ORIGINAL ARTICLE

Nocturnal enuresis in sickle cell disease and thalassemia major:associated factors in a clinical sample

Ozalp Ekinci • Tanju Celik • Sule Unal •

Gonul Oktay • Fevziye Toros • Cahit Ozer

Received: 13 September 2012 / Revised: 20 August 2013 / Accepted: 23 August 2013 / Published online: 8 September 2013

� The Japanese Society of Hematology 2013

Abstract In this study, we aimed to investigate the

prevalence and associated factors of nocturnal enuresis in

sickle cell disease (SCD) and thalassemia major (TM)

patients in a single center from Turkey. One hundred and

six patients, 51 (48.1 %) with TM and 55 (51.9 %) with

SCD, and 80 age-matched healthy controls were included in

the study. Semi-structured interviews were conducted with

the caregivers of pediatric and adult patients. The interview

included questions on nocturnal enuresis and psychosocial

variables. Patients’ hospital files were reviewed to search

for disease-related factors. Twenty-eight of the patients

(26.4 %) and three (3.7 %) of the controls had nocturnal

enuresis. Younger age, TM diagnosis, family history of

nocturnal enuresis and family problems were found to be

more frequent in patients with nocturnal enuresis. Among

the patients with SCD, frequencies of hospitalization and

painful crises were found to be higher in those with

enuresis. According to the binary logistic regression ana-

lysis, diagnosis of TM (p = 0.031, OR = 0.262) and

younger age (p = 0.005, OR = 0.869) were found to be

independent risk factors for nocturnal enuresis in the patient

group. Nocturnal enuresis is a common problem in children

and young adults with TM and SCD. Associated factors in

both conditions will be clarified with future studies.

Keywords Nocturnal enuresis � Sickle cell disease �Thalassemia major

Introduction

Sickle cell disease (SCD) and thalassemia major (TM) are

the two most common genetically inherited hemoglobin-

opathies. SCD is characterized by anemia and disabling

complications including episodic painful crises. SCD pri-

marily affects people of African, Caribbean, Asian, Middle

Eastern, and Mediterranean descent, whereas TM mostly

affects patients of Mediterranean descent [1, 2]. The clin-

ical features of TM mainly include severe anemia, jaun-

dice, hepatosplenomegaly, growth retardation and skeletal

abnormalities [2]. Both of the conditions require continu-

ous and distressing treatment regimens, including paren-

teral iron chelation therapy, regular medical supervision

and frequent admissions to hospital [1–4]. A number of

studies have shown that children and adults with SCD and

TM have a higher frequency of psychiatric problems when

compared to the normal controls [5–9].

Nocturnal enuresis is defined as the involuntary voiding

of urine in bed beyond the age at which bladder control is

normally expected [10]. The prevalence of nocturnal

enuresis is estimated to be around 3 % for males and 2 %

for females at the age of 10 [10, 11]. There is a spontaneous

remission rate of 15 % every year after age 5 in the general

population [11, 12]. The available research indicates that

nocturnal enuresis is more common and persistent among

children and adults with SCD when compared to the nor-

mal population [13, 14]. TM patients were also found to

have a higher frequency of nocturnal enuresis when com-

pared to healthy controls [15]. However, etiological

explanations and associated factors of nocturnal enuresis in

O. Ekinci (&) � F. Toros

Child and Adolescent Psychiatry Department, Mersin University

School of Medicine, 33079 Mersin, Turkey

e-mail: ozalpekinci@yahoo.com

T. Celik � C. Ozer

Pediatrics Department, Mustafa Kemal University Faculty

of Medicine, Hatay, Turkey

S. Unal � G. Oktay

Hematology Clinic, Antakya State Hospital, Hatay, Turkey

123

Int J Hematol (2013) 98:430–436

DOI 10.1007/s12185-013-1422-9

SCD and TM have not been studied thoroughly. Although

not completely identified, the etiology for this condition in

SCD has been proposed to be the same as children with

enuresis without a hemoglobinopathy [11, 14].

This study aims to investigate the prevalence and

associated factors of nocturnal enuresis in children and

adults with SCD and TM in Hatay, Turkey.

