The 2019 Novel Coronavirus Disease (COVID-19) pandemic has had an impact on mental and physical health in both children and adults. Social restrictions have jeopardized mental health of previously otherwise healthy individuals [1] while they have worsened pre-existing symptoms of anxiety and reactive disorders in others [1]. 
As children can develop some urological conditions that may be related to emotional distress or anxiety [2], such as extraordinary daytime urinary frequency (EDUF), pediatric urologists, as well as other clinicians, need to be aware that they could be involved and challenged by these emerging reactive disorders during the Covid-19 pandemic. 

Since the impact of the COVID-19 pandemic on children as a stressor factor remains unknown, the aims of this study are: 
i)	to describe a cohort of children and adolescents diagnosed with EDUF during the pandemic (October 2020 - March 2021) and during a similar period one year before (pre-pandemic period, October 2019 – March 2020); 
ii)	to investigate whether EDUF diagnosis have changed during the pandemic; 
iii)	to describe any clinical difference between the two cohorts of patients, especially related to sex and age.

All the data related to patients (between 3 and 18 years old) with a diagnosis of EDUF referred to our Centre between October 2019 and March 2021 were retrospectively collected. The adolescence cut off was 11 years old indifferently for male or female given the small cohort of patients (as per literature, the beginning of adolescent period in female is 10.5 years and in male is 11.5 years).
Following the EDUF ICCS guidelines definition [3], children who were toilet-trained and who complained of frequent urination with small micturition volumes exclusively during the daytime, without burning, urinary incontinence, frequent voiding during the nighttime, excessive fluid intake nor excessive urinary volume were selected.  Polydipsia, diabetes mellitus, urinary tract infections or viral syndrome, nephrogenic diabetes insipidus or other comorbidities were criteria of exclusion. The daytime voiding frequency had to be at least once per hour. Patients compliant with the above criteria were divided in two cohorts based on the time of presentation (October 2019 - March2020 or October 2020 - March 2021). Data was double-checked by two doctors using patient’s medical files.
A voiding diary to record each micturition for at least two weeks, paying attention to the very first urinary volume of the day in order to evaluate adequate bladder capacity was given to patients and parents.

During the study period 22 Caucasian patients were identified. The number of referrals during the pandemic was 53% higher than the same period the previous year: 7 patients were referred to our service between October 2019 and 11 March 2020 (pre-pandemic cohort), and 15 patients between October 2020 and March 2021(pandemic cohort). Relevant clinical and epidemiological data are exposed in table 1.
Age
In the pre-pandemic cohort, the median age of the patients was 7 (4.3-15.9) years, and only 1 (14%) was older than 11 year.
In the pandemic cohort, the median age of the patients was 5 (3-18.1) years, and 4 (27%) were older than 11 years.  
Gender 
While in the pre-pandemic cohort the vast majority of the patients were female (86%), in the pandemic cohort the male gender was prevalent (73%).

Based on a single centre experience, despite the general fear to attend the local hospital during the COVID-19 pandemic, the diagnosis of EDUF in children and adolescents was higher, resulting in more than double of the referrals compared to the same period in the previous year. The prevalence of patients older than 11 years was higher during the pandemic. The pandemic and its social consequences appear to have had an important impact on adolescents, as normally they are not frequently affected by EDUF. 
As for routine management, patients and their families were reassured on the self-limited nature of the condition.

Based on the recent literature, the impact and the burden of the current pandemic on mental health are undeniable. Adjusting to the massive changes of this moment might be even more complicated for children than it is for adults, leading to symptoms that are not always easily detected and interpreted as a clue of emotional distress. Although our data are limited and preliminary, in our experience, EDUF diagnosis have increased. Despite the brief period of time and the exiguous pool of patients reviewed, we suppose that the number of children suffering from this condition may be even higher, due to the restrictions applied to clinical activities in times of pandemic and to the resistance of parents in seeking unurgent medical support during these times. On the other hand, as telemedicine develops, pediatrician should be trained to include this condition as a differential diagnosis of lower urinary tracts symptoms. Simple tools like parent-administered urine dipsticks and voiding charts could prevent a misdiagnosis of urinary tract infection, thus avoiding unnecessary treatment with antibiotics. Moreover, follow-up of EDUF can be easily managed through virtual care.  We are deeply convinced that this moment of health crisis will force every health professional to be flexible and skillful. Awareness about this condition should be raised among primary care providers, pediatricians and child psychiatrists, promoting cooperation and a multidisciplinary approach.

Courtney D, Watson P, Battaglia M, Mulsant BH, Szatmari P. COVID-19 Impacts on Child and Youth Anxiety and Depression: Challenges and Opportunities. The Canadian Journal of Psychiatry. 2020;65(10):688-691.
von Gontard A, Baeyens D, Van Hoecke E, Warzak WJ, Bachmann C.   Psychological   and   Psychiatric   Issues   in   Urinary   and   Fecal   Incontinence. J Urol. 2011;185(4):1432-6.
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