Daytime wetting in children (diurnal enuresis)

What is daytime wetting (diurnal enuresis) in children?

Daytime wetting in children is defined as urinary incontinence or frequent urinary leaks during the day, when the child is awake.
Various medical terminology is used to describe daytime wetting and bedtime wetting, separately. Children will either suffer from a combination of both or sometimes urinary incontinence that occurs mainly during the daytime hours, when they are awake.

Is daytime wetting common in children?

Approximately 20% of children aged 4-6 years will have urinary incontinence, and some of them will also suffer from bedwetting. Similarly to bedwetting, the prevalence of daytime wetting in children decreases with age, to about 5% in children aged 12 years. It is important to remember that daytime wetting can range from slight urinary spotting to large quantities of urinary leaks.

How is potty training normally achieved?

Potty training and the development of control over urination is complex and we will not be going into the depth of the anatomy and physiology behind it in this post. Generally speaking, one can say that several different processes occur that allow the child to learn how to accumulate and hold urine in their bladder, become aware of the need to urinate and finally to synchronize the neurogenic actions in their brain and spinal cord to cause a contraction of the bladder and relaxation of the sphincter that prevents urinary incontinence.

At what age should a child be potty trained?

Most children are daytime toilet trained by the age of 4 years. Within the months following that, they will usually achieve nighttime continence. Most children are able to control their urine once they have full control over their bowel movements (both day and night).
Therefore, daytime wetting is commonly defined as daytime urinary incontinence in children over the age of 5 years.

What could be the causes of diurnal enuresis?

Bladder dysfunction can occur due to a problem in any one of the physiological steps required for correct urination; it could be an issue in the bladder or the neurogenic mechanisms that control it. We will try to elaborate on these without getting into the complex anatomy and physiology behind them.
Neurogenic – a condition causing a bladder dysfunction or a problem with the neurogenic mechanisms controlling the bladder and sphincter (such as issues with the development of the spinal cord, etc.)
Anatomical – a condition affecting the structure of the urinary tract (such as a bladder outlet obstruction, improper drainage of renal ureters, etc.)
Functional – these are non-neurogenic and non-anatomical problems that affect voiding (anything from constipation, to holding in urine and other habits). We often use the term ‘functional’ to describe medical conditions that do not fall under a specific disease or do not have a clear cause.
Emotional (behavioural) – in many children the underlying cause for daytime wetting is emotional or behavioural.

Each one of these different groups contains a number of different conditions or diseases, but we will not be able to expand on all of them in this post.
Additional conditions that may cause wetting are: recurrent urinary tract infections, diabetes, disorders affecting the renal urinary concentrating ability, constipation (read more about encopresis here), attention deficit and hyperactivity disorder (read more here) developmental disorders, sleep disorders, obesity and more.
Two other important conditions related to daytime wetting are bladder-bowel dysfunction (wetting that is related to constipation) and overactive bladder.

How are urinary incontinence and constipation associated?

These two are connected. The association is, in practice, quite intuitive if you consider how close the relevant structures are in the body.

We are aware that many children who suffer from constipation (link here), encopresis (more here) and fecal retention also have a higher prevalence of urinary incontinence. And the opposite is true as well. It is difficult to tell what came first. The connection between the two is complex and includes structural, mechanical, neurogenic, psychological and behavioural problems.

What is an overactive bladder?

This is the term used to describe a condition where children feel a strong and sudden urge to urinate, and sometimes find it difficult to control this urge. Often, this will be accompanied by complaints of urgency and the need to urinate overnight or bedwetting episodes. The underlying cause of an overactive bladder is an involuntary contraction of the bladder as it is filing up, when the volume of urine in the bladder is still low (normally this shouldn’t occur, the bladder needs to be able to hold a certain volume of urine).

Make sure not to confuse this with this simple condition here, that tends to resolve spontaneously.

How is daytime wetting in children diagnosed?

Those of you who have read the chapter about bedwetting know that bedwetting does not require a complicated workup. However, daytime wetting needs to be fully investigated. Since there is a range of possible underlying causes of daytime wetting, the child will need to undergo medical assessment. The investigation required is individual and will be determined by their pediatrician and sometimes specialists from the fields of pediatric urology, nephrology and/or neurology and it will include several examinations.

How is diurnal enuresis managed?

The management of daytime wetting in children can be divided into two main categories.

One is ‘medical’ and it is tailored to the diagnosis and underlying cause. This management includes pharmacological treatments, surgeries and more, depending on the underlying cause and its severity. As this is a very wide-span topic, we will not be able to go into it in this post.

The second category is the emotional-behavioural management, which includes:

Treating the underlying cause in some children (such as those that suffer from functional daytime wetting, where there are no neurogenic or structural disorders).