Materials and methods

Sample

Sickle cell disease and TM patients between the ages of 6

and 40 who attended Hatay Thalassemia center were

included in the study. The study period lasted from

December 2011 to March 2012. The study was carried out

with the approval of the Human Medical Ethics Committee

of the Mustafa Kemal University Faculty of Medicine in

Hatay. In the study procedure, study questionnaires were

explained to the participants by a member of the study

team and informed consent from each patient and parent

was obtained. The children and adults with documented

mental retardation (MR) and autistic spectrum disorders

were excluded from the study. A total number of 112

patients were included in the study. Age-matched healthy

controls were recruited from the healthy siblings of patients

admitted to the same hospitals’ general pediatrics and

internal medicine outpatient clinics for diseases other than

hemoglobinopathies. The control group consisted of 80

subjects.

The semi-structured interview

The semi-structured interview used in the study was

designed by the study team. During the interview, which

was held in the clinic, one member of the study team

directly asked the study questions to the sample. The

interview with the adult patients and the parents’ of chil-

dren patients included questions on the following issues.

Demographic variables

The age, sex and the hematological diagnosis of the patient

were evaluated.

Nocturnal enuresis

For the definition of nocturnal enuresis, previous studies on

the topic were reviewed [11, 13–15] and the definition used

by Barakat et al. [11] was chosen for the study. For present

enuresis, the sample was asked if they had presently wet

the bed at night more than once a week for at least

3 months. For past enuresis, the sample was asked if they

had ever wet the bed at night more than once a week for at

least 3 months after the age of five. All the patients with

present nocturnal enuresis were consulted to the urology

department of the same hospital for the differential diag-

nosis. After the urological evaluation, the patients with a

urological diagnosis of a structural urogenital abnormality

or a genitourinary infection were excluded from the study.

After this exclusion, the total number of the sample was

determined as 106. All of the patients with present noc-

turnal enuresis were also asked if any of their primary

relatives or siblings had a history of enuresis.

Daily life problems

The sample was asked if they had one or more of the

following daily life problems: academic underachievement

and/or school attainment problems, problems in social life,

occupational failure and/or compliance problems at work.

The same question was asked to the parents’ of pediatric

patients. The patients and parents’ of children and ado-

lescents who stated ‘‘yes’’ were asked to choose one of the

following choices for the severity of the problems:

‘‘never’’, ‘‘rarely’’, ‘‘occasionally’’, ‘‘frequently’’. In the

analysis of this question, the participants who gave the first

two answers were identified as not having daily life prob-

lems, and those who gave last two responses were identi-

fied as having daily life problems.

Family problems

The sample was asked if they had family problems (con-

flicts and/or quarrels with parents and/or other family

members). The same question was asked to the parents’ of

pediatric patients. The patients and parents’ of children and

adolescents who stated ‘‘yes’’ were asked to choose one of

the following choices for the severity of the problems:

‘‘never’’, ‘‘rarely’’, ‘‘occasionally’’, ‘‘frequently’’. In the

analysis of this question, the participants who gave the first

two answers were identified as not having family problems,

and those who gave last two responses were identified as

having family problems.

Disease-related variables

The frequencies of hospitalization and painful crises in the

previous year were evaluated for patients with SCD. These

two variables were classified as ‘‘between 1 and 4 times’’,

‘‘between 5 and 10 times’’ and ‘‘over 10 times’’. All of TM

patients were having regular blood transfusions at the rate

of 10 ml/kg every 3–4 weeks. The information taken from

the patients was also confirmed with the hospital records.

Patients’ hospital files were also reviewed to determine the

Enuresis in sickle cell disease and thalassemia 431

123

use of hydroxyurea, presence of splenectomy and the lab-

oratory findings including ferritin, alanine aminotransfer-

ase (ALT), creatinine, albumin, hemoglobin (Hb),

hematocrit (Htc), white blood cells (Wbc) and platelets.

The mean values of the three consecutive measurements of

laboratory findings in the previous year were used in the

study.

Statistical analysis

The collected data were analyzed by using the SPSS ver-

sion 15.0 (SPSS Inc., Chicago, IL, USA). Demographic

variables and study variables that are categorical in nature

were presented by using descriptive statistics. v2 test was

used for the comparison of normally distributed categorical

variables. For the comparison of categorical variables

which were not normally distributed, Fisher’s exact prob-

ability test was used. Normally distributed parametric

variables were compared between groups by using Stu-

dent’s t test. The Mann–Whitney U test was used for the

comparison of continuous variables which were not nor-

mally distributed. Binary logistic regression analysis was

performed for the risk factors of nocturnal enuresis. The

p value \0.05 was accepted to be statistically significant.

