Anne Weaver and Eileen Jacques outline continence problems that may affect young people and discuss how nurses can play a key role in engaging them in appropriate and effective treatment.
Anne Weaver, RGN, is helpline and clinical assistant; Eileen Jacques, MA, is helpline and information manager; both at Education and Resources for Improving Childhood Continence (ERIC), Bristol.
Adolescence is recognised as a time of physical and emotional change that can be confusing and challenging for young people and their families. There are additional anxieties for 11–19-year-olds who have continence problems. They may feel embarrassed and the fear of being teased or bullied can be a barrier to seeking help.
The National Service Framework for Children, Young People and Maternity Services core standards recognise that young people aged 12–19 years should have access to age-appropriate services that are responsive to their specific needs (Department of Health, 2004). This is particularly important for young people accessing continence services as some may need ongoing support throughout their lives. Continence problems that commonly affect adolescents are listed in Box 1.
Box 1. Continence problems and definitions
Urinary incontinence: Uncontrollable leakage of urine (Neveus et al, 2006).
Nocturnal enuresis: Involuntary voiding of urine during sleep. Nocturnal enuresis without daytime symptoms is referred to as mono-symptomatic. It can be primary (continuous) or secondary if there has been a period where the patient has been dry which lasted for more than six months.
Daytime wetting: Leakage of urine in the day.
Faecal incontinence: Passage of stools in an inappropriate place. Faecal incontinence can be organic and result from neurological damage as a result of trauma or congenital conditions such as anal sphincter abnormalities. It can also be functional where there is no organic cause. It is reported that 95% of children who are incontinent of faeces have functional constipation with overflow (Price and Elliott, 2001).
Some teenagers may have a recognised permanent disability or condition that affects continence and this means that they will require ongoing support to manage their needs independently as they move into adult life.
A study of healthy adolescents in 1998 indicated that 3% of 15–16-year-olds have experienced regular daytime wetting and 1.1% are affected by nocturnal enuresis. Some young people who reported problems at 15–16 years had no symptoms when they were 11–12 years (Swithinbank et al, 1998).
There is very little data about soiling in this age group but a prevalence of 1.2% in girls and 0.3% in boys aged 10–12 years has been 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 (Van Ginkel et al, 2003).
There is a social stigma attached to daytime wetting, bedwetting and soiling that can cause young people to fear ridicule from their peers and even bullying if their problem is discovered (Joinson et al, 2006; Williams et al, 1996). This can be a barrier to the young person seeking help. Young people may also believe that nothing can be done, feel different or even fear that there may be something wrong with them ‘mentally’.
Incontinence, especially in older children and teenagers, is sometimes incorrectly associated with laziness or a lack of discipline, and the child and the family can experience a negative response from teachers and youth workers and even some healthcare professionals because of this.
School staff and youth workers are often unsure how to address the situation and may feel confused about the cause of the problem. Studies carried out in the 1970s suggested that emotional and behavioural problems were the primary cause of faecal incontinence in children but more recent research has indicated that the soiling itself contributes to behavioural problems (Joinson et al, 2006).
It is important that people who work with adolescents are informed about continence problems, and can react with sensitivity, support and understanding. Young people need to know it is not their fault and be encouraged to ask for help.
The effect of continence problems on young people
Studies show that children over 10 years of age (especially girls) with secondary enuresis and those with additional daytime symptoms are particularly vulnerable to emotional distress and low self-esteem (Butler and Swithinbank, 2007).
Many young people miss out on social opportunities, such as sleepovers and school trips, and feel lonely and excluded because of their continence problems. Without help, symptoms may continue into the late teens and have far-reaching effects on decisions about leaving home or starting a sexual relationship.
Encouraging young people to seek advice
Teenagers need accessible information, using appropriate language, to reassure them that they are not alone with the problem, so they feel more comfortable about asking for advice.
The internet has created a discreet and immediate method of finding information. ERIC has developed a website specifically for adolescents. Young people can access the site and make choices about how to proceed with their concerns in confidence and feel in control of the situation. Sharing ideas and feelings with others in an anonymous, safe way is often the first step towards seeking help.
Furthermore, reliable information that explains the reasons why some young people have continence problems can increase the understanding of treatments and improve motivation.
Role of the nurse
Community nurses, such as school nurses and specialist continence nurses, are ideally placed to help young people. They should try to advertise their availability in a variety of community settings by, for example, displaying teen-friendly posters.
Young people are likely to feel nervous about attending a clinic where younger children are waiting. Allocating times at the end of a session to accommodate this age group can take away the fear and embarrassment associated with having to explain why they are there.
There should be sensitivity towards the young person’s right to confidentiality and the wishes of the young person should be respected, depending on their age and circumstances. Most importantly, the young person should feel totally involved with any decision-making and treatment planning.
The nurse can refer to other agencies if required and also offer to liaise with schools about toilet access and drinking facilities. The nurse can do this by raising awareness of the ERIC campaigns to improve toilets and water provision in schools for all pupils (see Box 2).
Box 2. Possible causes of daytime wetting
• Overactive bladder (sometimes called urge syndrome)
• Ignoring full bladder signals
• Toilet avoidance, especially at school
• Urinary tract infection
• Stress incontinence – sometimes associated with laughing, coughing or strenuous exercise
Nurses are valuable members of the multiprofessional team involved in setting up care plans for young people who require long-term continence management due to disability. It is important that young people have a seamless transition from child and adult services.
Assessment and treatment
A medical examination is recommended before assessing and treating bedwetting, daytime wetting or soiling. This should identify any underlying contributory factors, such as infection, constipation or signs of renal problems. It will also exclude rarer neurological conditions, such as sacral cord tethering that very occasionally presents in adolescence, although most abnormalities of the urinary tract or bowel would have been diagnosed at an earlier age.
