International Journal of Pediatric Otorhinolaryngology (2008) 72, 665—668

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Prevalence of adenoid hypertrophy and nocturnalenuresis in primary school children in Istanbul,Turkey

Sedat Aydin *, Arif Sanli, Ozlem Celebi, Omer Tasdemir,Mustafa Paksoy, Mehmet Eken, Umit Hardal, Emin Ayduran

Kartal Training and Research Hospital, II ENT Department, 34860 Istanbul, Turkey

Received 4 May 2007; received in revised form 21 January 2008; accepted 21 January 2008Available online 6 March 2008

KEYWORDSAdenoid hypertrophy;Nocturnal enuresis;Primary school children

Summary

Objective: The purpose of this study is to investigate the prevalence of an existingrelationship between adenoid hypertrophy and nocturnal enuresis in primary schoolchildren.Methods: The study was performed in four primary schools that were chosen ran-domly in Kartal, Istanbul. The children’s parents were asked to fill out a questionnairethat included questions concerning the associated symptoms of adenoid hypertrophyand nocturnal enuresis. The interrelations between adenoid hypertrophy and noc-turnal enuresis items were examined by X2 tests.Results: The study population consisted of 1132 (625 girls, 621 boys) primary schoolchildren between 5 and 14 years of age (mean 9.59 � 2.60 years). The children weredivided into three groups with 5—7 years old children in Group I (n = 232), 8—10 yearsold children in Group II (n = 506) and 11—14 years old children in Group III (n = 394). Ofthe 1132 distributed questionnaires, 1090 (87.4%) were filled in adequately and wereaccepted for evaluation. Prevalence of adenoid hypertrophy in school children wasfound to be 58 in Group I (27%), 94 in Group II (19.5%) and 78 in Group III (19.9%).Prevalence of nocturnal enuresis in school children was found to be 35 in Group I(15.1%), 51 in Group II (10.1%) and 18 in Group III (4.6%). No statistically significantassociation was present between adenoid hypertrophy and nocturnal enuresis ineither Group I, II or III school children.Conclusion: In contrast to previous studies, our prevalence study did not find anassociation between adenoid hypertrophy and nocturnal enuresis. Thus, this pre-valence study provides otolaryngologists new and interesting information.# 2008 Elsevier Ireland Ltd. All rights reserved.

* Corresponding author. Tel.: +90 2164732023.E-mail address: sedataydin63@yahoo.com (S. Aydin).

0165-5876/$ — see front matter # 2008 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ijporl.2008.01.028

666 S. Aydin et al.

1. Introduction

The adenoids are very small at birth progressivelyenlarge over the first four years of life and tend toregress in adolescence [1]. During this time periodchildren with adenoid hypertrophy may show somepathologic signs and symptoms [2]. In some chil-dren, recurrent acute or chronic inflamation wasalso proposed as a cause of adenoid hypertrophy[2,3]. Adenoid hypertrophy is the most commoncause of both pharyngeal obstruction and sleeprelated breathing disorders that range in diseaseseverity from habitual snoring to obstructive sleepapnea syndrome. Nighttime signs consist of snoring,snorting, mouth breathing, apnea and enuresis noc-turia [1].

Nocturnal enuresis has been associated withobstructive sleep-disordered breathing mostly inhospital-referred adults and children [4]. Nighttimeenuresis is usually defined as the involuntary loss ofurine during sleep after the age of 5 years [5].Nocturnal enuresis is a common problem that canbe troubling for children and their families. Agenetic component likely exists in many affectedchildren [6]. Research also indicates the possibilityof two subtypes of patients with nocturnal enuresis:those with a functional bladder disorder and thosewith a maturational delay in nocturnal argininevasopressin secretion. This prevalence study setout to determine the association between adenoidhypertrophy and nocturnal enuresis.

