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Trajectories of Urinary Incontinence in Childhood and Bladder and Bowel Symptoms in Adolescence: Prospective Cohort Study

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Trajectories of Urinary Incontinence in Childhood and Bladder and Bowel Symptoms in Adolescence: Prospective Cohort Study Open Access Research BMJ Open: first published as 10.1136/bmjopen-2016-014238 on 14 March 2017. Downloaded from Trajectories of urinary incontinence in childhood and bladder and bowel symptoms in adolescence: prospective cohort study Jon Heron,1 Mariusz T Grzeda,1 Alexander von Gontard,2 Anne Wright,3 Carol Joinson1 To cite: Heron J, Grzeda MT, ABSTRACT et al Strengths and limitations of this study von Gontard A, . Objectives: To identify different patterns (trajectories) Trajectories of urinary of childhood urinary incontinence and examine which ▪ incontinence in childhood A major strength of the study is the availability patterns are associated with bladder and bowel and bladder and bowel of repeated measures of bedwetting and daytime symptoms in adolescence: symptoms in adolescence. wetting across childhood in a large, representa- prospective cohort study. Design: Prospective cohort study. tive cohort. BMJ Open 2017;7:e014238. Setting: General community. ▪ The study is the first to model parallel trajector- doi:10.1136/bmjopen-2016- Participants: The starting sample included 8751 ies of bedwetting and daytime wetting across 014238 children (4507 men and 4244 women) with parent- childhood. reported data on frequency of bedwetting and daytime ▪ Adolescent bladder and bowel symptoms were ▸ Prepublication history and wetting for at least three of five time points (4½, 5½, based on self-report rather than clinical additional material is 6½, 7½ and 9½ years—hereafter referred to as diagnosis. available. To view please visit 4–9 years). Study children provided data on a range of ▪ Information about lower urinary tract symptoms, the journal (http://dx.doi.org/ bladder and bowel symptoms at age 14 (data available soiling or constipation, and organic causes of 10.1136/bmjopen-2016- for 5899 participants). incontinence was not included in the trajectories. 014238). Outcome measures: Self-reported bladder and bowel ▪ We did not consider whether treatment for symptoms at 14 years including daytime wetting, urinary incontinence might have impacted on the findings. http://bmjopen.bmj.com/ Received 9 September 2016 bedwetting, nocturia, urgency, frequent urination, low Revised 8 February 2017 voided volume, voiding postponement, passing hard Accepted 9 February 2017 stools and low stool frequency. Results: We extracted 5 trajectories of urinary INTRODUCTION incontinence from 4 to 9 years using longitudinal latent Urinary incontinence is common in child- class analysis: (1) normative development of daytime hood12and, if poorly managed, can ser- and night-time bladder control (63.0% of the sample), iously undermine a child’s quality of life and (2) delayed attainment of bladder control (8.6%), (3) self-esteem.3 Children who attend contin- bedwetting alone (no daytime wetting) (15.6%), (4) ence clinics have high rates of comorbid on September 30, 2021 by guest. Protected copyright. daytime wetting alone (no bedwetting) (5.8%) and (5) emotional distress, with 20–40% meeting persistent wetting (bedwetting with daytime wetting to 4 age 9) (7.0%). The persistent wetting class generally diagnostic criteria for psychiatric disorders. showed the strongest associations with the adolescent Despite the prevalence and impacts, little is bladder and bowel symptoms: OR for bedwetting at known about the prognosis of childhood 14 years=23.5, 95% CI (15.1 to 36.5), daytime wetting incontinence. Parents and clinicians often (6.98 (4.50 to 10.8)), nocturia (2.39 (1.79 to 3.20)), adopt a ‘wait and see’ approach to childhood urgency (2.10 (1.44 to 3.07)) and passing hard stools incontinence, due to the common belief that (2.64 (1.63 to 4.27)) (reference category=normative it resolves with age.5 A significant proportion development). The association with adolescent of children, however, continue to suffer from bedwetting was weaker for children with bedwetting persistent incontinence into adolescence167 alone (3.69 (2.21 to 6.17)). and adulthood.8 Increased understanding of For numbered affiliations see Conclusions: Trajectories of childhood urinary end of article. the prognosis of childhood incontinence is incontinence are differentially associated with needed to improve identification of those adolescent bladder and bowel symptoms. Children who should be prioritised for specialist ser- Correspondence to exhibiting persistent bedwetting with daytime wetting Dr Carol Joinson; Carol. had the poorest outcomes in adolescence. vices to help prevent chronic incontinence [email protected] and secondary impacts. Heron J, et al. BMJ Open 2017;7:e014238. doi:10.1136/bmjopen-2016-014238 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2016-014238 on 14 March 2017. Downloaded from There is evidence that adolescents experience more includes a fully searchable dictionary of available data severe incontinence than children.1 A cross-sectional (http://www.bris.ac.uk/alspac/researchers/data-access/ study of 5–19-year-olds