Pediatr Nephrol (2012) 27:597–603
DOI 10.1007/s00467-011-2028-1
ORIGINAL ARTICLE
Prevalence of lower urinary tract symptoms
in school-age children
Giovana T. Vaz & Monica M. Vasconcelos & Eduardo A. Oliveira & Aline L. Ferreira &
Paula G. Magalhães & Fabiana M. Silva & Eleonora M. Lima
Received: 17 February 2011 / Revised: 26 August 2011 / Accepted: 6 September 2011 / Published online: 4 October 2011
# IPNA 2011
Abstract Epidemiological studies have demonstrated rates
of incontinence and enuresis as high as 20% in school-age
children. This cross-sectional study aimed to investigate the
prevalence of lower urinary tract (LUT) symptoms in 739
children aged 6–12 years enrolled in three government
schools with different socioeconomic levels in Minas
Gerais, Brazil. Symptoms of LUT were evaluated using a
modified version of the Dysfunction Voiding Scoring
System in which the cutoff point considered as an indicator
of LUT dysfunction is >6 for girls and >9 for boys.
Children with a score indicative of symptoms received an
educational booklet on the functioning of the LUT and were
sent for clinical evaluation. LUT dysfunction symptoms
were detected in 161 (21.8%) children. Symptoms were
most frequent in girls (p<0.001), children aged 6–8 (p<
0.028), and attended the school with the lowest social level
(p<0.001). Intestinal constipation was the most prevalent
finding (30.7%), independent of LUT score. The most
common urinary symptoms in children with an elevated
score were diurnal urinary incontinence (30.7%), holding
maneuvers (19.1%), and urinary urgency (13.7%). Stress
factors were associated in 28.4% of children. Our findings
suggest that LUT symptoms must be investigated carefully
at routine pediatric visits.
Keywords Lower urinary tract dysfunction . Urinary
incontinence . Intestinal constipation . School-age children
G. T. Vaz : M. M. Vasconcelos : E. A. Oliveira : A. L. Ferreira :
P. G. Magalhães : F. M. Silva : E. M. Lima (*)
Pediatric Nephrology Unit, Hospital das Clinicas,
Federal University of Minas Gerais (UFMG),
Rua Piauí, 933 apt 502,
Belo Horizonte, MG 30150-320, Brazil
e-mail: eleonoralima@uol.com.br
Introduction
Children with lower urinary tract dysfunction (LUTD) may
present urinary incontinence (UI), urinary tract infection
(UTI), vesicoureteral reflux (VUR), and intestinal constipa-
tion in isolation or in combination. Epidemiological studies
demonstrate rates of incontinence and enuresis as high as 20%
in school-age children. These problems may be responsible
for a significant percentage of the number of pediatric visits or
visits to specialists such as nephrologists or urologists [1].
Symptom terminology, signs, and conditions of the LUT in
children may be a factor of semantic confusion. The
International Children’s Continence Society (ICCS) has
established standard definitions for urinary symptoms that
are classified according to the phase of bladder function:
storage or voiding [2]. According to the ICCS definition of
storage, symptoms are increased or decreased urinary
frequency, urinary incontinence, urinary urgency, and noctu-
ria. Voiding symptoms are classified as hesitation, straining,
weak stream, and intermittency. Other symptoms are:
holding maneuvers, feeling of incomplete emptying, post-
micturition dribble, and genital and LUT pain [2].
Relevant epidemiological studies allow for the supposi-
tion that the prevalence of LUTD in children is variable,
possibly affecting between 2% and 25% of the population
[3–12]. Despite this disparity in the prevalence reported in
studies, in which the informants are generally the parents,
LUTD is common in the pediatric population and repre-
sents a challenge for specialized interdisciplinary teams.
The literature shows that school-age children are able to
efficiently communicate their health needs and symptoms,
and the American Academy of Pediatrics and other
pediatric organizations recommend involvement and direct
questioning of children regarding the functioning of their
health [13, 14].
598
The association between LUTD and UTI has been
established, though the causal relationship is not clear.
