Diurnal enuresis

Diurnal enuresis also called daytime enuresis or “daytime urine accidents”, is an unintended leakage of urine during waking hours in a child who is old enough to maintain bladder control. Primary diurnal enuresis is incontinence that persists beyond the age when a child otherwise would be expected to be toilet trained. Secondary diurnal enuresis is incontinence in a child who was toilet trained successfully and experienced at least 3 consecutive months of dry days.

Daytime wetting is twice as common in girls as it is boys. About 3 to 4 percent of children between the ages of 4 and 12 have daytime wetting. It is most common among young school-aged children.

Daytime wetting should be considered a problem in a child older than 4 years of age who wets on most days, a child who previously was continent, or a child whose parents are concerned about the problem, regardless of the child’s age.

Although each child is unique, doctors often use a child’s age to decide when to look for a bladder control problem. In general:

• by age 4, most children are dry during the day
• by ages 5 or 6, most children are dry at night

Children can manage or outgrow most bladder control problems with no lasting health effects. However, accidental wetting can cause emotional distress and poor self-esteem for a child as well as frustration for families.

Bladder control problems can sometimes lead to bladder or kidney infections (UTIs). Bedwetting that is never treated during childhood can last into the teen years and adulthood, causing emotional distress.

Diurnal enuresis key points

• Daytime wetting should be considered a problem in a child who is older than 4 years of age or in a child who previously was continent.
• Urge syndrome is a common cause of wetting in preschool-and elementary-age children and presents with daytime and nighttime wetting, increased frequency of voiding, urgency, and squatting behavior.
• If a child who has a urinary tract infection continues to wet or has other symptoms of voiding dysfunction despite successful treatment of the infection, another cause of daytime wetting should be suspected.
• Most causes of daytime wetting can be determined by taking a thorough history, performing a complete physical examination, and obtaining a urinalysis. Ultrasonography of the kidney and bladder is a helpful noninvasive investigation.
• Management considerations for patients who have urge syndrome include a regular voiding routine, good posture during voiding, physiotherapy, prevention or treatment of urinary tract infection, and an anticholinergic medication.

Daytime wetting causes

Many children who have daytime urine accidents have a parent or other relative who did, too. Bedwetting often runs in families. Researchers have found genes that are linked to bedwetting. Genes are parts of the master code that children inherit from each parent for hair color and many other features and traits.

Daytime wetting in children is commonly caused by holding urine too long, constipation, or bladder systems that don’t work together smoothly. Health problems can sometimes cause daytime wetting, too, such as bladder or kidney infections (UTIs), structural problems in the urinary tract, or nerve problems.

When children hold their urine too long, it can trigger problems in how the bladder works or make existing problems worse. These bladder problems include:

• Overactive bladder or urge incontinence. Bladder muscles squeeze at the wrong time, without warning, causing a loss of urine. Your child may have strong, sudden urges to urinate. She may urinate frequently—8 or more times a day.
• Underactive bladder. Children only empty the bladder a few times a day, with little urge to urinate. Bladder contractions can be weak, and your child may strain when urinating, have a weak stream, or stop-and-go urine flow.
• Disordered urination. Muscles and nerves of the bladder may not work together smoothly. As the bladder empties, sphincter or pelvic floor muscles may cut off urine flow too soon, before the bladder empties all the way. Urine left in the bladder may leak.

Habits

There are some habits that your child may have that can lead to daytime wetting. These include:

• Waiting until the last minute before going to the bathroom.
• Not going pee often enough (you may find yourself saying: “It seems like they can hold their pee all day”).
• Not emptying their bladder all the way. This is called dysfunctional voiding.
• Children may squat down on their heels, cross their legs, or hold between their legs to keep from wetting. Other children may urinate (pee) small amounts often. These habits lead to incomplete urination, wetting and bladder infection.

