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 (www.trusteric.org). 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).
Nurses are valuable members of the multiprofessional team involved in setting up
care plans for young people who require longterm 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 on 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 waterbased 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.