Combining it with pharmacological and surgical treatments, as needed

Daytime bedwetting causes significant difficulties in the child’s daily routine and may lead to substantial emotional distress. If the child is not supplied with an emotional-behavioural therapy that is tailored to the family’s needs, he/she will experience further emotional distress, impaired self-esteem, feelings of shame, frustration and disappointment and will avoid social interactions. The child will feel that they are unable to trust themselves and their capabilities. In adolescence, the low self-esteem and the social effect this condition may have on the child are even more significant, and will cause them to avoid everyday activities, social gatherings, school trips, camps, etc. It is important to realize that daytime wetting does not only cause emotional distress but may also occur as a result of emotional and behavioural distress and could even be a ‘cry for help’.

Are there emotional or behavioural problems characteristic to children with daytime wetting?

Most children who suffer from daytime wetting suffer from anxiety, stubbornness, inflexibility, a desire to be in control and attention-seeking behaviour. Both the stubbornness and the need to be in control are very evident in their behaviour, and they usually find it difficult to tackle failures.
Daytime wetting in children may be associated with a child’s tendency to hold in their urine. It can represent a significant underlying cause and may therefore play a major role in treatment. Some of these children avoid going to the toilet because they are timid and feel embarrassed.
From our experience, different life events such as divorce, death and sometimes exciting events such as the birth of a sibling can cause sensitive children, who are hesitant to share their feelings, to start experiencing daytime wetting.
Children with attention deficit and hyperactivity disorder who “daydream” frequently, are also at risk of having daytime wetting, as they tend to get frightened when they need to move from one place to another and this may cause them to wet themselves.

What do parents need to be aware of at the start of therapy for diurnal enuresis?

Prior to starting therapy the parents need to be aware of the child’s baseline condition and are encouraged to keep a diary containing the following information:
How many episodes of wetting does the child experience during the day?
Does it occur at home, in kindergarten or elsewhere?
Does the child tend to hold their pee? For how long? Does he/she suffer from constipation?
Does the child initiate going to the toilet on their own?
Does the child cooperate when asked to go to the toilet or does he/she refuse?
Does the child continue to act normally after they have had an episode of wetting?

What are the available emotional-behavioural methods of treatment for children with daytime wetting?

These are the important aspects of emotional-behavioural treatment in children:
The therapy is for the entire family and is performed through parental guidance. Since the child is young, there is no need to involve them in the treatment, and will improve once the parents receive guidance from a professional who specialises in this field.
This condition is not easy for the parents. Often, parents will report feelings of frustration, desperation, concern or even anger. These are all normal and understandable, and sometimes the parents may feel that their child is behaving in a certain way on purpose. Remember, children do not wet themselves on purpose, even when it happens only a few minutes after you had told them to go to the toilet and they refused. These children are suffering from a condition, and this is exactly how it presents. These situations require the parents to be very patient and tolerant. It is important to refer to a professional with experience in treating daytime wetting so that the therapy is short, practical and to the point.

When the parents control and reduce the anger they feel towards the child, it decreases the stressful atmosphere that arises due to the episodes. An empathetic reaction by the parents provides the child with a secure environment where they can express their feelings. Being less strict about it and showing less of a need to be in control encourages the child not to hold their urine in.

It is very important not to show any signs of anger when the child has an episode or refuses to cooperate and wash up. The parents’ anger and frustration are completely understandable. It is not easy (for both the parents and the child) to deal with a child who suffers from daytime wetting, but being angry with them is not helpful and only makes the situation worse. It is important to maintain a neutral reaction when the episodes occur – this means, neither to get angry nor embrace the situation, neither to use positive nor negative feedback. We recommend saying “it must be very uncomfortable to be in wet panties, let’s go wash up and change together” and to give positive feedback when they cooperate.

It is important to positively reinforce patterns of behaviour that include identifying the need to go to the toilet and stopping any activities in order to go to the toilet. Also, it is important to encourage situations where the child shows signs of ability to overcome difficulties, to take initiative, to be flexible, to cooperate, to undergo new experiences and to find solutions to problems. Such reinforcement will allow the child to discover their own abilities and to gain the confidence to overcome the wetting problem.
It is important to demonstrate to the child, by pointing out his/her daily achievements, that they should be able to trust themselves.

It is also a good idea to talk to the team at the educational institute that the child attends and to explain his/her condition. Providing the team with professional information about the disorder will encourage tolerance and reduce feelings of anger towards the child. It is important to distinguish between problems that arise due to difficulties with toilet training and daytime wetting. Similarly to the parents, the educational team tends to think that the child is behaving a certain way on purpose. It is important to explain to them that this is a condition that the child is dealing with and that they are not trying to be purposefully defiant.

In addition, the child’s emotional wellbeing improves when parents give him/her attention and initiate playtime with them. All these together will bring about successful resolution of the condition.

In summary, this is a relatively common medical condition. It may require extensive investigation, but it is easy to treat. Nonetheless, treatment is best managed by a professional who specialises in the field.
Good luck!