Nocturnal enuresis (NE), commonly known as bedwetting, affects children and adolescents worldwide [1]. It may impair emotional well-being, self-esteem, social participation, academic functioning, and quality of life, while also placing stress on families [2]. Enuresis refers to repeated voiding into bed or clothes in a child who has reached an age at which bladder control is developmentally expected [3]. For research purposes, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) requires a developmental age of at least five years, clinically significant distress or impairment or a frequency of at least twice weekly for three consecutive months, and exclusion of substance effects or another medical condition [4].

Enuresis is often underreported, and many parents do not perceive it as a condition requiring medical care [5]. Prevalence estimates vary according to age, study design, diagnostic definition, and cultural context. Approximately 10% - 20% of five-year-old children may be affected, with prevalence decreasing to about 1% - 3% by adolescence [3][6]. Some studies report higher prevalence among boys, particularly at younger ages [3].

NE is multifactorial. Reported associated factors include age, sex, family history, urinary tract infection, stressful events, constipation, sleep problems, socioeconomic conditions, and behavioral or emotional difficulties [3][6][7].

Regional estimates also vary, including 10.2% in Iran [8], 18% in Egypt [9], and 30.5% in a referral continence clinic in Abu Dhabi [10]. Local hospital-based estimates may help clinicians recognize the burden among children attending care, although they cannot provide a population estimate for all children in Baghdad.

This study aimed to estimate the prevalence of nocturnal enuresis among children aged 5 - 15 years attending selected pediatric clinics and to identify factors associated with wet-night frequency among affected children.

1) To estimate the prevalence of nocturnal enuresis among children aged 5 - 15 years attending the selected pediatric clinics.

2) To identify the demographic and sociodemographic profile of patients with nocturnal enuresis.

3) To evaluate medical and physiological factors, including family history and underlying health conditions, and psychological and behavioral factors, such as stress, anxiety, and sleep patterns, linked to nocturnal enuresis.

4) To evaluate factors associated with wet-night frequency among children with nocturnal enuresis.

A total of 1087 caregivers, each representing one unique child, were screened. No eligible caregiver declined participation, and duplicate visits were excluded. Of the screened children, 252 had nocturnal enuresis, giving a prevalence of 23.18% (95% CI, 20.77% - 25.78%) among children attending the selected pediatric clinics (Figure 1).

Figure 1. Prevalence of nocturnal enuresis among children aged 5 - 15 years attending the selected pediatric clinics (N = 1087).

Among the 252 participants, the mean caregiver age was 34.5 ± 7.0 years. The largest age group was 30 - 39 years, including 129 (51.2%) caregivers. Most caregivers were mothers, 198 (78.6%), and 175 (69.4%) were housewives. Most children lived with both parents in the same household, 230 (91.3%), and 146 (57.9%) had 1 - 3 siblings. Among fathers, 113 (44.8%) had completed primary education; among mothers, 116 (46.0%) had completed primary education. Most families reported no consanguinity, 139 (55.2%), as shown in Table 1.

Table 1. Sociodemographic characteristics of affected children and their families (N = 252).

A family history of enuresis was reported in 150 (59.5%) children. The most common family history was on the father’s side, 49 (19.4%), followed by siblings, 42 (16.7%). A history in both parental families was reported in only nine (3.6%), as shown in Figure 2 and Figure 3.

Figure 2. Reported family history of nocturnal enuresis among affected children (N = 252).

Among the 252 children, the mean age was 8.9 ± 3.0 years. Males accounted for 127 (50.4%) and females for 125 (49.6%). The largest proportion was first-born children, 69 (27.4%). A younger sibling born after the involved child was present in 147 (58.3%), as shown in Table 2.

Figure 3. Family members reported to have had nocturnal enuresis among children with a positive family history (N = 150).

Table 2.Demographic characteristics of children with nocturnal enuresis (N = 252).

Most children were free from chronic illness, 224 (88.88%), and 231 (91.7%) were not taking medications that might affect the urinary system. Congenital anomalies were identified in 12 children (4.8%), including inguinal hernia (0.8%), atrial septal defect (0.4%), blindness (0.4%), and other unspecified anomalies (2.7%).

Pinworm infestation was present in 49 children (19.4%), while chronic constipation was noted in 27 (10.7%). Twenty-seven children had undergone previous surgery. The most frequently reported procedures included tonsillectomy (1.6%), bilateral orchiopexy (0.8%), cystocele repair (0.8%), hernia repair (0.8%), and tonsillectomy with adenoidectomy (0.8%), with other procedures reported in 5.1%. ADHD was reported in nine children (3.6%), as shown in Table 3.

Table 3.Medical and surgical characteristics of children with nocturnal enuresis (N = 252).

