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Adolescents with nocturnal enuresis and daytime urinary incontinence—How can pediatric and adult care be improved—ICI-RS 2015?

Gontard, A., Cardozo, L., Rantell, A., Djurhuus, J.-C.

Neurourology and Urodynamics 2017, 36 ( 4 ) pp. 843 - 849

Abstract

AIMS:

Nocturnal enuresis (NE) and daytime urinary incontinence (DUI) are common in adolescents. The aim of this paper was to review studies on prevalence, clinical symptoms and associated risk factors and to formulate recommendations for assessment and treatment.

MATERIALS AND METHODS:

A systematic Scopus search was performed and relevant publications were selected. The topic was discussed during the ICI-RS meeting in 2015.

RESULTS:

One to two percent of older adolescents are affected by NE and 1% by DUI. NE and DUI are associated with multiple risk factors such as fecal incontinence and constipation, obesity, chronic illness, and psychological impairment. Chronic treatment-resistant, relapsing and new-onset cases can occur. Adolescent NE and DUI can be treated by a multidisciplinary team according to pediatric principles. Additional treatment components have been developed for adolescents. Transition from pediatric to adult services is frequently disorganized.

CONCLUSIONS:

Incontinence in adolescents is a neglected research topic and clinical care is often suboptimal. As adolescents are seen by both pediatric and adult services, alignment and harmonization of diagnostic and therapeutic principles is needed. Also, an organized transition process is recommended to improve care for adolescent patients. Neurourol. Urodynam. 36:843-849, 2017. © 2017 Wiley Periodicals, Inc.

Commentary by Charlotte van Herzeele

Adolescence is the transition from childhood to adulthood. There is no clear dividing line in between, resulting in a different approach to handle nocturnal enuresis and daytime urinary incontinence, depending where the adolescent is treated, pediatric or adult care. Although both services share the same goal, dryness, the way to achieve the goal is often different. Even the starting point is divergent because the definitions of nocturnal enuresis and daytime urinary incontinence of the International Children's Continence Society (ICCS) are not equal to the definitions of the International Continence Society (ICS). The ICCS consider nocturnal enuresis and daytime urinary incontinence as conditions with subtypes whereas the ICS focusses more on defining signs and symptoms. Pediatric and adult care vary in assessment and treatment guidelines. Although assessment and treatment should be individualized to the patient and its family, the authors clearly identified the need for alignment and harmonization of diagnostic and therapeutic guidelines.

The major barrier in adolescence is treatment adherence. Adherence is extremely challenged in adolescence due to normal developmental tasks in this age period. Adolescents shift from the dependence from parents and caregivers to independence, making their own decisions with full responsibility. Decreased impulse control and increased risk-taking behavior are common but complicate treatment adherence. The risk of non-adherence in adolescents is important and should not be underestimated.

Research on nocturnal enuresis and daytime urinary incontinence in adolescence is scarce. Although the incidence of both conditions decrease by age, it are the most severe cases that persist into adolescence and sometimes adulthood. Therefore it is important to identify the need of this specific group of patients.

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Consensus Guidelines

Practical consensus guidelines for the management of enuresis. 
Evaluation and management of enuresis, a common condition, is not a priority in training programs for medical doctors (MDs), despite being a common condition. 

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Diagnosis and Treatment of Nocturnal Enuresis developed by the Working Group of Nocturnal Enuresis Belgium.