found a greater proportion of fre- data-dictionary). Pregnant women residents in the quent bedwetting (≥3 wet nights/week), accompanied former Avon Health Authority in south-west England, by daytime wetting and other lower urinary tract symp- having an estimated date of delivery between 1 April 91 toms (LUTS), in older (11–19 years) compared with and 31 December 92, were invited to take part, resulting younger children (5–10 years).1 The authors argue that in a cohort of 14 541 pregnancies and 13 973 single- this provides evidence that frequent bedwetting with tons/twins (7217 boys and 6756 girls) alive at 12 daytime LUTS, referred to as non-monosymptomatic months.24 nocturnal enuresis (NMNE), is less likely to resolve with age. NMNE can often be attributed to overactive Exposures: daytime wetting and bedwetting during bladder (OAB, syndrome characterised by urge symp- childhood toms, increased urination frequency and small voided Postal questionnaires were sent out to parents when the volumes)9 and is distinguished from monosymptomatic study children were aged 4½, 5½, 6½, 7½ and 9½ years NE (MNE, bedwetting without daytime symptoms),10 (hereafter referred to as 4–9 years). Over 90% of ques- which is often attributed to nocturnal polyuria and a tionnaires were returned within 1–2 months of the deficit in the basic inhibitory function of the brainstem target age. Parents were asked ‘How often usually does leading to a lack of inhibition of the micturition reflex your child wet him/herself during the day?’ and ‘during during sleep.11 A prospective cohort study found that the night?’ and for both questions were given the childhood urinary incontinence (UI; wetting in the day response options ‘Never’; ‘Occasional accidents but less or several nights a week at age 6) was associated with than once a week’; ‘About once a week’; ‘2–5 times a severe incontinence and urge symptoms in women at week’; ‘Nearly every day; and ‘More than once a day’. age 48, while occasional bedwetting was not linked to adult incontinence.12 There are also associations Outcomes: bladder and bowel symptoms in adolescence reported between retrospective reports of childhood UI A self-report postal questionnaire was sent out to study – and adult UI and LUTS,13 16 childhood bedwetting and children when they were 13 years 10 months (IQR: adult nocturia,17 and childhood bladder and bowel 13 years 10 months—13 years 11 months, hereafter symptoms and bedwetting in adolescents and adults.18 referred to as 14 years; over 90% of participants UI is known to be linked to bowel habits (eg, low stool returned the questionnaire within 3 months of the frequency and passage of hard stools),19 but no pro- target age). Of the 8751 samples, 5899 (67.4%) returned spective studies have examined whether childhood the 14-year questionnaire. The questionnaire included incontinence is related to bowel symptoms in adoles- questions about the frequency of incontinence (daytime cence. All previous studies have examined only the pres- wetting and bedwetting), LUTS (nocturia, urgency, fre- http://bmjopen.bmj.com/ ence or absence of incontinence and/or bladder and quent urination, low voided volume and voiding post- bowel symptoms in childhood and the association with ponement) and bowel symptoms (passing hard stools subsequent daytime wetting, bedwetting and/or LUTS. and stool frequency) over the last 2 weeks. Table 1 pro- None have taken into account the heterogeneity in vides the exact questions used to derive these outcomes. developmental trajectories of incontinence during child- hood. There is evidence for distinct patterns of UI char- Estimation of the parallel trajectory model acterised by delayed attainment of bladder control, We previously used longitudinal latent class analysis – on September 30, 2021 by guest. Protected copyright. persistent wetting and relapses.20 23 No studies have (LLCA) to derive separate models of daytime wetting examined whether different patterns of UI in childhood and bedwetting in childhood.21 23 In this earlier work, are differentially associated with adolescent outcomes. we showed that patterns of daytime wetting at 4–9 years The current study uses longitudinal data from a large could be adequately explained by a four-class solution UK cohort to identify subgroups of children who differ and patterns of bedwetting could be explained by five in patterns of daytime wetting and bedwetting during classes (see online supplementary material). Separate childhood. The aims are to study the overlap between latent class models for daytime wetting and bedwetting patterns of daytime wetting and bedwetting in childhood ignore the comorbidity between these continence pro- (4–9 years) and to examine whether these patterns are blems. Therefore, in the current study, we derived a ‘par- differentially associated with bladder and bowel symp- allel LLCA’ (using in Mplus V.7.11, Muthén & Muthén) toms in adolescence (14 years). in order to describe the repeated bivariate data of daytime wetting and bedwetting in tandem. We then examined the association between the latent classes and METHODS bladder and bowel symptoms in adolescence using logis- The sample comprised participants from the Avon tic regression.
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