Daytime urinary incontinence is disabling and occurs in 17% of school-aged children. Timed-voiding is part of standard therapy. Can an alarm watch to aid timed-voiding improve treatment response to standard therapy?
The WATCH (Watch with Alarm for Timed-Voiding in Children) study is a randomized controlled trial. Participants were randomly assigned (1:1) to a vibrating alarm or nonalarming watch for 3-months. The primary outcome was the proportion who achieved a complete response (14 consecutive dry days) after 3-months of treatment. Children aged 5 to 13 years who were prescribed timed-voiding for daytime urinary incontinence.
Overall, 243 children, with a mean age of 8 years, were enrolled, with 62% girls. At 3-months, the complete response rates were similar between the 2 groups (22% alarm versus 17% control; difference: 5%; 95% confidence interval (CI): −5% to 16%; P = .42). In the alarm group, treatment adherence was higher (40% vs 10%; difference: 30%; 95% CI: 20% to 40%; P < .001), frequency of incontinence was lower (25% dry; 40% had 1–3 wet days per week, 24% had 4–6 wet days per week, and 12% had daily wetting, compared with 19%, 30%, 35%, and 16%, respectively; P =.05), and fewer had abnormal postvoid residual urine volumes (12% vs 24%; difference: −12%; 95% CI: −21% to −1%; P = .04) compared with the control group. Improvement was transient and did not persist 6 months beyond the treatment period.
Alarm watches do not appear to lead to complete resolution of urinary incontinence in children but did promote treatment adherence, normalization of postvoid residual volumes, and reduction in incontinent episodes while being used.
Study participants collected detailed data daily in their diaries for the first 6 months of treatment and noted if or when relapses occurred after that - our trial coordinator collected this data every 2 months. As the study was testing the effect of the different watches on treatment adherence and clinical outcomes, we did not use the collected data or interactions with participants to enhance treatment response.
We appreciated the paper by Caldwell et al investigating the role of an alarm watch for the treatment of daytime urinary incontinence [1]. The authors concluded that alarm watch doesn’t lead to complete resolution of urinary incontinence, but is more effective than non-alarming watch in improving treatment adherence with time-voiding, in normalizing postvoid residual urine volumes and in reducing frequency of urinary incontinence. Six months after completion of treatment, relapses after complete response were common in both groups (42% alarm group, 33% control group).
We suggest that the Authors missed some possible limits of the study. First, patients were not divided into age groups and children with behavioural comorbidities such as attention deficit hyperactivity disorder (ADHD) were not excluded from the study. A 2015 study showed that children with ADHD and daytime urinary incontinence are more difficult to treat, show lower compliance and have less favourable treatment outcomes for incontinence [2]. Moreover, healthy younger children might not have the cognitive skills or motor abilities to understand and complete the training [3] so that adolescents may have higher incontinence resolution rates.
Finally, participants in the study were followed up every 2 months from enrolment to assess relapse after the treatment period. We suggest that such a long period between follow-up visits may have influenced the study results. In a 2004 study concerning the use of behavioural therapy in children with enuresis, follow-up included at least a monthly examination of the voiding diary and of daytime symptoms modification, and examination every 2 weeks during the first 2 months for subjects with poor compliance [4]. Most of the children with enuresis in this study also had daytime urinary incontinence. In the group of patients who had a good response to therapy, only 9 of 111 patients (8.1%) had a relapse during follow-up. According to those data and to a time honoured practice we suggest that a closer follow-up, by increasing patients’ comprehension and compliance, could increase the resolution rate of urinary incontinence and reduce the relapse rate.
Thank you
Sincerely
Marco Persoglia, MD, University of Trieste
Marco Pennesi, MD, Institute for Maternal and Child Health – IRCCS Burlo Garofolo
Egidio Barbi, MD, PhD, University of Trieste, Institute for Maternal and Child Health – IRCCS Burlo Garofolo
References:
1. Caldwell, Patrina HY, et al. "An Alarm Watch for Daytime Urinary Incontinence: A Randomized Controlled Trial." Pediatrics 149.1 (2022)
2. von Gontard A, Equit M. Comorbidity of ADHD and incontinence in children. Eur Child Adolesc Psychiatry. 2015 Feb;24(2):127-40. doi: 10.1007/s00787-014-0577-0. Epub 2014 Jul 1. PMID: 24980793.
3. Nieuwhof-Leppink AJ, Schroeder RPJ, van de Putte EM, de Jong TPVM, Schappin R. Daytime urinary incontinence in children and adolescents. Lancet Child Adolesc Health. 2019 Jul;3(7):492-501. doi: 10.1016/S2352-4642(19)30113-0. Epub 2019 May 4. PMID: 31060913.
4. Pennesi M, Pitter M, Bordugo A, Minisini S, Peratoner L. Behavioral therapy for primary nocturnal enuresis. J Urol. 2004 Jan;171(1):408-10. doi: 10.1097/01.ju.0000097497.75022.e8. PMID: 14665944.