VOL: 100, ISSUE: 20, PAGE NO: 61
Anne Weaver, RGN, is clinical adviser
Penny Dobson, MSc, RGN, CQSW, is director; both at Education and Resources for Improving Childhood Continence (ERIC); in consultation with Lucy Swithinbank, MD, director of the urodynamic unit, Southmead Hospital, Bristol
The International Continence Society defines urinary incontinence as ‘the complaint of any involuntary leakage of urine’ (Abrams et al, 2002). There do not appear to be internationally recognised definitions for faecal incontinence. A study of healthy adolescents indicated that 3 per cent of 15 to 16-year-olds experienced regular daytime wetting. Nocturnal enuresis is reported in 1.1 per cent of the same age group. Some of those who reported problems at this age had no symptoms at 11-12 years (Swithinbank et al, 1998). Little data exists for soiling in this age group, but prevalence of 1.2 per cent in girls and 0.3 per cent in boys aged 10-12 years is recorded (Bonner, 2001). A longitudinal study of children with constipation showed that one-third of children, followed up beyond puberty, continued to have the condition (Ruk Van Ginkel et al, 2003). This suggests a number of teenagers will have bowel management issues, with or without soiling.
Teenagers with nocturnal enuresis are often reluctant to seek advice (Lukeman, 2003) and those unsuccessfully treated in childhood may believe there is no other help available. Family attitudes can affirm this. Reduced self-confidence may affect motivation and embarrassment can severely restrict social life. This particularly affects older teenagers planning to leave home or begin a sexual relationship.
Wetting or soiling accidents in the day can be very stressful. Teenagers feel vulnerable to teasing or bullying and may try to hide the problem. Anxiety can rise when toilet facilities in school are poor. Depression and suicidal behaviour may be linked with victimisation and bullying (BMA, 2003), and it is suggested that teenagers with continence problems could be at higher risk of emotional and mental health problems.
Previously identified conditions affecting continence in adolescence
Some young people enter adolescence with a known condition affecting continence. Specialised management and multi-professional assessment aim to ensure that they are supported in school. A Statement of Special Educational Needs and ongoing care plans should help these teenagers manage their incontinence independently.
Encouraging access to services
The first step for teenagers is to realise that there are professionals available who can offer confidential help. Teenage magazines are already targeting this age group to encourage them to seek advice. School nurse drop-in clinics or youth information services can provide information anonymously. Young people want clinics that are sensitive and responsive to their needs (Richardson- Todd, 2003). However, they are often treated in children’s settings although their needs are different (BMA, 2003). In the absence of clinics exclusively for older teenagers, they should be seen at the end of an afternoon enuresis clinic. This enables them to avoid explaining their absence from school or work.
Depending on the young person’s age and situation a parent or carer may not be involved but she or he may wish to bring a friend for support. During any clinic visit professional judgement is required regarding the issues of obtaining informed consent and child protection.
Assessment and treatment
A full medical assessment is advised when a young person experiences nocturnal enuresis (night-time wetting), diurnal enuresis (daytime wetting) or soiling. This can identify health problems, such as urine infection and constipation. It will also exclude rarer neurological conditions, such as sacral cord tethering, that very occasionally present in adolescence. Most congenital abnormalities of the urinary tract or bowel will have been diagnosed at an earlier age (Box 1).
There are two forms of nocturnal enuresis: primary nocturnal enuresis if the young person has never been dry; secondary nocturnal enuresis if the problem has occurred after more than 12 months of being dry. Stressful life events can be a factor, especially in secondary enuresis. In order to offer the most appropriate treatment strategy, assessment is based on the three main causes of bedwetting known as the ‘Three Systems’ (Butler and Holland, 2000):
- Inability to wake to the sensation of a full bladder;
- Low nocturnal vasopressin levels (antidiuretic hormone that decreases the production of urine) resulting in night-time urine production that exceeds the bladder’s capacity;
- Bladder contractions in the filling stage, which can result in wetting before the bladder is full (Butler and Holland, 2000).