Regarding wet nights per week, 139 (55.2%) children experienced enuresis every night, 60 (23.8%) had more than two wet nights but not every night, and 53 (21.0%) had two or fewer wet nights. Involuntary urination occurred only at night in 222 (88.1%), while 30 (11.9%) had both daytime and nighttime wetting. A total of 219 (86.9%) had never achieved dryness, 13 (5.2%) had previously been dry for less than six months, and 20 (7.9%) had been dry for at least six months. Accordingly, 232 (92.1%) were classified as primary and 20 (7.9%) as secondary enuresis. Eighty-nine (35.3%) never had recurrent urinary tract infections. Nighttime fluid intake was common, with 101 (40.1%) always consuming fluids at night. Daytime thirst occurred most of the time in 84 (33.3%), while excessive daytime urination occurred most of the time in 61 (24.2%). Symptoms had lasted more than four years in 131 (52.0%), as shown in Table 4.

Table 4. Clinical presentation and timing of nocturnal enuresis (N = 252).

Among the children, 64 (25.4%) were younger than six years. Of 188 school-aged children, 180 (95.7%) were enrolled in school and eight (4.3%) were not. Among the 180 enrolled children, 99 (55.0%) had good, 56 (31.1%) intermediate, and 25 (13.9%) poor academic performance. Bullying responses were valid for 178 enrolled children; 23 (12.9%) reported bullying and 155 (87.1%) did not. Two bullying entries contained inapplicable response categories and were excluded from that percentage calculation (Table 5).

Table 5. School enrollment, performance, and bullying among affected children.

Regarding sleep regularity, 121 (48.0%) had regular sleep most of the time. Continuous sleep was always reported in 109 (43.3%), whereas only nine (3.6%) rarely had continuous sleep. Most children, 171 (67.9%), never experienced nightmares, as shown in Table 6.

Table 6. Sleep characteristics of children with nocturnal enuresis (N = 252).

The behavioral responses of the 252 children with enuresis were diverse. Figure 4 presents the frequency spectrum of emotional states among children coping with enuresis.

Figure 4. Emotional reactions of children to enuresis (N = 252); children may have had more than one emotional reaction.

The impact of enuresis on parents and family dynamics was substantial. Psychological stress was reported by 133 (52.8%) families, while nine (3.6%) reported financial effects, as shown in Figure 5.

Figure 5. Effects of nocturnal enuresis on parents and families (N = 252).

Family reactions to wet nights varied. Most families, 145 (57.5%), reassured the child. However, 40 (15.9%) reported verbal punishment and eight (3.2%) used physical punishment. Motivational strategies were reported by 14 (5.6%), while 45 (17.9%) reported no specific response, as shown in Figure 6.

Figure 6. Family reactions to children’s wet nights (N = 252).

Table 7.Family management of nocturnal enuresis (N = 252).

Regarding management, 175 (69.4%) families did not seek medical consultation. Behavioral interventions were common: 141 (56.0%) reduced the child’s fluid intake before bedtime, and 115 (45.6%) regularly awakened the child at night to urinate. Enuresis alarms were used by only three families (1.2%). Medical treatment was used in 29 (11.5%), although 23 (9.1%) could not recall the specific medication. Reported treatments included Tofranil in three (1.2%), amitriptyline in one (0.4%), desmopressin tablets in one (0.4%), and desmopressin nasal spray in one (0.4%), as shown in Table 7.

Table 8.Sociodemographic and familial characteristics by wet-night frequency (N = 252).

Values are n (row %) unless otherwise indicated. P values were obtained using one-way ANOVA, Pearson’s chi-square test, or Fisher’s exact test with Monte Carlo estimation, as appropriate.

In unadjusted analyses, most caregivers in all wet-night frequency groups were mothers, and caregiver type was not associated with frequency (P = 0.503). Caregiver age differed among groups (P < 0.001), with the highest mean age in the group with more than two wet nights per week (37.6 ± 8.6 years) and the lowest in the every-night group (33.3 ± 5.7 years). Parents’ living status was not associated with wet-night frequency (P = 0.262).

Sibling number was associated with wet-night frequency in the unadjusted analysis (P < 0.001). Consanguinity was not associated with frequency (P = 0.273). Paternal and maternal education also differed across frequency groups (P = 0.023 and P = 0.017, respectively), as shown in Table 8. These comparisons are bivariate and do not account for confounding.

Child age differed across frequency groups in the unadjusted analysis (P = 0.044). Children in the group with more than two wet nights per week were oldest, 9.7 ± 3.1 years, while the every-night group was the youngest, 8.5 ± 2.9 years. Sex was not associated with frequency (P = 0.139). Birth order, chronic disease, medication use, pinworm infestation, chronic constipation, and previous surgery were also not associated with frequency (all P > 0.05). Congenital anomalies were more frequent in the every-night group, although the association was not statistically significant (P = 0.100).