2. Materials and method

The study was performed in four primary schoolsthat were chosen randomly in Kartal, Istanbul. Aquestionnaire about adenoid hypertrophy and night-time enuresis was constructed. Informed consentwas obtained from the parents of the children, who

Table 1 Comparison of adenoid hypertrophy according to

Age groups Sex Adenoid vegetatio

+(n)

Group I Female 29 (13.5%)Male 29 (13.5%)Total 58 (27.0%)

Group II Female 46 (9.5%)Male 48 (9.9%)Total 94 (19.5%)

Group III Female 36 (9.2%)Male 42 (10.7%)Total 78 (19.9%)

p < 0.01.

were asked to answer a questionnaire about theirchildren. The questionnaire included questions con-cerning frequency of constant mouth breathing dur-ing sleep, upper respiratory system infections, thesnoring regularity, observed apneas, sleep distur-bances, history of adenoidectomy and/or tonsillect-omy, growl breathing and nighttime enuresis.

All the children were examined with a 08(2.7 mm) portable telescope to diagnose the pre-sence of adenoid hypertrophy. An obstructing ade-noid was accepted as at least 50% obstruction at thechonae. The children with adenoidectomies wereexcluded from the study.

A detailed form was filled out for each child. Theinterrelations between adenoid hypertrophy andnocturnal enuresis were examined by x2 tests. Sig-nificant difference was indicated by a p value<0.05.

3. Results

The study population consisted of 1132 (547 girls and585 boys) primary school children between 5 and 14years of age (mean 9.59 � 2.60 years). Because ofuncompleted or improperly completed question-naires, 42 children were excluded from the study.Children who had adenoidectomies were alsoexcluded from the study. The children were dividedinto three groups with 5—7 year old children inGroup I (n = 232), 8—10 year old children in GroupII (n = 506) and 11—14 year old children in Group III(n = 394). The evaluations of adenoid hypertrophyaccording to these different age groups are sum-marized in Table 1. Prevalence of adenoid hyper-trophy in school children was found to be 58 in GroupI (29 girls and 29 boys), 94 in Group II (46 girls and 48boys) and 78 in Group III (36 girls and 42 boys). Therewas no statistically significant association betweenadenoid hypertrophy and gender in the Groups I, IIand III. The comparison of adenoid hypertrophy and

different age groups

n examination Total (n) p

�(n)68 (31.6%) 97 (45.1%)89 (41.4%) 118 (54.9%)

157 (73.0%) 215 (100%) 0.382

194 (40.2) 240 (49.7%)195 (40.4) 243 (50.3%)389 (80.5%) 483 (100%) 0.871

152 (38.8%) 188 (48.0%)162 (41.3%) 204 (52.0%)314 (80.1%) 392 (100%) 0.721

Prevalence of adenoid hypertrophy and nocturnal enuresis 667

Table 2 Comparison of adenoid hypertrophy and noc-turnal enuresis in Groups I, II and III

Age groups Adenoidvegetation

examination p+(n) �(n)

Enuresis nocturna Group I 10 25 0.745Group II 13 38 0.231Group III 6 12 0.138

p < 0.01.

nocturnal enuresis in Groups I, II and III is shown inTable 2. There was no statistical associationbetween adenoid hypertrophy and nocturnal enur-esis in any of the groups.

4. Discussion

In most children, adenoid hypertrophy is normalduring early childhood, when infections of the noseand throat are most common. It continues untilpuberty after which atrophic changes may occur[1,3]. Adenoid hypertrophy can result in snoring,breathing through the mouth and/or speaking with ahyponasal sound Additionally, this can result in otitismedia because of blockage of the eustachian tube.With an enlarged adenoid, airflow is prevented frommoving through the backmost part of the nasalcavity down into the airway. Therefore, individualswho have a hypertrophic adenoid often have diffi-culty breathing through their nose and tend tomouth-breathe. As a result, these children take along time to eat because they have to stop chewingto mouth-breathe.

Previous studies mainly focused on pre-schoolchildren and on children with sleep disorders dueto adenoid obstruction [7—10].

