Enuresis is defined as involuntary voiding beyond the age of anticipated control.  Diurnal enuresis is daytime wetting, nocturnal enuresis is nighttime wetting.  Both of these conditions can occur at the same time, however, many children with nighttime wetting will not have wetting during the day. Daytime wetting is more common in girls than in boys, but bedwetting is twice as prevalent in boys.  Daytime wetting was found to have occurred more than once a week in 3% of girls with the mean age of 5.9 years.  (1)  Children with daytime wetting may have frequent urination, have urgent urination or dribble after urinating.   

Causes for daytime wetting, or leaking, are quite varied.  These could include:

• Incomplete emptying of the bladder
• Irritable bladder
• Constipation
• Urinary tract infection
• Urgency (not “making it” to the bathroom in time)
• Anatomic abnormality
• Poor toileting habits
• Small bladder capacity
• Others

As you can see, this list is quite long.  In most cases, seeing your health care provider or urologist to rule out conditions that need specific treatment is a good place to begin.  They will begin with a voiding history and physical exam, as well as a urinalysis and culture.  Other tests may be warranted, based on their findings.

Major changes in the management of daytime wetting came about in the 1990s.  In most current programs, non-invasive treatments incorporate hydration, timed voiding, correction of constipation and in some cases, computer assisted pelvic floor retraining.  These methods have been extremely successful in correcting daytime wetting. (2)  Bladder stretching exercises (where the child tries to hold their urine as long as possible) are no longer recommended.  In fact, some urologists actually believe that this can be dangerous because the child could develop the long-term habit of tightening the sphincter muscle, which can cause bladder or kidney problems.  Urinating on a regular basis is much preferred.

Timed voiding means that the bladder is emptied on a regular basis—not only when the urge to void is felt.  In theory, timed voiding seems relatively simple.  In reality, however, remembering to do an activity every two hours without a reminder is difficult.  Watches that can be programmed to vibrate at regular intervals of time are sensational in implementing any timed reminder program.  Some people use reminder watches not only for timed voiding, but for taking medication, checking blood sugar, carpool schedules, etc.  (Read our tips for choosing a watch)

When you’re dealing with children who have little concept of time, timed reminders are even more difficult to institute.  Once children start school, most of their waking hours are not spent with the parent.  It’s unrealistic to expect a teacher who has more than 20 children in her/his care to provide regular reminders to a single child to urinate every two hours.  Most teachers are more than willing to cooperate with a timed voiding program if they understand that it will help the child maintain daytime dryness.

Helpful hints when implementing a timed voiding program
(These hints are applicable for anyone using a reminder watch, whether you are a child or adult).

• Use a vibratory reminder watch.  A noise making watch can be disruptive to the other children and will draw unnecessary attention to the child or adult.  Unfortunately, beeping watches are also easy to ignore, especially in a noisy environment.
• Look at your child’s daytime schedule.  Avoid setting times that are impossible to follow.  For example, it is impossible to follow the reminder if your child is on the bus, coming home from school.  By the time she walks in the door, she has forgotten about that message and wetting is likely to occur.  A much better time to be reminded would be as she was packing her things up before leaving school.
• If you’re using an interval watch, carefully think through the exact intervals you will program in.  Most timed voiding programs recommend emptying the bladder every 2 hours.  However, if an interval of 1 hour and 55 minutes or an interval of 2 hours and 5 minutes is a better schedule for you or your child, there is no harm in making this adjustment.
• A watch that can be programmed with specific times may be preferable.   For example, if lunch is at 11:55, voiding before lunch at 11:50 would make sense.  However, if your interval watch reminds you at 12:00, getting out of line in the lunchroom might be difficult. 
• If the child can independently know when the voiding should occur, he/she can discreetly excuse themselves to the bathroom using the pre-arranged method of by-passing getting a hall pass, signaling, etc.  Usually, a meeting with or a note to the teacher explaining the purpose of the timed voiding program, as well as an indication of the actual times they can expect the child to be up using the bathroom, is helpful.
• The watch should be used seven days a week.  Learning a new behavior is more effective if it is consistently reinforced.
• If it isn't possible for a watch to be worn, an effective alternative is the Invisible Clock.  This small vibrating unit clips to the waistband or pocket to provide a discreet reminder.
• Initially, a reward or token system for following the watch’s direction (going to the bathroom when the watch vibrates) may be an added incentive.  The reward would not be for dry underwear initially, but for following direction.  Dry underwear will happen later.
• Remind your child that she/he have to go to the bathroom when their watch reminds them, even if they don’t feel that they have to go.
• Since constipation and daytime wetting often happen in the same child, setting a reminder for a scheduled time to sit on the potty to have a bowel movement may be helpful.
• Do not let your child rush through toileting.  Children who rush often do not empty their bladder completely. 
• Preserve self-esteem . Washable absorbent briefs contain the urine and prevent leakage to outer garments. OdorZyme can be used as a pre-soak to treat clothing or bedding that smells of urine.
• Voiding posture is important.  Girls should sit with their legs spread apart so that urine can flow freely.  Small children need to have a stool beneath their feet to support them.
• Use the watch several months past the time that you think the problem has been resolved.  The nice thing about a watch is that it can be used just to tell time once your child toilets at regular intervals without a reminder. 

1. Sureshkumar P, Craig JC, Roy LP et al.  Daytime urinary incontinence in primary school children: a population-based survey.  J Pediatr 2000;137:814-8.
2. McKenna, P.  Voiding Dysfunction Non-Neurogenic.  Presentation at AAP 2004 National Conference.