that enuretic children have a higher incidence of SBO [6],[7]. In this study, we have studied the incidence of SBO in children with nocturnal enuresis and the clinical outcome of these enuretic children with SBO compared with enuretics without SBO.


  Aims of the study Top


To study the incidence of SBO in children with nocturnal enuresis and the response to treatment of these enuretic children with SBO compared with enuretics without SBO.


  Patients and methods Top


Design and setting

From January 2014 to June 2015, we prospectively reviewed 100 patients who visited Al-Hussain University Hospital in Cairo, Egypt, with nocturnal enuresis as the chief complaint to determine the relationship between the SBO and enuresis.

The frequency of bedwetting occurred at least once a week in these children for three consecutive months after the age of 5 years.

We excluded cases in which physical signs of spina bifida are evident or cases with other urological or medical diseases that may be associated with enuresis or cases with obscure digital radiography because of intestinal gas.

Eventually, 100 individuals with nocturnal enuresis (NE) (60 men and 40 women) were included in the present study and their ages ranged between 5.5 and 14 years with a mean age of 9.1±2.6 years. Patients diagnosed with NE completed a questionnaire including basic information such as past medical history and present illness for NE, voiding, and defecation symptoms during the initial examination.

All of the participants underwent lumbosacral radiography, routine urine tests, blood glucose, and ultrasonography of the urinary system to establish the diagnosis of primary nocturnal enuresis.

Plain spinal and sacral radiographs obtained from all patients were assessed by senior radiologists who had no knowledge about the continence status of the patients for the presence or absence of fusion of the posterior elements of the lumbar and/or sacral vertebrae above S3.

All patients were divided into two groups: SBO groups and non-SBO groups. They were given the same treatment programs. The frequency of enuretic episodes per week was recorded. The follow-up was carried out once a month for 1 year.

All patients were treated with behavioral therapy and imipramine (tricyclic antidepressant).

Ethical consideration

Ethical approval was obtained from the local ethics committees at Al-Hussain University Hospital. Investigations and scanning were performed after obtaining a signed written informed consent from parents. Privacy and confidentiality were maintained throughout the study process.

Statistical analysis

Statistical analysis was carried out using SPSS 21.0 software (SPSS Inc., Chicago, Illinois, USA). For descriptive statistics, the number and percentage were used for qualitative variables, while mean and SD were used for quantitative variables. Fisher’s exact test was used to determine the differences of frequencies of qualitative variables and independent samples t test was used to determine the differences of means of quantitative variables. A P value of less than 0.05 was denoted as statistically significant.


  Results Top


A total of 100 patients with enuresis were included in our study. There were 60 men and 40 women. Their age ranged between 5.5 and 14 years. None of the patients had urgency, urge incontinence, or hesitancy of urine. Family history was positive in 20% of patients.

SBO was detected in 33 patients. No statistically significant difference was found between both groups regarding age or sex ([Table 1]).
Table 1 Patient characteristics

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Levels of spina bifida was at L5 in nine patients, L5–S1 in eight patients, S1 in 12 patients, and S1–S2 in four patients ([Table 2] and [Figure 1] and [Figure 2]).
Table 2 Level of spina bifida occulta

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Figure 1 S1 spina bifida occulta.

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Figure 2 Lumbar (L5) spina bifida occulta.

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Fifteen patients were lost from follow up; three with SBO and 12 without SBO. The outcome of the 85 patients who continued to follow for 1 year showed significant improvement in patients without SBO ([Table 3]).
Table 3 Comparison between outcomes in both groups

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  Discussion Top


SBO is a common vertebral anomaly. Recently, there has been an interest in the association between SBO with voiding dysfunction. Our study attempts to define the incidence of SBO and its impact on the clinical outcome in a group of enuretic children.

We have found that children with enuresis had a 33% incidence of SBO with S1 level being the most common. In Kumar et al. [2] the incidence was 37% while in Kawauchi et al. [8] the incidence of SBO was 36%.

These results are corroborated by our findings of a higher SBO rate in NE patients (33%) than the rate in the general population.

This incidence is higher than the incidence of spina bifida in general population reported by Boone et al. [9] which was 17%.

In this study, there was a significant difference between the two groups in response to treatment, suggesting the presence of SBO could affect treatment results. This cope with the study done by Shin et al. [4] who found significant correlation between the presence of SBO and responses to treatment for NE.

It is not clear why SBO should affect the response to treatment of NE. Recent studies have shown that SBO does not cause any structural spinal cord abnormality observable through imaging modalities, such as MRI. However, the absence of any visual structural abnormality does not necessarily translate into a lack of clinical relevance [10],[11]. Determining the underlying pathophysiology may requires development of tests that will allow the diagnosis of functional abnormalities [12].