Results

Among the patient group (N = 106), 51 (48.1 %) were

diagnosed with TM and 55 (51.9 %) were diagnosed with

SCD. 55 (51.9 %) patients were male and the mean age of

the patient group was 18.57 ± 9.7 (min 6, max 40). The

mean ages of TM and SCD patients were 14.31 ± 6.27 and

22.49 ± 10.66, respectively (p = 0.001). The control

group (N = 80) had a mean age of 17.8 ± 8.14 (min 7,

max 38) and 52.5 % (N = 42) of them were males. 28

(26.4 %) of the patient group and 3 (3.7 %) of the control

group had present nocturnal enuresis (p = 0.001). The

patients with enuresis were significantly younger than those

without enuresis (12.05 ± 5.4 vs 20.8 ± 9.9, p = 0.001).

Patients with TM had a higher frequency of enuresis when

compared with those with SCD (p = 0.001). The fre-

quency of enuresis was 45 % (n = 23) in patients with TM

while it was 9.1 % (N = 5) in patients with SCD. The

mean ages of TM and SCD patients with enuresis were

12.28 ± 5.32 and 11.0 ± 2.82, respectively. In addition to

these findings on present enuresis, 7 patients with TM

(13 %) and 4 patients with SCD (7 %) reported past

enuresis but not at the time of study procedure. Table 1

summarizes the comparison of demographic variables,

diagnosis and psychosocial variables of the control group

and patient group with and without enuresis. Family history

of enuresis and family problems were more common in the

patient group with enuresis when compared to those

without (p = 0.029 and p = 0.016, respectively). In the

control group, family history of enuresis was found in all of

those with enuresis (N = 3), and 46 % (N = 36) of those

without enuresis.

Table 2 shows the comparison of study variables in

patients with TM according to the presence of enuresis. TM

patients with enuresis were found to be younger than the

ones without enuresis (12.28 ± 5.32 vs 15.67 ± 6.41,

p = 0.048). The frequency of family history of enuresis

was found to be higher in patients with enuresis when

Table 1 Demographic variables, diagnosis and psychosocial variables of the control group and patient group with and without enuresis

Control group Patient group p value*

N = 80 N = 106

Enuresis present Enuresis not present Enuresis present Enuresis not present

3 (3.7) 77 (96.3) 28 (26.4) 78 (73.6)

N (%) N (%) N (%) N (%)

Age (mean ± SD) 10 ± 4.6 19 ± 8.2 12.05 ± 5.4 20.8 ± 9.9 0.001

Sex

Male 3 (100) 39 (48.7) 15 (53.5) 40 (51.2) 0.51

Diagnosis

TM – – 23 (82.1) 28 (35.8) 0.001

SCD – – 5 (17.9) 50 (64.2)

Family history of enuresis 3 (100) 36 (46.7) 20 (71.4) 37 (47.4) 0.029

Daily life problems 2 (66.6) 24 (31.1) 23 (82.1) 55 (70.5) 0.231

Family problems 2 (66.6) 12 (15.5) 17 (60.7) 27 (34.6) 0.016

Significance level = p \ 0.05

* The comparisons of those with and without enuresis among the patient group

432 O. Ekinci et al.

123

compared to those without enuresis (p = 0.030). Family

problems were also found to be more common in patients

with enuresis (p = 0.042).

Table 3 shows the comparison of study variables in

patients with SCD according to the presence of enuresis.

Those with enuresis were found to be younger than the

ones without enuresis (11.0 ± 2.82 vs 23.64 ± 10.51,

p = 0.010). The frequencies of family history of enuresis

and hospitalization in the previous year were found to be

higher in patients with enuresis when compared with those

without, although both findings did not reach statistical

significance (p = 0.068 and p = 0.053, respectively). The

frequency of painful crises in the previous year was also

found to be higher in the ones with enuresis when com-

pared with those without (p = 0.010).

Tables 4 and 5 show the comparison of laboratory

findings in patients with SCD and TM according to the

presence of enuresis, respectively. As seen in Table 4, ALT

levels were found to be higher in the TM patients without

enuresis when compared to the ones with enuresis

(p = 0.020). As seen in Table 5, Hb and Htc levels were

lower in the patients with SCD when compared to those

without enuresis, although both findings did not reach

statistical significance (p = 0.067 and p = 0.086,

respectively).