Treatments for nocturnal enuresis include:
- Alarms to prompt arousal from sleep;
- Desmopressin, a drug that mimics the effect of the hormone arginine vasopressin;
- Oxybutynin, an anticholinergic drug that reduces bladder contractions.
It is important to advise the young person that:
- Fluid intake should not be limited (6 to 8 water-based drinks are advised daily);
- Drinks such as coffee and alcohol can increase urinary output (diuretic effect);
- Treatments that have failed in the past can be successful at a later stage.
Treating bedwetting can be challenging, with low compliance (Nappo et al, 2002) and professionals should adapt resources and assessment tools to suit individuals. For example, progress charts can be more acceptable to this age group if they are created by the client on a computer or put in a diary and regarded as ‘personal research’. This moves away from the star charts used with younger age groups.
- Common physical causes of diurnal enuresis in teenagers are:
- Overactive bladder syndrome resulting in urgency, usually with frequency and with or without incontinence (Abrams, 2002). In children, urinary tract infection can be an associated factor;
- Dysfunctional voiding associated with an interrupted stream and incomplete emptying of the bladder resulting in a residual volume of urine;
- Stress urinary incontinence - involuntary leakage on effort or exertion, or on sneezing or coughing;
- ‘Giggle micturition’ - when urine starts to leak during laughing and the bladder empties completely.
Investigations and assessment should include:
- A full history, including baseline frequency/volume chart (record of fluid intake/urine output over several days);
- Examination (abdominal, spine and neurological);
- Post-void bladder scan can be arranged if there is a concern about a residual volume of urine in the bladder;
- Ultrasound scan of urinary tract may be advised;
- Urodynamic studies (cystometry) may be helpful in more complex cases, after referral to a specialist.
Advice and possible treatment
- Treat any urinary tract infection or constipation;
- Encourage six to eight water-based drinks a day. Caution is needed with drinks that have a diuretic effect (coffee, fizzy drinks, and alcohol);
- Suggest a timed toilet routine;
- Discuss any problems with using school toilets;
- Encourage unhurried voiding. Girls should sit with feet supported and slightly apart and maintain a steady stream. Boys can be encouraged to aim for a target in the toilet;
- Ensure the bladder is emptied. The young person should return to the toilet a short time after micturition to check that her or his bladder is empty;
- Teach pelvic floor awareness and exercises. Pelvic floor awareness can be included in sex education programmes in school;
- Anticholinergics, such as oxybutynin can be used to treat symptoms such as urgency and frequency;
- Encourage good hygiene.
Constipation with faecal overflow is a common cause of soiling. When there is faecal impaction, medication will be required to clear the bowel.
A routine of sitting on the toilet regularly after meals, with a maintenance dose of laxatives and adequate fluids and diet may be needed for some time while the bowel regains tone. Exercise and abdominal massage can also help.
Older children with longstanding or secondary faecal soiling should be referred to the Child and Adolescent Mental Health Team to identify underlying emotional or behavioural problems.
School nurses and health visitors have a key role in identifying and supporting this frequently neglected group. Much still needs to be done to improve the number and quality of treatment services and ERIC is addressing this at government level, as well as through its national campaigns.
The ‘Water is Cool in School’ campaign is already improving access to and quality of water provision for school pupils. ‘Bog Standard’, a campaign for better toilets in schools will be launched soon.
ERIC (Education and Resources for Improving Childhood Continence) provides:
An interactive website www.eric.org.uk and a new website for teenagers www.trusteric.org
A telephone helpline Monday-Friday 10am-4pm 01179 603060.
Publications for teenagers ‘Growing up and coping with bedwetting’ and ‘Don’t laugh’ until you read this’ (BMA Commended 2003) can be obtained free by sending a stamped address envelope to ERIC (see below). ERIC also produces Guidelines on Minimum Standards of Practice and Training for Health Professionals, and items such as alarms and bed protection products.
Quarterly magazine ‘ERIC Says’ is available by subscription
34 Old School House
Bristol BS15 8DB