Nocturnal enuresis(NE) is common disorders in children and adolescent, and its risk factor has been reported widely. However, the research on the prevalence of behavioral problems and its risk factors in children and adolescent with enuresis is limited. Our hypothesis was that NE is associated with higher risk of behavioral problems. So, the aims of study is to investigate the prevalence of behavioral problems and its risk factors in children and adolescent with enuresis in China.

From October 2019 to January 2020, students (aged 7~15 years) from five primary and secondary schools in mainland China were selected. An anonymous questionnaire was used to collect information including the sociodemographic characteristics, history of NE, family history, daytime voiding symptoms, strength, and Difficulties Questionnaire (SDQ).  SDQ covers 25 attributes which are divided into 5 subscales of 5 items each: conduct problems, emotional symptoms, peer-relationship problems, Hyperactivity-inattention and prosocial behavior. The higher the total score, the more serious the problem. All statistical analyses were performed using SPSS version 25.0. Comparative statistics were done using Chi-square tests. Multiple regression analysis was done to determine the SDQ behavioral problem subscale (abnormal) which was significantly and independently associated with enuresis independent to other problems. P < 0.05 were considered to indicate statistical significance.

A total of 4500 questionnaires were actually distributed, 4120 were collected, and 94.9% (3912/ 4120) of them were qualified for statistical analysis. The prevalence of enuresis is 7.31% (The prevalence of 7-year-old children is 10.12%, and the prevalence of 16-year-old children is 4.21%). The scores of emotional symptoms, hyperactivity-inattention symptoms and SDQ in the NE group were significantly higher than those in the normal group, and the differences were statistically significant (P<0.001). However, there was no significant difference in the scores of conduct problems, peer-relationship problems and prosocial behavior between the two groups (P> 0.05). There was an overlap of behavioral problems in 54.9% of children with nocturnal enuresis. The results of univariate analysis showed that there were significant differences in gender, age, daytime lower urinary tract symptoms, and whether the caregiver and children with NE had behavioral disorders (P<0.05). There was no statistically significant difference in BMI, personality, academic performance, caregiver's education, caregiver's occupation, family history and residence in NE children with or without behavioral disorders (P>0.05).Multiple regression analysis showed that emotional symptoms (OR=3.489, 95% CI:2.349, 5.183)and hyperactivity-inattention (OR=2.080, 95% CI: 1.453, 2.978) were significantly associated with enuresis independent to other problems.

Epidemiological studies have reported that children with enuresis are two to four times as likely to have behavioral problems as children without enuresis[1]. Our results are consistent with the previous studies, in that 54.9% of the children with enuresis had psychiatric disorders, and they were 1.783-fold more likely to have psychiatric disorders than those without enuresis. Zink et al[2] found that different subtypes of enuresis and urinary incontinence demonstrate differences in behavioral problems and psychiatric comorbidity. The highest rates of psychiatric comorbidity were found in the group of children with voiding postponement and the lowest were in children with monosymptomatic nocturnal enuresis. our results are nearly the same in comparison to a previous study. The lowest rates of behavioral problems were in children with monosymptomatic nocturnal enuresis. Our research results show that in children with NE, whether they are combined with psychological and behavioral disorders has nothing to do with BMI. Gontard et al[3] investigated 1638 children with urinary incontinence and found that NE children have the highest rate of overweight/obesity, and overweight/obesity will increase the risk of behavioral problems in children with enuresis. Because the relationship between obesity, behavioral disorders and NE is very complex, the specific mechanism needs to be further studied.

NE is associated with higher risk of behavioral problems particularly emotional and 
hyperactivity-inattention symptoms. Behavioral disorders compromise compliance with treatment and lead to poorer prognosis. So, in clinical settings, all children with NE should be screened with a behavioral questionnaire is as recommended by the ICCS. Those with clinically relevant scores should receive further assessment, and, if indicated, counseling and treatment, especially in patients with non-monosymptomatic nocturnal enuresis.

Gulisano M, Domini C, Capelli M, Pellico A, Rizzo R. Importance of neuropsychiatric evaluation in children with primary monosymptomatic enuresis. J Pediatr Urol. 2017. 13(1): 36.e1-36.e6.
Zink S, Freitag CM, von Gontard A. Behavioral comorbidity differs in subtypes of enuresis and urinary incontinence. J Urol. 2008. 179(1): 295-8; discussion 298.
von Gontard A, Mattheus H, Anagnostakou A, et al. Behavioral comorbidity, overweight, and obesity in children with incontinence: An analysis of 1638 cases. Neurourol Urodyn. 2020. 39(7): 1985-1993.