In addition to the above-mentioned comparative analysis

in the diagnostic groups, a binary logistic regression ana-

lysis on the risk factors of nocturnal enuresis was also

performed among the total group. As shown in Table 6, the

diagnosis of TM (df = 1, p = 0.031, OR = 0.262) and

younger age (df = 1, p = 0.005, OR = 0.869) were found

as independent risk factors for enuresis.

Discussion

In this study, the prevalence of nocturnal enuresis was

found as 26.4 % in the patient group while it was 3.7 % in

Table 2 The comparison of

study variables in patients with

TM according to the presence of

enuresis

Significance level = p \ 0.05

* The comparisons of those

with and without enuresis

Total group Enuresis present Enuresis not present p value*

N (%) N (%) N (%)

51 (100) 23 (45.1) 28 (54.9)

Age (mean ± SD) 14.31 ± 6.27 12.28 ± 5.32 15.67 ± 6.41 0.048

Sex

Male 32 (62.8) 13 (56.5) 19 (67.9) 0.29

Family history of enuresis 25 (49) 15 (65.2) 10 (34.8) 0.030

Daily life problems 42 (82.3) 20 (87) 22 (78.6) 0.34

Family problems 21 (41.1) 13 (56.5) 8 (28.5) 0.042

Presence of splenectomy 17 (33.3) 8 (47.1) 9 (52.9) 0.53

Table 3 The comparison of

study variables in patients with

SCD according to the presence

of enuresis

Significance level = p \ 0.05

* The comparisons of those

with and without enuresisa In the previous yearb Only significant findings

between frequency groups were

presented

Total group Enuresis present Enuresis not present p value*

N = 55 (%) N = 5 (%) N = 50 (%)

Age (mean ± SD) 22,49 ± 10.66 11.0 ± 2.82 23.64 ± 10.5 0.010

Sex

Male 20 (36.4) 2 (40) 18 (36) 0.34

Family history of enuresis 32 (58.1) 5 (100) 27 (54) 0.068

Daily life problems 36 (65.4) 3 (60) 33 (66) 0.41

Family problems 23 (41.8) 4 (80) 19 (38) 0.091

Frequency of hospitalizationa,b

1–4 28 (50.9) 0 24 (48) 0.053

5–10 20 (36.4) 3 (60) 20 (40)

[10 7 (12.7) 2 (40) 6 (12)

Frequency of painful crisesa,b

1–4 37 (67.3) 0 32 (64) 0.010

5–10 16 (29.1) 4 (80) 16 (32) 0.053

[10 2 (3.6) 1 (20) 2 (4)

Hydroxyurea use 29 (52.7) 2 (40) 27 (54) 0.44

Presence of splenectomy 7 (12.6) 0 (0) 7 (14) 0.35

Enuresis in sickle cell disease and thalassemia 433

123

the control group. The prevalence in the patient group is

much higher than the estimated ratios of general population

[11, 12]. When the mean age of 18 in our patient group is

taken into account, this frequency may mean much more

clinical significance. Regarding the demographic findings,

younger age was found to be linked with nocturnal enuresis

in our sample. This finding is in concordance with the

literature in normal population [16–18]. The available

limited research on SCD also supports this finding. Barakat

et al. [11] found that nocturnal enuresis was more common

in younger ages in SCD. In their population-based study on

SCD patients aged between 5 and 20, Babela et al. [19]

found that the frequency of nocturnal enuresis decreased

significantly from the age of 5–20. A recent study has also

shown nocturnal enuresis to be more prevalent in younger

ages with the frequencies of 42 % in children between the

ages of 6 and 8 years and 9 % in ages 18–20 years,

respectively [13].