Data from the literature suggest that LUTD predisposes
children to recurring UTI and kidney damage. The risk of
bladder colonization and of UTI increases in children with
incomplete bladder emptying due to urinary dysfunction or
a hyperactive bladder [15, 16]. Early diagnosis and a
therapeutic approach has thus become essential and,
therefore, knowledge of the epidemiology and clinical
manifestations of LUTD are important for selection of
primary and secondary preventive measures.
This study was designed with the objective of investi-
gating the prevalence of LUT symptoms in children aged
6–12 years enrolled at three government schools in the
State of Minas Gerais, Brazil.
Methods
Study design, participants, and location
This is was cross-sectional study in which students from
three government schools participated. The first (school 1)
was located in the city of Belo Horizonte, the second
(school 2) in the town of Inhaúma, and the third (school 3)
in the outskirts of Belo Horizonte. Student socioeconomic
level was classified according to the National Association
of Research Companies – ANEP [17]: School 1 – class C,
schools 2 and 3 – class D; school 3 is located in a zone of
high social risk. Table 1 shows the distribution of students
in the schools.
This study consisted of 739 students of both genders
between the ages of 6 and 12 years enrolled in one of the
schools above. Informed consent from the children and
their legal representatives was obtained in all cases. The
initial aim was to reach nearly 100% (1,760) of school
children aged 6–12 years in these three schools. However,
of 420 informed consent forms that were sent to school 1,
only 239 (56.9%) were returned. In school 2, 600 informed
consent forms were distributed and 267 (44.5%) returned.
In school 3, 233 of 740 informed consent forms were
returned (31.4%). Therefore, the 739 children assembled in
Table 1 Sample characteristics
Schools Gender
Male Female
1 117 122
2 120 147
3 103 130
Total
C, D school class
Pediatr Nephrol (2012) 27:597–603
our analysis represent 42% of the total number of students
in the focus age group. Children who did not understand
the questions on the questionnaire and those who presented
neurologic LUTD were excluded, as were those who
refused or whose parents refused to participate in the study.
Only one child, who has a cognitive delay, was excluded
for refusing to answer questions.
Instruments
Symptoms of LUTD were evaluated using an adaptation
of the semantic equivalent of the Brazilian version of
the Dysfunctional Voiding Scoring System (DVSS)
instrument [18, 19] developed by Farhat et al. [5] was
applied by the researchers and two academics in the
school environment. Although the questionnaire was
originally designed to be applied to both parents and their
children, we subsequently decided to interview children
only because of the difficulty for parents to come for the
interview. Moreover, we previously conducted a pilot
study interviewing 96 parent/child pairs, and symptoms
were confirmed in 67 (70%) cases by both parents and
children.
The questionnaire contained ten questions, of which nine
were related to clinical symptoms and one to environmental
factors (social and family). The questions were assigned
scores of 0–3 according to symptom presence and severity.
Urinary symptoms evaluated in questions 1, 2, 5–9 are,
respectively: diurnal urinary incontinence, volume of urine
leakage, urinary frequency, holding maneuvers, urinary
urgency, mictruition straining, and mictruition pain. Ques-
tions 3 and 4 evaluated symptoms related to intestinal
function, and question 10 dealt with stressful events
experienced by the children in their family environment.
