URApp

Urine (wee) is made in your kidneys. Long thin tubes called ureters carry the wee from your kidneys to your bladder.

Your bladder is like a muscular balloon that stretches to hold the wee.  Stretching muscles in your bladder relax to hold the wee.  Squeezing muscles in your bladder squeeze your wee out when you go to the toilet.

If you wait too long between wees, your bladder muscles will be doing too much stretching and not enough squeezing. 

If you are doing lots of extra wees to try to stay dry, your bladder muscles will be doing too much squeezing and not enough stretching. 

You can ‘exercise’ your stretching muscles by drinking regularly and you can ‘exercise’ your squeezing muscles by going for a wee regularly. 

Regular drinking is important to keep your bladder healthy.  Concentrated wee irritates the bladder and makes it squeeze when it shouldn’t. 

Most young people with daytime wetting have a normal bladder, but you should have your bladder checked by your doctor just to make sure.  

Some common causes of daytime wetting

• An overactive (twitchy) bladder makes you need to wee urgently. You might do lots of small wees and have some leaks.  If you have an overactive bladder, you might need to combine bladder training with medicine to relax your bladder muscles.  
• The stretching and squeezing muscles in your bladder might not work properly.
• Delaying going to the toilet until it’s too late.
• Not completely emptying your bladder when you go to the toilet.
• If the muscles that stop urine escaping from the bladder are weak, you can leak when you laugh, cough, or exercise.
• Constipation – if your bowel is full of poo it presses against the bladder and can cause wee to leak out.
• Having a urinary tract infection.

This work was supported by the Elizabeth Blackwell Institute for Health Research:  Medical Research Council (Confidence in Concept) grant and the Wellcome Trust Institutional Strategic Support Fund

We would like to thank all the people and organisations that helped us to develop URApp.
These include:

• ERIC- The Children’s Bowel & Bladder Charity
• Natural Apptitude
• Dr Anne Wright  MBBCh, MRCPCH, MSc, Children’s Bladder Clinic, Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust.
• Bladder & Bowel UK
• The Paediatric Continence Forum
• Pure Usability
• All the doctors and nurses who gave us feedback

A big thank you to all the young people who helped us!

It’s important to make sure you sit on the toilet properly and don’t rush when you’re having a wee.  The best way to empty your bladder properly is to relax when you’re sitting on the toilet. This helps the tap-like muscle (the sphincter) at the bottom of your bladder to open fully to let all the wee out.  

Boys don’t have to stand up to wee. Many boys actually find it easier to empty their bladders fully if they’re sitting down (try to sit down for some wees each day).

Here are some tips:

• Sit properly on the toilet seat and don’t hover!  If you’re worried about sitting on public toilet seats, cover the seat with toilet paper.
• Hovering over the toilet seat will make your pelvic floor very tense.  You may have to push hard when you’re having a wee and your bladder may not empty properly.
• Relax when you’re sitting on the toilet and make sure your feet are flat on the floor (or on a stool).  Your knees should be level with (or slightly higher than) your hips.
• Don’t squeeze your thighs together – leave them in a relaxed position.
• Relax your tummy and sit up straight.
• Don’t rush!

I’m not allowed to drink in class

If you’re at school, drinking water should be available to you during the school day. If your teacher doesn’t allow you to have a water bottle on your desk, talk them about keeping it in your bag next to you or in close reach. In some lessons like IT or science, water may need to be kept outside for safety reasons. If you don’t feel comfortable talking to your teacher, you could ask your parent or carer to do this for you. 

I don’t like the taste of water

If you don’t like the taste of plain drinking water you could try adding low sugar squash or a little fruit juice, or even some cucumber or slices of fruit.  Avoid drinks containing caffeine (tea, coffee, hot chocolate, cola and energy drinks). Fizzy drinks, blackcurrant, orange, and drinks containing artificial colourings, flavourings and sweeteners might also cause problems for the bladder. 

I forget to have drinks

URApp provides drinking reminders to help you remember to drink. You can set these to remind you to drink at regular times during the day and you can customise your reminder message. To turn these on go to ‘reminders’ in the side menu (View guide: How to setup reminders). 

Some people find it helpful to draw lines on their water bottle to keep track of how much they’ve been drinking. URApp helps by asking you to record your drinks. 

I run out of water during the day

Make sure you top up your water bottle at break time. You don’t need to finish your bottle before topping it up. In URApp you can record part-finished drinks. When you top up your bottle, just start a new drink and the old one will be stored in your daily drinks library. You can see all the drinks you’ve had that day by swiping left and right (View guide: How to add drinks). 