In the present study, patients with TM were found to

have a higher frequency of nocturnal enuresis when com-

pared to those with SCD. The available literature on he-

moglobinopathies mainly links nocturnal enuresis with

SCD, although there are reports of enuresis in patients with

TM. Previous studies on patients with SCD generally

revealed distinctively higher rates of nocturnal enuresis

when compared to the normal population. Babela et al. [19]

reported a frequency of 50.9 %, while Akinyanju et al. [20]

and Figueroa et al. [14] reported the frequencies of 41.6

and 29.6 %, respectively. A more recent study also found

the frequency of nocturnal enuresis as 32.3 % in children

and adolescents with SCD [21]. The literature on the

prevalence of nocturnal enuresis in TM is relatively limited

and lower frequencies were reported. In these studies,

which focused on general psychopathology in TM, enuresis

was only a variable among certain psychopathologies. In an

earlier study, Beratis [15] found the prevalence of noctur-

nal enuresis as 12 % in their sample of pre-adolescent

children with TM. Aydın et al. [4] reported the prevalence

of nocturnal enuresis as 8 % in their sample of children

with TM. In a more recent study, only one case of noc-

turnal enuresis was reported in 38 children and adolescents

with TM [9]. The nephropathy characteristics, in relation

Table 4 The comparison of

laboratory findings in patients

with TM according to the

presence of enuresis

Significance level = p \ 0.05

Total group with TM Enuresis present Enuresis not present p value

N (%) N (%) N (%)

51 (100) 23 (45.1) 28 (54.9)

Ferritin (ng/ml) 3620 ± 2234 3040 ± 1869 4115 ± 2420 0.087

ALT (IU/l) 40.3 ± 32.9 28.65 ± 23 49.89 ± 36 0.020

Creatinine (mg/dl) 0.44 ± 0.12 0.45 ± 0.14 0.42 ± 0.13 0.46

Albumin (g/dl) 4.59 ± 2.98 4.63 ± 0.28 4.56 ± 0.30 0.38

Hb (g/dl) 8.91 ± 0.9 9.01 ± 0.9 8.84 ± 0.9 0.50

Htc (%) 26.45 ± 3.4 26.52 ± 3.3 26.39 ± 3.5 0.895

Wbc (9109/l) 13.94 ± 12.8 15.19 ± 15.8 12.91 ± 9.9 0.535

Platelets (9109/l) 395 ± 183 401 ± 178 390 ± 190 0.837

Table 5 The comparison of

laboratory findings in patients

with SCD according to the

presence of enuresis

Significance level = p \ 0.05

Total group with SCD Enuresis present Enuresis not present p value

N = 55 (%) N = 5 (%) N = 50 (%)

Ferritin (ng/ml) 908 ± 1313 1120 ± 1256 881 ± 1331 0.678

ALT (IU/l) 48 ± 23.40 24.3 ± 8.5 23.2 ± 9.5 0.799

Creatinine (mg/dl) 0.43 ± 0.1 0.39 ± 0.1 0.46 ± 0.1 0.313

Albumin (g/dl) 4.51 ± 0.5 4.6 ± 0.3 4.5 ± 0.5 0.667

Hb (g/dl) 8.6 ± 1.2 7.6 ± 1.1 8.8 ± 1.2 0.067

Htc (%) 24.7 ± 3.6 21.6 ± 3.6 25.1 ± 3.5 0.086

Wbc (9109/l) 19.7 ± 54.9 12.3 ± 55.5 20.7 ± 80.3 0.728

Platelets (9109/l) 438 ± 196 304 ± 177 444 ± 195 0.1

Table 6 Binary logistic regression analysis of enuresis risk factors in

the total group

B SE Wald df p OR

Hemoglobinopathy

type

-1.340 0.623 4.626 1 0.031 0.262

Female sex -0.108 0.536 0.041 1 0.840 0.898

Family history of

enuresis

-0.415 0.559 0.552 1 0.457 0.660

Age -0.141 0.050 7.939 1 0.005 0.869

Significance level = p \ 0.05

434 O. Ekinci et al.

123

with anemia levels, might have affected the enuresis rates

in our sample with TM and SCD. It has been shown that

TM patients have a longer history of anemia which may

contribute to nephropathy due to the anemic status [22, 23].

Patients with SCD have a more heterogeneous course

ranging from normal to lower Hb levels and also none to

frequent vaso-occlusive crises [24]. However, our findings

of lower Hb levels in patients with SCD and the higher

enuresis rates despite the higher Hb levels in patients with

TM may indicate that additional factors contributed to

enuresis frequencies in these patients. The lack of an in-

depth investigation of renal functions in the study largely

limits the validity of discussing nephropathy as a possible

etiological factor. On the other hand, there is also a pos-

sibility that the relationship between Hb and enuresis rates

may be incidental or related to the variable stress status of

each patient to the chronic disease and not related to any

nephropathology, as well. Regarding the laboratory find-

ings, there was no statistically significant difference in

serum creatinine levels of patients with or without enuresis

in both TM and SCD groups. Interestingly, the ALT levels

of TM patients without enuresis were found to be higher

than that of those with enuresis. However, this finding

appears to be coincidental and may be interpreted as lar-

gely related to the small sample size.