Simplified language was used to allow understanding of the
questions. In order to better evaluate and attribute points for
the symptoms reported by the students, an adaptation of the
frequency of these symptoms was necessary. Questions 1,
2, 6, 7, and 8 were given scores according to symptom
frequency as: 0=0–2 times/month; 1=1–2 times/week; 2=
3–4 times/week; 3=5–7 times/week. The attribution of a
score in questions 3 and 4 for defecation frequency was as
Age (years) Number Location Social level
6–8 9–12
133 106 239 Belo Horizonte C
150 117 267 Inhaúma D
132 101 233 Metropolitan Belo Horizonte D
Region
739
Pediatr Nephrol (2012) 27:597–603 599

follows: 0=≥7 times/week, 1=5–6 times/week, 2=3–4 Results

times/week, 3=2–1 times/week. Daily urinary frequency
(question 5), was given a score of: 0=7–8 times/day, 1=5– Table 2 presents a description of the sample (general and
6 times/day, 2=3–4 times/day, 3 =1–2 times/day. A stratified by gender) in accordance with the urinary
score of ≥2 was considered a positive symptom. In symptoms assessed by the DVSS. According to the Farhat
question 10, the answers were dichotomic: yes for a score of 3 score, LUT symptoms were observed in 161 (21.8%) of
and no for a score of 0. The children were asked if they had 739 children observed. A higher frequency of holding-
experienced any stressful situations in the previous month. The maneuver symptoms was detected in the girls in
cutoff point considered by the score as an indicator of the comparison with boys (p=0.019). There was also a
possible presence of LUTD was >6 points for girls (92.7% tendency toward a higher frequency of constipation and
sensitivity, 87% specificity) and >9 for boys (80.9% sensitivity, urinary urgency symptoms in girls vs. boys (p=0.058 and
91.3% specificity) [5]. 0.078 ,respectively, Table 2).
Univariate analysis of categorical variables is presented
Statistical analysis in Table 3. It was observed that the chances of a child of 6–
8 years of age presenting LUT symptoms were 1.5 times
Continuous data are reported as median and respective greater than for those between 9 and 12 years of age.
interquartile range (IQ) or mean and standard deviation Regarding gender, we observed that girls were 3.7 times
(SD) when appropriate. The following variables were more likely to present LUT symptoms than were boys.
included in the analysis: age, gender, and location Regarding school location, it was observed that the chances
(school), and the questionnaire was given to the of LUT symptoms in children at school 3 were 3.5 times
children. The age variable was grouped into two higher than those at school 1, and two times higher than
categories: subgroup 1, 6–8 years of age; subgroup 2, those at school 2. Comparing school 2 to school 1, this
9–12 years of age. Nonparametric variables were
compared using the Mann–Whitney U or Kruskal–Wallis
tests. Dichotomous variables were compared using the Table 2 Description of symptoms general and stratified by gender
chi-square test, and binary logistic regression was used for Variable Total (%) Male (%) Female (%) P value
multivariate analysis. For univariate and multivariate
analyses, the end-point variable was LUTD symptoms Diurnal urinary incontinence
considered as a dichotomous variable (presence or Yes 30.7 29.6 31.7 0.540
absence). The category considered as the standard is No 69.3 70.4 68.3
indicated in the tables with a value of 1.0 in the odds Constipation
ratio (OR) value column. As the response variable is Yes 30.7 27.2 33.7 0.058
categorical (presence vs. absence of symptoms), an No 69.3 72.8 66.3
adjustment was made to a logistic regression model in Reduced diurnal urinary frequency
which all variables with a p value of ≤0.25 were included Yes 10.7 10.1 11.2 0.610
in the univariate analysis. Then, using a backward No 89.3 89.9 88.8
elimination strategy, variables that retained a significantly Holding maneuvers
independent association with the presence LUTD symp- Yes 19.1 15.4 22.2 0.019
toms were included in the final model. In addition, No 80.9 84.6 77.8
interactions between all covariables present in the final Urinary urgency
regression model were tested until only variables with a p Yes 13.7 11.2 15.7 0.078
value ≤0.05 remained. Analyses were carried out using the No 86.3 88.8 84.3
public domain software R Statistical Package. Straining
Yes 4.5 3.6 5.2 0.265
Ethical aspects No 95.5 96.4 94.8
Voiding pain
The study was approved by the Ethics Committee of the Yes 4.2 3.3 5.0 0.242
Federal University of Minas Gerais. In the three schools, No 95.8 96.7 95.0
children with elevated scores were sent for a medical Stressful events
evaluation and given an illustrated educational booklet Yes 28.5 30.5 26.9 0.288
produced by the staff of the Pediatric Nephrology Unit at No 71.5 69.5 73.1
the UFMG, which contained information on the functioning Total (n=739) 100.0 45.7 54.3
of the LUT.