Table 9.Child demographic and clinical characteristics by wet-night frequency (N = 252).

Values are n (row %) unless otherwise indicated. P values were obtained using one-way ANOVA, Pearson’s chi-square test, or Fisher’s exact test with Monte Carlo estimation, as appropriate.

ADHD differed across the frequency groups in the unadjusted analysis (P = 0.016), although only nine children had ADHD. Duration of enuresis was not associated with wet-night frequency (P = 0.14), as shown in Table 9.

In the adjusted multinomial model, children with four or more siblings had higher odds of wetting on more than two nights rather than two or fewer nights per week (aOR, 3.96; 95% CI, 1.61 - 9.74; P = 0.003). Maternal primary education, compared with secondary education or higher, was associated with every-night wetting rather than two or fewer wet nights (aOR, 3.86; 95% CI, 1.24 - 12.02; P = 0.020). Child age, caregiver age, paternal education, and ADHD were not statistically significant after adjustment. Estimates for ADHD were imprecise because only nine children had this diagnosis. The overall model was statistically significant (likelihood-ratio χ² = 51.97, 16 degrees of freedom; P < 0.001), as shown in Table 10.

Table 10.Adjusted multinomial logistic regression of wet-night frequency (N = 252).

Reference outcome: two or fewer wet nights per week. Education reference: secondary education or higher. Sibling reference: fewer than four siblings. Overall likelihood-ratio χ² = 51.97, df = 16, P < 0.001. aOR, adjusted odds ratio; CI, confidence interval.

Nocturnal enuresis, defined as involuntary urination during sleep beyond the age of expected bladder control, remains a significant pediatric concern with implications for child development, caregiver stress, and long-term psychosocial outcomes. This study adds data from an Iraqi pediatric population and examines a broad range of demographic, familial, behavioral, and medical factors.

1) The hospital-based, non-probability sample represents children attending selected pediatric clinics and cannot be generalized to all children in Baghdad.

2) Detailed associated-factor data were collected only from children with enuresis. Therefore, the study evaluates factors associated with wet-night frequency among cases, not factors associated with developing nocturnal enuresis.

3) The cross-sectional design does not establish temporality or causality.

4) Some sensitive variables, including ADHD, emotional difficulties, and punishment, were caregiver reported and may be affected by recall or social desirability bias.

5) Although diagnosis and exclusion of important medical causes were confirmed by a specialist pediatrician or pediatric neurologist, the questionnaire did not contain a complete ICCS daytime lower urinary tract symptom inventory. Monosymptomatic and non-monosymptomatic enuresis could therefore not be classified reliably.

6) ADHD was uncommon, and several educational categories were small. The resulting adjusted estimates had wide confidence intervals.

7) Two bullying responses among enrolled children used inapplicable categories. Bullying percentages were therefore calculated using valid responses.

1) Nocturnal enuresis was identified in 23.18% (95% CI, 20.77% - 25.78%) of children aged 5 - 15 years attending the selected pediatric clinics. This estimate should not be generalized to all children in Baghdad.

2) In the adjusted model, having four or more siblings was associated with wetting on more than two nights rather than two or fewer nights per week.

3) Maternal primary education, compared with secondary education or higher, was associated with every-night wetting rather than two or fewer wet nights per week. Other adjusted associations were not statistically significant.

4) Psychological stress and physical exhaustion were commonly reported by families, while professional consultation and evidence-based treatment use were limited.

5) Most families reassured their children, but verbal and physical punishment remained present in some households.

1) Incorporate screening for nocturnal enuresis into routine primary care and preschool health assessments. Screening should address urinary control, sleep patterns, psychosocial stressors, and family history. Systematic screening may support timely intervention, reduce stigma, and guide families toward appropriate behavioral, pharmacological, or supportive treatment.

2) Implement school- and community-based awareness programs to educate caregivers about the causes and management of enuresis, reduce stigma, and encourage supportive parenting.

3) Integrate behavioral, sleep, and urological screening into primary pediatric care, particularly for children with ADHD or sleep disorders.

4) Improve access to evidence-based treatments, including enuresis alarms and desmopressin, through public health services.

5) Conduct multicenter, longitudinal, and interventional studies in Iraq to clarify cultural influences and optimize management strategies.

Dhuha Qassim Mohammed Salih, data collection and writing;

Sahar A. Esa Al-Shatari, supervision, data analysis, and writing;

Hassan Mahmoud Salman, data collection and writing.