We suggest that the SBO affects the neural control of urination by failure of bladder filling to stimulate the sacral nerve excitement sufficiently, which makes the stimulation intensity of cerebral cortex lower than waking threshold, causing the disorder of arousal. Thus, as a result of the existence of SBO, the severity of nocturnal enuresis symptoms may increase, so is the difficulty in treatment.

In Kumar et al. [2] despite the high incidence of spina bifida in enuretic children there was no difference in the outcome between patients with spina bifida and others without spina bifida. This can be explained by the shorter (6 month) duration of follow up in their study.

Limitation of the study

The present study had limitations. We did not have a urodynamic study. Why patients with SBO have a poorer response to treatment by evaluation of their bladder function needs to be determined through an advanced prospective study.

A consideration in the present study was radiation exposure of children. Children show higher radio-sensitivity than adults, mainly because of their longer life expectancy so that dose monitoring and the establishment of diagnostic reference levels are mandatory to reduce radiation exposure.


  Conclusion Top


It may be concluded that the incidence of SBO is higher in enuretic children and its presence may adversely affect the response to treatment in such children. We agree with the notion that the presence of SBO, verified by radiography, can facilitate the prediction of the response to enuresis treatment. The cause-and-effect relationship between SBO and NE should not be overlooked and should be further elucidated.

Acknowledgements

The authors thank the patients and their families for their participation in the study. The authors also thank Department of Radiology for their help.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arda E, Cakiroglu B, Thomas D. Primary nocturnal enuresis: a review. Nephrourol Mon 2016; 8:e35809.  Back to cited text no. 1
    
2.
Kumar P, Aneja S, Kumar R, Taluja V. Spina bifida occulta in functional enuresis. Indian J Pediatr 2005; 72:223–225.  Back to cited text no. 2
    
3.
Sakakibara R, Hattori T, Uchiyama T, Kamura K, Yaminishi T. Uroneurological assessment of spina bifida cystica and occulta. Neurourol Urodyn 2003; 22:328–334.  Back to cited text no. 3
    
4.
Shin SH, Im YJ, Lee MJ, Lee YS, Choi EK, Han SW. Spina bifida occulta: not to be overlooked in children with nocturnal enuresis. Int J Urol 2013; 20:831–835.  Back to cited text no. 4
    
5.
Zaganjor I, Sekkarie A, Tsang B, Williams J, Razzaghi H, Mulinare J et al. Describing the prevalence of neural tube defects worldwide: a systematic literature review. PLoS One 2016; 11:e0151586.  Back to cited text no. 5
    
6.
Cakiroglu B, Tas T, Eyyupoglu S, Hazar A, Balcı MB, Nas Y et al. The adverse influence of spina bifida occultaon the medical treatment outcomeof primary monosymptomatic nocturnal enuresis. Arch Ital Urol Androl 2014; 86:270–273.  Back to cited text no. 6
    
7.
Kurt O, Yazici CM, Paketci C. Nocturnal enuresis with spina bifida occulta: Does it interfere behavioral management success? Int Urol Nephrol 2015; 47:1485–1491.  Back to cited text no. 7
    
8.
Kawauchi A, Kitamori T, Imad N, Tanaka Y, Watanabe H. Urological abnormalities in 1.328 patients with nocturnal enuresis. Eur Urol 1996 29:231–234.  Back to cited text no. 8
    
9.
Boone D, Parsons D, Lachmann SM, Sherwood T. Spina bifida occulta: lesion or anomaly? Clin Radiol 1985; 36:159–161.  Back to cited text no. 9
    
10.
Cakmakci E, Cinar H, Uner C, Ucan B, Eksioglu A, Pala M et al. Ultrasonographic clues for diagnosis of spina bifida occulta in children. Quant Imaging Med Surg 2016; 6:545–551.  Back to cited text no. 10
    
11.
Yavuz A, Bayar G, Kilinc MF, Sariogullari U. The relationship between nocturnal enuresis and spina bifida occulta: a prospective controlled trial. Urology 2018; 120:216–221.  Back to cited text no. 11
    
12.
Albrecht TL, Scutter SD, Henneberg M. Radiographic method to assess the prevalence of sacral spina bifida occulta. Clin Anat 2007; 20:170–174.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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  In this article
   Abstract
  Introduction
  Aims of the study
  Patients and methods
  Results
  Discussion
  Conclusion
   References
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