600 Pediatr Nephrol (2012) 27:597–603

Table 3 Ratio of chances per age group, gender, and school attended Discussion
in relation to the symptoms

Covariable Symptoms P value OR 95% CI This transverse study shows a high prevalence of LUTD
symptoms among school-age children attending three
Present Absent government schools in Belo Horizonte (21.8%). These
(n) (%) (n) (%)
symptoms are particularly associated with children between 6
and 9 years of age, girls, and schools located in areas of low
Age (years) socioeconomic levels. LUTD symptoms were significantly
6–8 100 62.1 303 52.4 0.028 1.5 1.02 – 2.2 more frequent among girls (77.6%) than boys (22.4%), a ratio
9 – 12 61 37.9 275 47.6 1.0 of 3.5:1. Vasconcelos et al. [20] undertook urinary reeduca-
Gender tion in 55 children with LUTD refractory to conventional
Female 125 77.6 277 47.9 < 0.001 3.7 2.5 – 5.7 treatment. Of these, 66% were girls, reinforcing the
Male 36 22.4 301 52.1 1.0 observations of a higher prevalence of LUTD among girls,
Location as is described in the literature [21–23].
School 1 30 18.6 209 36.2 1.0 Diurnal urinary incontinence is not an issue that has been
School 2 53 32.9 214 37.0 1.7 1.01 – 2.9 given much importance by families and is therefore not a
School 3 78 48.5 155 26.8 < 0.001 3.5 2.1 – 5.8 determining factor that leads to medical consultations [11,
21]. Consequently, LUTD is investigated and commonly
ORodds ratio, CI confidence interval diagnosed following episodes of UTI. It should be noted
that LUTD is not always evident and, many times, is only
chance was 1.7 times higher [95% confidence interval (CI) diagnosed following irreversible damage to the upper
1.3–3.1). A statistical significance (p value ≤0.05) was urinary tract [24]. Though diurnal urinary incontinence is
observed in this comparison for all covariables. common, its causes are unknown. Associated risk factors
In the final multivariate analysis model, all three have been identified, such as nocturnal enuresis, intestinal
variables (gender, age and school) remained signifi- constipation, UTI, female gender, social difficulties, and
cantly associated with LUTD (Table 4). Children attention deficit disorder [25].
between 6 and 8 years of age presented a 1.7-times In general, the majority of children over the age of 4
greater risk of having symptoms when compared with years have complete diurnal sphincter control; however,
children between 9 and 12 years of age. Regarding 21.8% of school-age children evaluated in this study still
gender, the chances of a symptom being present in girls presented urinary incontinence or other symptoms such as
were 3.9 times higher than in boys. In terms of location, decreased voiding frequency, holding maneuvers, and urgency.
the chances of children from school 2 presenting the The prevalence of urinary incontinence reported in the
symptoms were 1.7 times greater than those from school literature varies from 1.8% to 20% [12, 25, 26] and diminishes
1. Comparing children from schools 3 and 1, this risk was with age: 10% in children aged 5–6, 5% from 6–12, and 4%
3.7 times higher in school 3. from 12–18 years [27]. In our study, urinary incontinence
occurred in 30.7% of children (Table 2), whereas the presence
Table 4 Final logistical regression model for the presence of urinary of LUTD detected by the DVSS was observed in 21.8%,
symptoms indicating that urinary incontinence was the most frequent
symptom in children whose score did not reach the target
Model Coefficient Standard-error P value OR 95% CI
cutoff level. It is probable that in these children, urinary
Constant −2.3 0.4 <0.001 incontinence was present but was minor and associated with
Age (years) the low score. Using the Farhat score, Mota et al. [11]
6–8 0.5 0.2 0.008 1.7 1.1 – 2.4 conducted a population sample study of 580 children between
9 – 12 1.0 3 and 9 years of age and detected an LUTD prevalence of
Gender 24.2%, with a higher prevalence in girls, younger children,
Female 1.4 0.2 <0.001 3.9 2.6 – 5.9 and children from a lower social level. These findings are in
Male 1.0 agreement with those of this study. In general, we found
School symptoms were more common in children from school 3
1 1.0 situated in a slum area of Greater Belo Horizonte where
2 0.5 0.3 0.036 1.7 1.1 – 2.8
poverty level and violence rates are much higher than areas in
3 1.3 0.3 <0.001 3.7 2.3 – 6.0
which the the other two schools are located. Results shown in
Tables 3 and 4 confirm this observation. In an environment of
OR odds ratio, CI confidence interval poverty, there is a greater probability of the existence of
Pediatr Nephrol (2012) 27:597–603
stressful factors, such as domestic problems, lack of financial
resources, unemployment, split families, and learning diffi-
culties. Children from stressful environments are at a greater
risk of a variety of developmental and behavioral problems,
which could also cause LUT symptoms [28]. However, the
aim of our study does not permit us to establish a cause/effect
link between the stress of a poverty situation and an increased
prevalence of LUTD.