Health conditions

There are health conditions that can contribute to daytime wetting. These include:

• Constipation can lead to decreased bladder capacity, problems emptying the bladder completely, and bladder spasms. Stool in the colon can create pressure on the bladder and cause spasms, which lead to daytime wetting
• Poor bathroom habits, such as not emptying the bladder completely or “holding it” for too long
• Urinary tract infection (UTI)
• Overactive bladder. Your child’s bladder squeezes without warning, causing frequent runs for the toilet and wet clothes.
• Underactive bladder. Your child uses the toilet only a few times a day, with little urge to do so. Children may have a weak or interrupted stream of urine.
• Disordered urination. Your child’s bladder muscles and nerves do not work together smoothly. Certain muscles cut off urine flow too soon. Urine left in the bladder may leak.
• Nerve problems, such those seen with spina bifida, a birth defect
• Vesicouretal reflux (VUR), backward flow of urine from the bladder to the kidneys
• Diabetes, a condition in which blood glucose, also called blood sugar, is too high
• Problems with the structure of the urinary tract, such as a blockage or a narrowed urethra
• Obstructive sleep apnea (OSA), a condition in which breathing is interrupted during sleep, often because of inflamed or enlarged tonsils. Sleepwalking and obstructive sleep apnea (OSA) can lead to bedwetting. With OSA, children breathe poorly and get less oxygen, which triggers the kidneys to make extra urine at night. Bedwetting can be a sign that your child has OSA. Other symptoms include snoring, mouth breathing, ear and sinus infections, a dry mouth in the morning, and daytime sleepiness.
• Stress. Stress can sometimes lead to bedwetting, and worry about daytime or nighttime wetting can make the problem worse. Stresses that may affect your child include a new baby in the family, sleeping alone, moving or starting a new school, abuse, or a family crisis.
• Making too much urine. Your child’s kidneys may make too much urine overnight, leading to an overfull bladder. If your child doesn’t wake up in time, a wet bed is likely. Often this excess urine at night is due to low levels of a natural substance called antidiuretic hormone (ADH). ADH tells the kidneys to release less water at night.

Children with medical conditions such as cerebral palsy, Down syndrome, neurologic conditions and attention deficit and hyperactivity disorder (ADHD) may continue to have daytime wetting at a later age than other children.

Daytime enuresis prevention

Often, you can’t prevent a bladder control problem, especially bedwetting, which is a common pattern of normal child development. However, good habits may help your child have more dry days and nights, including

• avoid or treat constipation.
• urinate every 2 to 3 hours during the day—4 to 7 times total in a day.
• drink the right amount of liquid, with most liquids consumed between morning and about 5 p.m. Ask your child’s health care provider how much liquid is healthy, based on age, weather, and activities.
• avoid drinks with caffeine or bubbles, citrus juices, and sports drinks. These drinks may irritate the bladder or produce extra urine.

Daytime enuresis signs and symptoms

Signs that your child may have a condition that causes daytime wetting include:

• the urgent need to urinate, often with urine leaks
• urinating 8 or more times a day, called frequency
• infrequent urination—emptying the bladder only 2 to 3 times a day, rather the usual 4 to 7 times a day
• incomplete urination—not fully emptying the bladder during bathroom visits
• squatting, squirming, leg crossing, or heel sitting to avoid leaking urine

Daytime enuresis diagnosis

Diurnal enuresis is only diagnosed in children 5 years or older. The tests used for diagnosing nighttime and daytime wetting are the same.

In most cases, enuresis is diagnosed based on a review of a complete medical history along with a physical exam. However, diagnostic tests may be used to determine if there is an underlying medical problem. These tests include:

• Urinalysis. The lab may also perform a urine culture, if requested. White blood cells and bacteria in the urine can be signs of a urinary tract infection.
• Urodynamic testing (a non-invasive test used to measure pattern and quality of urine flow). Urodynamic testing is a group of tests that look at how well the bladder, sphincters, and urethra are storing and releasing urine. These studies are not used often, but they may be helpful when simple bladder management methods are not as successful as expected.
• Ultrasound. An ultrasound uses sound waves to look at structures inside the body without exposing your child to radiation. During this painless test, your child lies on a padded table. A technician gently moves a wand called a transducer over your child’s belly and back. No anesthesia is needed.
• X-ray of the abdomen and pelvis
• Voiding cystourethrogram (VCUG). A voiding cystourethrogram uses x-rays of the bladder and urethra to show how urine flows. A technician uses a catheter to fill your child’s bladder with a special dye. The technician then takes x-rays before, during and after your child urinates. A VCUG uses only a small amount of radiation. Anesthesia is not needed, but the doctor may offer your child a calming medicine, called a sedative.
• MRI. Magnetic resonance imaging (MRI) uses magnets and radio waves to make pictures of the urinary tract and spine. During this test, your child lies on a table inside a tunnel-like machine. MRI scans do not expose your child to radiation. No anesthesia is needed, but the doctor may offer your child a calming medicine or suggest watching a children’s program during the test.

Daytime enuresis treatment

Treatments for daytime wetting depend on what’s causing the wetting, and will often start with changes in bladder and bowel habits. Your child’s doctor will treat any constipation, so that hard stools don’t press against the bladder and lead to wetting.

The most important thing you can do is be patient and understanding. Make sure your child knows that daytime wetting is a temporary problem, and that you are there to help.

Bladder training

If your child is having daytime urine accidents, try these steps:

• Create a schedule for your child to urinate at least every two to three hours during the day, even if she doesn’t feel like it. This is called“timed voiding”. They should go to the bathroom often and on a regular schedule at home, school, childcare and when out. It is important that they empty their bladder whether they feel like they need to pee or not.
• Children ages 3 to 8 need an adult to remind them to go to the bathroom on schedule at school. Letting them go to the bathroom “whenever they need to” does not work for children with dysfunctional voiding.
• Your child should not wait until they feel the urge to pee to go to the bathroom.
• Keep a diary of how often your child goes pee for the next two days. This shows your child’s current habits. It can also be a starting point from which to make improvements.
• Use a sticker chart to track your child’s trips to the bathroom, and reward progress.
• Make sure your child is eating a healthy, fiber-rich diet and drinking lots of fluids. This can help prevent constipation, a common cause of daytime wetting accidents.
• Help your child relax and not rush while urinating. Breathing deeply or putting their feet on a stool while sitting on the toilet can help.
• Eating less of foods such as citrus fruits (oranges, lemons, grapefruits, limes), acidic fruits (pineapples, tomatoes), carbonated beverages, caffeine and chocolate. These can irritate the bladder, leading to nighttime urine accidents.

Be positive and give support to your child. Punishment is not effective, and could make the situation worse.

In extremely rare cases, doctors may suggest using a thin, flexible tube, called a catheter, to empty the bladder. Occasional use of a catheter may help develop better bladder control in children with a weak, underactive bladder.

Emotional support

Let your child know that bedwetting is very common and most children outgrow it. If your child is age 4 or older, ask him or her for ideas on how to stop or manage the wetting. Involving your child in finding solutions may provide a sense of control.

Calming your child’s stresses may help—stresses about a new baby or new school, for example. A counselor or psychologist can help treat anxiety.

Medicine

Your child’s doctor may suggest medicine to limit daytime wetting or prevent a urinary tract infection (UTI).

Oxybutynin (Ditropan) is often the first choice of medicine to calm an overactive bladder until a child matures and outgrows the problem naturally.

If your child often has bladder infections, the doctor may prescribe an antibiotic, which is a medicine that kills the bacteria that cause infections. Your child’s doctor may suggest taking a low-dose antibiotic for several months to prevent repeated bladder infections.

Motivational therapy

For motivational therapy, you and your child agree on ways to manage bedwetting and rewards for following the program. Keep a record of your child’s tasks and progress, such as a calendar with stickers. You can give rewards to your child for remembering to use the bathroom before bed, helping to change and clean wet bedding, and having a dry night.

Motivational therapy helps children gain a sense of control over bedwetting. Many children learn to stay dry with this approach, and many others have fewer wet nights. Taking back rewards, shaming, penalties, and punishments don’t work; your child is not wetting the bed on purpose. If there’s no change in your child’s wetting after 3 to 6 months, talk with a health care professional about other treatments.