There are some practical things you can do to help you feel less worried about your bladder problem. Here are some tips from other young people with daytime wetting and urgency: 

Plan your toilet visits 

Planning when you will go to the toilet and which toilets to use can help you feel more in control. Find out if there are disabled toilets you can use, these have more space and privacy. URApp has reminders you can set to help you stick to your plan. 

Needing the toilet during lessons

Find out if your school provides toilet passes or medical cards. These passes allow you to go to the toilet whenever you need to, without having to ask the teacher or explain. 

Accidents at school

Keep an emergency bag at school with spare underwear, pads, wet wipes, plastic bags for wet underwear or pads, and spare trousers or a skirt in case you have a wetting accident. 

Going on a school trip or staying overnight at someone’s house? You can find more advice on nights away from home on the ERIC website. 

Information about dealing with continence problems at secondary school: http://www.bristol.ac.uk/policybristol/policy-briefings/young-people-continence-schools/

ERIC – The Children’s Bowel and Bladder Charity (https://eric.org.uk) provide help and support for children and young people with bowel and bladder problems.  If you would like more information about continence problems in young people, visit the ERIC website. There are also stories from young people who have shared their experiences of continence problems.

For more advice and support contact the ERIC helpline.

There are other helpful resources offering advice to young people with bladder and bowel problems:

• Bladder & Bowel UK
• Continence Foundation of Australia
• Incontinence in Confidence (Part of Continence Foundation of Australia)

We developed URApp to aid adherence to bladder training in young people (aged 10-19 years) with urinary incontinence and urgency. Urinary incontinence (UI) is among the most common paediatric problems and it is commonly assumed to resolve with age. Consequently, parents and clinicians often adopt a ‘wait and see’ approach to childhood UI¹. A significant proportion of children, however, continue to suffer from persistent UI into adolescence^2-5.

The perceived stigma of UI in adolescence can seriously undermine a young person’s self-esteem and quality of life. Some young people with UI suffer from depressive symptoms, bullying, and problems at school^{6, 7}.

“Always thinking about it, always worrying about it”

“…kind of feeling like an outsider, I suppose, feeling that you’re not normal”

“It’s the sheer fact that I have to lie constantly and I’m hiding. I feel like it’s a huge secret”

Young people who are being treated for UI often report poor treatment experiences including a lack of continuity in care, high rates of relapse, and treatment failure. This can lead to feelings of hopelessness⁸.

“When I’m at the hospital it’s always a new person and they always say a different thing to what the other doctor said”.

“For quite a lot of the time, I felt really pessimistic about this problem, just like there is absolutely no hope that it’s ever going to be better and I’m going to be stuck with this problem forever”.

The majority of cases of UI in young people are not due to organic (structural, anatomical or neurological) causes but arise from functional impairments in the bladder⁹. Bladder training (standard urotherapy) is the first-line treatment for UI in children and adolescents¹⁰. It is a behaviour modification intervention that aims to establish a regular schedule of drinking and toilet visits.

The goal is to ‘train’ the bladder to hold more urine and to reduce the number of times patients need to pass urine per day. Bladder training also educates patients about how the bladder works and common causes of UI, as well as providing guidance on how to have good posture whilst emptying the bladder (e.g. sitting up straight and relaxing the pelvic floor).

There is evidence that bladder training can be an effective intervention for UI in children and adolescents^{11, 12}. However, it takes time to be effective and success strongly depends on adherence, self-motivation and clinician support, which our research shows is often lacking⁸.

Our research with young people with UI found that adherence to bladder training is often challenging. Clinicians recognise that young people need ongoing support tailored to their needs to enable them to effectively manage their bladder symptoms.

“Urotherapy, which is the mainstay of treatment, requires considerable effort, motivation and self-discipline, which may be difficult for adolescents”

“As a clinician who has worked for years in the incontinence field, it’s clear to me that adolescents require more bespoke understanding, management and care”

In response to this need, we developed a smartphone app (URApp) to aid adherence to bladder training in young people with UI.

We co-designed URApp with extensive input from young people and a team including expert clinicians, health psychologists, health technology design experts, and app developers. Co-designing URApp with young people will help to ensure it is age appropriate, acceptable and usable.

In developing URApp, we were guided by the Person-Based Approach to planning, optimising, evaluating and implementing behavioural health interventions¹³. This approach involved participatory co-design workshops and in-depth interviews with young people with continence problems to understand and accommodate their needs. We also worked closely with clinicians to ensure that URApp performs the functions needed to support bladder training.

We identified user requirements for URApp at three participatory co-design workshops with young people with UI (see below for examples).