Urinary frequency is not generally investigated in clinical
practice. The consensus published by the International Child-
ren’s Continence Society [2] states that a normal urinary
frequency is between four and seven times per day. Numbers
below and above these values would be classified as reduced
and increased frequency, respectively. Urinary frequency
represents an important symptom that should be evaluated in
children with LUTD. In healthy students between 7 and
15 years of age, the average number of voidings was five
times per day, with roughly 50% of them reporting four to
six episodes/day and 95% three to eight times/day [29].
In a population study that assessed 8,475 school-age
children, von Gontard et al. [30] detected diurnal urinary
incontinence in 10.4% of children who had significantly
more gastrointestinal, urinary, and psychological symptoms
than those in the control group. High urinary frequency is
also an important symptom in children with diurnal urinary
incontinence. Children who had severe diurnal urinary
incontinence (>5 times/week) were more likely to have a
higher voiding frequency [30]. Although in our study it was
not possible to evaluate the high urinary frequency (>8 times/
day), 10.7% of children reported a reduced frequency (≤ 3
times/day). Some children delay voiding, generally in special
situations, such as when the hygienic conditions at school are
poor. However, some develop a decreased voiding frequency
that results in an increase in bladder capacity. With this
increase in bladder repletion, the detrusor muscle distends
excessively and may become underactive. These children are
at an increased risk of UTI, vesicoureteral reflux, and damage
to the upper urinary tract [2, 31, 32]. Therefore, children
diagnosed in this study with reduced urinary frequency may
present the alterations described above and, as a result, need
a clinical and propedeutic investigation to reach a diagnosis
of their condition that will lead to the adoption of appropriate
therapeutic measures. A study conducted in Germany
regarding quality of life and self-esteem found that children
with LUTD have a poor quality of life and a higher rate of
behavioral disturbances than children not suffering from
incontinence. The authors [33] concluded that such children
require attention, especially those with voiding postpone-
ment. These are the patients with the lowest quality of life
and the highest rate of behavioral disturbances. Therefore
their parents must be adequately oriented regarding the need
for a psychological approach [33]. Also, evaluation of
quality of life of children and adolescents with LUTD found
601
that such children share positive perceptions toward their
family life and their playtime but tend to develop an
introspective behavior in relation to their peers because they
fear discrimination that may result from exposure of their
dysfunction [34].
Our analysis detected a lower prevalence of LUTD
symptoms in children from 9 to 12 years of age in
comparison with those 6–8 years of age, as has also been
described by other authors [20, 35]. Urinary incontinence in
its various forms has an age-dependent factor. A study of
11,000 English children found a reduction in diurnal
urinary incontinence from 10.5% to 2.2% in boys and from
11% to 3.2% in girls between 4.5 and 9.5 years of age,
respectively [36]. Chung et al. [7] evaluated 19,240
children aged between 5 and 13 years whose parents had
completed a questionnaire regarding their child’s hyperac-
tive bladder condition and voiding and defecating habits.
The overall prevalence of a hyperactive bladder was 16.5%
and reduced from 22.9% at 5 years to 12.2% at 13 years of
age. The authors found that nocturnal enuresis, constipa-
tion, fecal incontinence, a delay in bladder control, a history
of UTI, and poor toilet facilities were factors associated
with a hyperactive bladder.
