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The influence of delay elimination communication on the prevalence of primary nocturnal enuresis-a survey from mainland china

  • Wang XZ 1,
  • Wen YB 1,
  • Shang XP 1,
  • Wang YH 1,
  • Li YW 1,
  • Li TF 1,
  • Li SL 2,
  • Yang J 1,
  • Liu YJ 1,
  • Lou XP 1,
  • Zhou W 2,
  • Li X 3,
  • Zhang JJ 1,
  • Song CP 4,
  • Jorgensen CS 5,
  • Rittig S 5,
  • Bauer S 6,
  • Mosiello G 7,
  • Wang QW 1,
  • Wen JG 1
1 Pediatric Urodynamic Centre, Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China 2 Department of Urology, Shenzhen Children's Hospital, Shenzhen, China 3 Xiamen Maternal and Child Health Care Hospital, Xiamen, China 4 Pediatric Surgery, First Affiliated Hospital of Xinxiang Medical University, Xinxiang, China 5 Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark 6 Department of Urology, Boston Children's Hospital, Boston, Massachusetts 7 Department of Urology, Bambino Gesù Children's Hospital, Rome, Italy

Publication: Neurourol Urodyn., April 2019

DOI: 10.1002/nau.24002


A pilot survey shows that primary nocturnal enuresis (PNE) prevalence has increased significantly during the past decade in Mainland China. Whether it is related to the delay of elimination communication (EC) is unclear. This study retrospectively investigated the influence of delayed EC on the PNE prevalence in children and adolescents in mainland China.

A cross-sectional study of PNE prevalence was performed by distributing 19 500 anonymous self-administered questionnaires to parents in five provinces of mainland China from July 2017 to October 2017. The questionnaires included sociodemographic data, family caregivers’ information, and details about the disposable diapers (DD) usage, EC commencement date, psychological disorders, lower urinary tract symptoms, and family history of PNE in children and adolescents. The 2017 PNE prevalence was compared with that of 2006 in Mainland China.

The total response rate was 97.04% (18 631 of 19 500) and 92.39% (18 016 of 19 500) qualified for statistical analysis. The PNE prevalence in 2017 has increased significantly compared to that of 2006 (7.30% vs 4.07%, P < 0.001). The PNE prevalence in children with EC starting before 6 months of age was significantly lower than those who start after 12 months of age. The longer DD were used and the later the beginning of EC, the higher the PNE prevalence was found.

The PNE prevalence in Mainland China has increased significantly during the past 10 years. A longer use of DD and later onset of EC may be risk factors for PNE.

Editorial comment from Prof. Konstantinos Kamperis

There is a lot of strong beliefs and misconceptions regarding the relationship between timing of toilet training the usage of disposable diapers and enuresis. This probably reflects the lack of knowledge on the processes that enable a child to become dry.

This is the first study discussing a possible relationship between the timing for toilet training commence, the usage pf diapers and the risk for enuresis. Based on 19500 questionnaires the authors find an increase in the prevalence of enuresis in China between the years 2006 and 2017 from 4.07% to 7.30%. The prevalence of enuresis was lower in children who were started elimination communication early. This is a process that would prepare the child for toilet training and which could be initiated as early as infancy. It is based on the caregivers trying to read the signals of the baby when it needs to eliminate waste and facilitate the process thus avoiding the need for diapers. These findings challenge the current recommendations on toilet training which often advice to delay the process until the children are ready to control the process themselves. However, before we embark on toilet training infants more studies are needed to assess the value but also the drawbacks of early toilet training.