The goals of the workshops were to define the desired behaviour changes (e.g. regular drinking and toilet visits) and to identify factors that influence these behaviours (e.g. restricted access to toilets and drinks during class). The figure below shows some of the designs proposed by young people.

We also identified behaviour change techniques – strategies aimed at changing behaviours (e.g. goal setting and reviewing, action planning, reminders, rewards) to include in URApp that could promote adherence to bladder training (see figure below). There is evidence that embedding behaviour change techniques into digital interventions increases their effectiveness¹⁴.

URApp allows users to set goals for their daily drinking and provides discreet reminders to help them to establish a regular schedule of drinking and toilet visits. There is also a diary function to record daily drinking and toilet visits, and personalised feedback to enable users to track progress towards their drinking goals. URApp provides ‘rewards’ (stars and trophies) to motivate users to keep using the app and to achieve their drinking goals.

We investigated the usability and acceptability of URApp through in-depth qualitative research with young people.

“Much better than paper diaries…I never got around to filling them out, whereas this would be on my phone, which I would have on me, so I think that’s a lot handier”

“It makes you feel more committed to achieving your goals… You achieve stuff… It makes you feel good about yourself”

“The most motivating things for me were seeing my progress over time and charting the data”

Young people who have tried URApp found that it helped them to manage their daytime wetting.

“It got a lot better. During the day I stopped having accidents. My symptoms were getting better each week”

“I drink more in the mornings now, rather than lots before bed if I haven’t had enough, which can be problematic at night-time”

“It helped me drink more regularly and space my drinks out throughout the day”

We also interviewed clinicians who treat young people with UI to gain an in-depth understanding of their views of URApp to ensure that they will have confidence in it and will want to use it in clinical practice.

“I think we would use it on every single child that came to our clinic, anyone that came to bladder training, we would direct them all to it and say this is part of it”

“I’m already thinking of kids I could use this with”

We are currently planning to evaluate URApp in paediatric continence clinics to test its effective in improving adherence to bladder training.

References

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2. Heron J, Grzeda MT, von Gontard A, Wright A, Joinson C. Trajectories of urinary incontinence in childhood and bladder and bowel symptoms in adolescence: prospective cohort study. BMJ Open. 2017;7(3):e014238.
3. Yeung CK, Sreedhar B, Sihoe JD, et al. Differences in characteristics of nighttime enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int 2006;97:1069–73.
4. Swithinbank LV, Brookes ST, Shepherd AM, et al. The natural history of urinary symptoms during adolescence. Br J Urol 1998;81(Suppl 3):90–3.
5. Hellström AL, Hanson E, Hansson S, et al. Micturition habits and incontinence at age 17—reinvestigation of a cohort studied at age 7. Br J Urol 1995;76:231–4.
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7. Grzeda MT, Heron J, von Gontard A, Joinson C. Effects of urinary incontinence on psychosocial outcomes in adolescence. Eur Child Adolesc Psychiatry. 2017;26(6):649-658.
8. Whale K, Cramer H, Wright A, Sanders C, Joinson C. ‘What does that mean?’: a qualitative exploration of the primary and secondary clinical care experiences of young people with continence problems in the UK. BMJ Open. 2017;7(10):e015544.
9. Hjälmas K. Functional daytime incontinence: definitions and epidemiology. Scand J Urol Nephrol Suppl 1992; 141: 39–46.
10. Chang SJ, Van Laecke E, Bauer SB, von Gontard A, Bagli D, Bower WF, Renson C, Kawauchi A, Yang SS. Treatment of daytime urinary incontinence: A standardization document from the International Children’s Continence Society. Neurourol Urodyn. 2017;36(1):43-50.
11. Schäfer SK, Niemczyk J, von Gontard A, et al. Standard urotherapy as first-line intervention for daytime incontinence: a meta-analysis. Eur Child Adolesc Psychiatry. 2018;27(8):949-964.
12. Assis GM, Silva CPCD, Martins G. Urotherapy in the treatment of children and adolescents with bladder and bowel dysfunction: a systematic review. J Pediatr (Rio J). 2019;95(6):628-641.
13. Yardley L, Morrison L, Bradbury K, Muller I. The person-based approach to intervention development: application to digital health-related behavior change interventions. J Med Internet Res. 2015 Jan 30;17(1):e30.
14. Web T, Joseph J, Yardley L, Michie, S. Using the Internet to Promote Health Behavior Change: A Systematic Review and Meta-analysis of the Impact of Theoretical Basis, Use of Behavior Change Techniques, and Mode of Delivery on Efficacy. J Med Internet Res. 2010; 12(1): e4.