The ‘three systems’ approach to assessment and treatment of nocturnal enuresis gives a clear explanation of the physical reasons for bedwetting and removes blame from the young person (Butler and Holland, 2000).
The three identified systems are:
- Inability to wake from sleep to the sensation of a full bladder;
- Low nocturnal vasopressin levels, resulting in night-time urine production exceeding bladder capacity;
- Bladder contractions in the filling stage, resulting in wetting before the bladder is full.
Assessment is based on identifying which of the systems is involved and making a choice of treatments based on this.
The treatment options are:
- Alarms to interrupt sleep at the point of wetting;
- Desmopressin – a drug that mimics the effect of the hormone arginine vasopressin that increases reabsorption of water by the kidneys;
- Oxybutinin – an antimuscarinic drug that has a direct antispasmodic effect on smooth muscle and so reduces bladder contractions.
Fluid intake should not be restricted and it is recommended that in between six and eight water-based drinks are spread throughout the day.
The young person can be involved in individual research to find out if their bladder function is affected by particular drinks, such as coffee and alcohol. They can then make decisions about excluding these.
Young people can be reassured that treatments they might have tried unsuccessfully when they were younger could have a more favourable outcome if they try them again.
A full reassessment is the key to finding the best treatment for the individual.
Causes of wetting in adolescents are listed in Box 2 (above).
The assessment should include:
- History (including a baseline frequency/volume chart to assess fluid intake and output);
- Urine test using a reagent stick;
- Ultrasound scan of the bladder (a post-micturition scan can be arranged if there is a concern about residual urine in the bladder);
- Urodynamic studies and cystometry may be helpful in more complex cases. These cases require a referral to a specialist.
Advice and possible treatment depends on the result of the assessment.
Strategies include one or a combination of the following:
- Treat any urinary tract infection or constipation;
- Encourage in between six and eight water-based drinks daily. Experiment with excluding drinks that might exacerbate the problem, such as coffee;
- Suggest a regular toilet routine linked to natural breaks in the day;
- Identify and try to resolve 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 hit a target in the toilet;
- Consider returning to the toilet within a very short time after voiding to ensure the bladder is completely emptied (double micturition);
- Teach pelvic floor awareness;
- Refer to the GP to consider prescription of antimuscarinic medication if there are signs of overactive bladder;
- Promote good hygiene – girls should wipe themselves from front to back to cut the risk of UTIs.
Constipation is a common cause of soiling. If constipation is a problem then medication may be required to clear the bowel and a maintenance dose established to keep stools soft and easy to pass.
A routine of sitting on the toilet for 5–10 minutes after meals (after waiting for about 15–20 minutes) will help to encourage regular bowel movements. In time the signals of a full bowel will be recognised by the child as the bowel regains tone but this may take many months or even longer.
A varied diet and in between six and eight drinks a day will help to maintain regular bowel function. The young person will need ongoing support and encouragement to ensure that they adhere to this.
Referral to Child and Adolescent Mental Health Services may be required if there are any associated emotional or behavioural problems.
Community-based services, delivered by skilled nurses who understand the needs of teenagers, is the key to successful assessment and treatment of continence problems in this often-neglected age group. Young people who feel positively motivated by evidence-based information about continence are more likely to achieve a favourable outcome, based on their own decisions and choices.
Services can transform the lives of young people, enhance job satisfaction for health professionals and prove cost-effective for the NHS. There is, therefore, a strong case for providing age-appropriate continence services to cater for the specific needs of teenagers.
- ERIC (Education and Resources for Improving Childhood Continence) offers support and information for young people on all aspects of childhood continence
- Telephone Helpline (weekdays, 10am-4pm) Tel: 0845 370 8008 (local rate)
- Interactive websites eric.org.uk and trusteric.org (for young people)
- Products such as bedding protection, protective garments and enuresis alarms (ericshop.org.uk or ring 0117 3012101 for a copy of ERIC’s Products Catalogue)
- ERIC Campaigns to improve access to water and toilet facilities in schools. ’Water is Cool in School’ and ’Bog Standard’
- Literature and leaflets on a variety of continence problems aimed at young people and families. Downloadable here.
- Guidelines and training for health professionals
Bonner, L. (2001) Childhood Soiling – Minimum Standards of Practice for Treatment and Service Delivery. Bristol: ERIC.
Butler, R., Holland, P. (2000) The Three Systems: a conceptual way of understanding nocturnal enuresis. Scandinavian Journal of Urology; 34: 4, 270–277.
Butler, R., Swithinbank, L. (2007) Childhood Nocturnal Enuresis and Daytime Wetting – A Handbook for Professionals. Bristol: ERIC.
Department of Health (2004) National Service Framework for Children, Young people and Maternity Services. Executive Summary. London: DH.
Joinson, C. et al (2006) Psychological differences between children with and without soiling problems. Pediatrics; 117; 5,
Neveus, T. et al (2006) The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardization Committee of the International Children’s Continence Society (ICCS) Journal of Urology;176: 1, 314–324.
Price, K.J., Elliott, T.M. (2001) Stimulant laxatives for constipation and soiling in children. CochraneDatabase of Systematic reviews; 3: Art no CD002040. DOI: 10.1002/14651858.CD002040.
Swithinbank, L.V. et al (1998) The natural history of urinary symptoms during adolescence. British Journal of Urology; 81:
Suppl 3, 90–93.
Van Ginkel, R. et al (2003) Childhood constipation: longitudinal follow-up beyond puberty. Gastroenterology; 125: 2, 357–363.
Williams, K. et al (1996) Association of common health symptoms with bullying in primary school children. British Medical Journal; 313: 7048, 17–19.