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George F. Steinhardt, M.D., F.A.A.P., F.A.C.S. BACKGROUND Isolated daytime frequency (IDF) refers to a harmless voiding pattern occasionally demonstrated by young children. Parents often express concern when their child has to void "every 5 minutes." The mothers typically observe that only a very small volume of urine is produced and with concern request physician evaluation. While there are many types of voiding dysfunction that do deserve medical scrutiny, IDF is generally a benign voiding dysfunction that does not warrant further investigation. Once the voiding pattern is recognized as harmless, the symptom can be treated in a straightforward fashion with sound fluid management and behavioral modification. First, a careful history is necessary to make sure that the affected child has no worrisome pediatric urologic issues. Daytime incontinence or constipation with soiling in children are troublesome symptoms that cannot be dismissed as harmless. At the very least children with wetting and soiling are at risk for urinary tract infection (UTI) and therefore benefit from imaging with a renal ultrasound (paying particular attention to both renal size and bladder wall thickness). Of course a positive history of UTI also mandates radiographic work up as 30% of any cohort of children with UTI will demonstrate vesicoureteral reflux (VUR) on cystography. While most children with IDF void "every 5 minutes" during parts of the day, no child voids that often over the course of an entire day; that would be 120 times in 10 hours! A crucial question relates to the frequency of voiding through the night. It is very reassuring to hear that the child can sleep through the night without getting up to void. This historical detail is not possible to obtain in children who still wet the bed, but clearly if the child voids often during the day, and sleeps through the night the symptom is behavioral. Second, in the office we do assess patients complaining of IDF with a urinalysis. Dilute urine signifies a water drinking habit. The absence of protein, blood, and sugar all help exclude medically significant causes of polyuria. Lastly, a physical examination delineating normal genitourinary anatomy including normal back legs and gait completes our recommended evaluation for IDF. As an aside, boys with true meatal stenosis do not present with IDF. Meatal stenosis generally is associated with narrow deviation of the urinary stream in an upward fashion with no effect on voiding frequency. In any event, if the above conditions are met, it is unlikely that the patient has a medical problem and no further evaluation is necessary. MANAGEMENT Most families can be reassured that everything is OK medically but parents still need advice on how best to control the symptom. There are a few important things to consider in trying having a child void less often. First of all constipation is very common in the U.S. A colon, if filled with stool, presses on the bladder compromising functional bladder volume …resulting in frequent urination. Also it is important to remember that the more a child drinks, the more often they have to void. There is nothing healthy about drinking a lot of fluid (unless you have kidney stones) and from my perspective our cultural obsession with over-hydration causes a great many pediatric urology problems. In any event fluid restriction is a cornerstone of management for patients with IDF. Obviously bladder stimulants such as caffeine and chocolate should also be avoided in affected. As voiding often is mostly a behavioral issue, IDF is best dealt with on behavioral terms. Psychologists tell us that the most effective way to change behavior (i.e. void less often) is to first observe the behavior to quantitate the severity. For this we recommend that the child, with the parental assistance, create a voiding diary by noting voiding occurrences on a small note pad, even at school. Memo books that fit in a shirt pocket and are used by engineers are good for this purpose. At the end of the day, the marks are counted to determine the total number of urinations. The observation period recommended is about two weeks, every day. Many parents think this is a silly recommendation. However we find it to be very important because the record informs the family that yes their child is going to the bathroom every 5 minutes….at times. At other times, the child voids much less often. The parents can then see the pattern of voiding often. It may become apparent that the child voids often at the mall and on the road, but not while watching videos or playing outside. Such patterns are reassuring that the problem is not medical. Once the voiding pattern is established, behavioral modification techniques are used to encourage the child to void less often. This is best accomplished with a reward system that makes good things happen if the child voids for the desired frequency throughout the course of the day. For example, if the child is voiding 18 times a day, the family might set 10 times as a reasonable target. The counting process continues and if the child voids 10 times or less, than a star is placed on the calendar. Five stars = 1 small treat. 5 small treats = something bigger. The challenge is to come up with age appropriate rewards that are not extravagant, but do get the child's attention. The child is never told to "hold it" but is merely reminded that if the desired number of voids is achieved, the reward is headed toward the youngster. Most of the children bothered with isolated daytime frequency are aged 5 to 9 and these are the exact ages where a simple reward system works best. The complaint is most often raised in the fall and many feel it represents simple school anxiety. In general more boys are bothered by this than girls. Regardless of age or gender, IDF is a benign voiding dysfunction and, absent the worrisome historical details noted above, referral to a specialist is not necessary.
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