Children with a hyperactive bladder present a higher risk
of having the same problem as adults. Diurnal urinary
incontinence and nocturnal enuresis in childhood double
the risk of urge incontinence in adulthood [37]. Another
retrospective study of 170 women found a high prevalence
of LUTD during childhood in women with the following
symptoms: increased urinary frequency, urgency, stress
incontinence, and urge incontinence [38]. These observa-
tions emphasize the importance of proper diagnosis in
childhood, as well as of studies to assess its role in the
development of hyperactive bladder in adults. They also
reinforce the need for greater attention to be paid by
healthcare professionals to these alterations, the diagnosis
and treatment of which should take place during childhood,
thereby avoiding their perpetuation into adulthood.
In our study, constipation was detected in 30.7% of
children, confirming results reported in the literature
regarding the association between LUTD and constipation.
Loening-Baucke [39] detected a 22.6% prevalence of
constipation in 482 children between 4 and 17 years of
age, with their findings being similar for both genders. The
prevalence of urinary incontinence in this group was
10.5%, with urinary and fecal incontinence being signifi-
cantly more common in children with constipation com-
pared with those without constipation. Treatment of
intestinal constipation resulted in improvement in 52% of
the children, whereas the resolution of diurnal incontinence
was 89% and nocturnal enuresis 63% [40]. Thus, treatment
of constipation has an important role in handling urinary
symptoms in many children with chronic constipation and
602
fecal incontinence. Therefore, the high frequency of intestinal
constipation detected in our study was expected. The presence
of constipation constitutes a comorbidity that is associated
with LUTD, affects relaxation of the pelvic-floor muscles, and
contributes to the perpetuation of urinary symptoms. In
addition, constipation is a symptom that may be under-
diagnosed, as, once children attain sphincter control, parents
rarely take an interest in their evacuation habits.
Our results must be considered in the light of several
limitations associated with study design. Farhat et al. [5]
made the first attempt to construct a dysfunctional voiding
symptom score system in the pediatric age group. The
Farhat questionnaire was originally designed to be an-
swered by children with the help of parents. In our study,
we used it directly with children, without parental help. The
value of obtaining children’s reports about their own health
from questionnaires has been discussed in clinical pediat-
rics, and some authors have demonstrated that an adequate
understanding and reliability of those reports is possible,
even at age 6 years, increasing after age 7 [13, 41]. The
observation that children's personal reports provide a viable
means of monitoring internal experiences of health and
distress during childhood and adolescence supported the
use of questionnaires about child health research specifi-
cally aimed at that age group [13]. Nevertheless, it is
important to point out that although the suggested modifi-
cation of the Farhat questionnaire may prove beneficial,
future studies comparing clinical confirmation results of the
questionnaire findings with and without parental help are
required to confirm whether the proposed score can be used
independently of parental participation. Thus, our study
could provide a useful step for validating this scoring
system as applied directly to children to assess the
prevalence of LUTD symptoms. Also, we need to confirm
the diagnosis obtained by the questionnaire using an
adequate clinical evaluation. Accordingly, children with an
elevated score are being clinically evaluated with the
objective of confirming the symptoms detected by the
DVSS instrument. On the other hand, some features of the
study may increase the strength of our findings, such as
sample size, the possibility of investigating children directly
and individually, and of using a standardized questionnaire.
We were unable to identify any other prevalence study
conducted in our field related to this age group concerning
LUT symptoms. The majority of studies select a symptom
or condition as the subject matter, and parents, but rarely
the children, are interviewed.
Conclusion
This study shows a high prevalence of urinary tract
symptoms among school-age children, being higher in
Pediatr Nephrol (2012) 27:597–603
younger children, girls, and those in a lower social class.
Such findings must be taken into consideration and
investigated carefully at routine pediatric consultations.
Acknowledgements This study was partially supported by CNPq
(Brazilian National Research Council) and FAPEMIG. Dr. EM Lima
and Dr. EA Oliveira received a research grant from the Brazilian
Research Council (CNPq).
Conflicts of interest None.
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