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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: [email protected]
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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