The frequency of family history of nocturnal enuresis

was found to be higher in our patients and controls with

enuresis when compared with those without. All of the 5

SCD patients with enuresis had a family history of enuresis

while the same frequency was 65 % in patients with TM.

Family history was reported in most of the previous studies

on enuresis in normal population [25, 26]. In children with

SCD, high frequencies of family history of enuresis have

also been reported in two studies. Barakat et al. [11]

showed that 18.5 % of their sample with SCD reported a

history of nocturnal enuresis among family members. In a

more recent study, Jordan et al. [27] found this frequency

as 28.5 %. This finding, as a clue for understanding

enuresis in hemoglobinopathies, may be interpreted that the

genetic predisposition of enuresis in SCD and TM is sim-

ilar to the general population.

In our sample, family problems were found to be more

common in patients with nocturnal enuresis. The frequency

of family problems was 80 and 56 % in SCD and TM

patients with enuresis, respectively. Previous studies on

normal population showed that enuretic patients had a

higher risk of psychosocial and family problems [28–30].

In case for the hemoglobinopathies, research on the rela-

tionship between enuresis and psychosocial functioning is

largely limited. A previous study on children with SCD has

used parent-report Pediatric Symptom Checklist and shown

that enuretic children had higher levels of total psychoso-

cial problems, although family functioning was not

examined in the study [27]. To the best of our knowledge,

this is first study that has shown the negative impact of

nocturnal enuresis on familial relations in SCD and TM

patients. It is largely known that SCD and TM patients

have a highly family-dependent life because of the chronic

nature of conditions. Therefore, the presence of enuresis

may be considered as an additional burden for the care-

givers and close family members. Waking up the patients

every night and repeatedly cleaning their clothes and/or

bed sheets may be considered as distressing for caregivers.

This situation may be even more distressing in the cases

which enuresis persist to adulthood and family members

may grow ambivalent feelings for their life-time social and

emotional burden. They may hesitate to criticize the

patients, but they may also express passive-aggressive

behaviors against their nursing duties. All of these factors

may lead to family problems and conflicts.

In the present study, disease-related factors were also

examined in terms of the presence of nocturnal enuresis.

Among the patients with SCD, those with enuresis were

found to have higher frequencies of hospitalizations and

painful crises when compared to the ones without enuresis.

Previous studies on patients with SCD linked frequent

hospitalizations with psychiatric and psychosocial prob-

lems [31, 32]. The relationship between painful crises and

enuresis in SCD has also been studied in two previous

studies. Babela et al. [19] showed a positive correlation

between a higher frequency of painful crises and nocturnal

enuresis, while Field et al. [13] did not report such an

association.

This study has several noteworthy limitations. Firstly,

the difference on the age distribution between TM and

SCD patients in our sample might have confounded our

findings. Given the developmental nature of the occurrence

and remission of enuresis, age distribution is especially

important for the investigations on prevalence. Secondly,

since the frequency of enuresis was relatively low in the

SCD group, some of the analyses could not reach statistical

significance. In addition to these, investigating family and

daily life problems with a single question was limiting. The

use of a standard questionnaire on psychosocial functioning

would increase the validity of our findings.

In conclusion, our findings in a clinical group of TM and

SCD patients replicate and extend previous findings on the

high prevalence of nocturnal enuresis in hemoglobinopa-

thies. Some of the previously shown correlates of nocturnal

enuresis in the general population, younger age and family

history, were also evident in our sample with nocturnal

enuresis. As an addition to the literature, TM patients were

found to have a higher frequency of nocturnal enuresis than

SCD patients, a finding which must be replicated by future

studies with higher sample size and appropriate method-

ology. In light of our findings and the previous literature,

Enuresis in sickle cell disease and thalassemia 435

123

children and adults with TM and SCD appear to be under

the risk of nocturnal enuresis. Clinical visits of these

patients must include timely screening of enuresis for the

early diagnosis and treatment.

Conflict of interest The authors declare that they have no conflict

of interest.

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