Children without adenoidal hypertrophy may pre-sent obstructive symptoms. However, these childrencan also present nasal pathologies like allergic rhi-nitis, septal deviation and concha hipertrophies.These pathologies due to adenoidal hipertrophy,rarely occur in this age group. Therefore, thesepathologies were excluded from our study.

Nocturnal enuresis is commonly referred to asnighttime bedwetting. This involuntary urinationduring sleep is present in the absence of any urolo-gical or neurological disorder. Nocturnal enuresiscan be divided into primary and secondary nocturnalenuresis. Primary nocturnal enuresis is found in 80%of children, and secondary nocturnal enuresis isfound in 20% of children. Primary nocturnal enuresisis lifelong bedwetting, whereas secondary nocturnalenuresis occurs when continence is lost after having

been dry for more than 6 months. Secondary noc-turnal enuresis often implies loss of normal conti-nence mechanisms and suggests that underlyingdisease may be present. One proposed cause ofsecondary enuresis is upper airway obstructions.This purpose of the study is to investigate therelationship between secondary enuresis and ade-noidal hypertrophy. The cause of primary nocturnalenuresis/bedwetting is unknown. There is a heredi-tary correlation [11] but a single explanation fornocturnal enuresis has been elusive. The currentbelief is that the condition is multifactorial. Numer-ous etiologic factors have been investigated, andvarious theories have been proposed [11]. Geneticpredisposition is the most freguently supportedetiologic variable [12].

The causes of nocturnal enuresis include psycho-logic factors, bladder problems, arginine vasopres-sin decreases and sleep disorders. Many studies haveshown a correlation between adenoid hypertrophyand nocturnal enuresis.

According to Cinar et al., there was a relationshipbetween nocturnal enuresis and upper airwayobstruction that was probably a more common etio-logical factor in nocturnal enuresis than previouslythought [13]. Alexopoulos et al. have been investi-gating the association between primary nocturnalenuresis and habitual snoring in children. Theyfound that, in a community sample of children,those with habitual snoring had primary nocturnalenuresis more often than those without snoring [4].Nocturnal enuresis is a relatively common finding inchildren with obstructive sleep apnea symptoms.Nocturnal enuresis was resolved or markedlyimproved in the vast majority of these patientspostoperatively as reported by Basha et al. [14].

There was a high prevalence of enuresis in cildrenwith suspected sleep-disordered breathing asreported by Brooks and Topol [15]. According toWeissbach et al., upper airway obstruction in chil-dren is greatly associated with nocturnal enuresis[16]. Adenotonsillectomy had a favorable therapeu-tic effect on enuresis in children presenting withobstructive sleep apnea symptoms. Similar resultshave been reported by Firoozi et al. [17] and Nowakand Weider [18].

Habitual snoring was a significant problem forchildren and might be associated with diurnal symp-toms, as reported by Ersu et al. [19].

Weider et al.described enuresis that is to bothchronic adenotonsillar hypertrophy and significantairway obstruction that was relieved by adenoton-sillectomy [20—21].

A proposed cause of enuresis is poor nocturnalregulation of antidiuretic hormone release and inc-reased atrial natriuretic peptide, which is related to

668 S. Aydin et al.

rapid eye movement (REM) sleep disorders. We couldnot show any relationship between adenoid hyper-trophy and enuresis in the primary school children,and there is a lack of knowledgeabout theprevalenceof adenoid hypertrophy in school children. This is nowone of the few prevalence studies about the relation-ship between adenoid hypertrophy and nocturnalenuresis.

In contrast to previous studies, we have shownthat no association was found between adenoidhypertrophy and nocturnal enuresis. Thus, this pre-valence study introduces new and interesting infor-mation for otolaryngologists. Enuresis has beenassociated with severe airway obstruction in chil-dren but is not a consistent finding.

Similar results have been reported by Kara et al.[1]. According to Elshreif et al. [22], nearly allpatients experienced an alleviation of all symptomsexpect enuresis, following adenoidectomy.

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