INCONTINENCE

Bladder problems affect more than 9.6 million women and 1.14 million men in the UK
At least another 650,000 adults have difficulties with bowel control
In general terms incontinence means difficulties with the retention of urine and/or faeces

In 2005 the first national audit of incontinence care for older people in the UK revealed widespread failure to diagnose and manage continence problems

Before we look at ‘incontinence’ we need to look at ‘continence’

What is ‘continence’?

Continence – A Definition

‘The ability to store urine in the bladder or faeces in the bowel and to excrete voluntarily where and when it is socially appropriate’
Key words – excrete voluntarily and socially appropriate

If ‘continence’ is seen as a voluntary action in socially acceptable circumstances then ‘incontinence’ is any variation from this. Many people do not consider themselves incontinent but do experience leakages from the bladder or bowel

Incontinence – Some Definitions

Urinary incontinence:

A condition in which the involuntary loss of urine is a social and hygienic problem

Faecal incontinence:

The involuntary or inappropriate passage of faeces

Enuresis

Enuresis is nocturnal incontinence (bedwetting)
Enuresis occurs most often in children but can continue into adulthood
Primary enuresis – where bladder control has never been achieved


Urinary incontinence affects, on average, 40% of men and women living in nursing homes
70% of incontinence sufferers can be cured

30% can benefit from proper management

Faecal Incontinence

Faecal incontinence can be:
Mild or severe
It can sometimes be referred to as staining
It affects
Children aged 5 to 16 - 1%
People under 65 (living at home) – 0.4%
People over 85 (living at home) – 15%

People living in nursing homes – 30%

The Need For Continence Awareness

 examined the quality of care for older people with urinary and faecal incontinence in England, Wales and Northern Ireland

It focused on:

Primary care

Secondary care

Care homes

The audit was undertaken by the Royal College of Physician’s Clinical Effectiveness and Evaluation Unit

It was commissioned by the Healthcare Commission known as the CQC since 2009
The audit was based on the following standards:

The National Service Framework for Older People [2001]

The Department of Health guidance “Good practice in continence services”[2000]

159 Trusts covering:

195 Hospitals

141 Primary Care Trusts

29 Care Homes

9,000 patients and 700 care home residents

Urinary incontinence affects some 24% of older people and 30 - 60% of people in institutional care

Faecal incontinence occurs in approximately 1-4% of adults and up to 25% of people in institutional care. The Care Value Base forms the basis of all ethical decisions and judgments made in health and social care. One of the components of the Care Value Base is that everyone has a right to dignity

Both urinary and faecal incontinence cause much distress and loss of dignity for the older person. Effective management of continence depends on a thorough assessment of the service user leading to a diagnosis

A service user may already have continence problems, or they may develop problems whilst in your care

Every care professional should be alert to the ongoing needs of the service user. An assessment should be carried out routinely for all service users as part of the care planning process, and Immediately a problem is identified reviews should be on an ongoing basis

Anyone in the care team could be the first person to identify a need

As assessment should be carried out routinely for all service users as part of the care planning process, and immediately a problem is identified reviews should be on an ongoing basis

The audit found that even specialist NHS staff with good continence knowledge did not examine patients thoroughly or give routine assessments

They also found that where a thorough examination and assessment had been made only the symptoms were managed when in some cases there could be a cure

The aim should always be to cure wherever possible rather than just manage the problem

The audit also identified:

A lack of written policies
Missing documentation
Limited provision of staff training
High use of indwelling catheters in hospital settings
Widespread rationing of continence pads

The National Service Framework for Older People set the requirement that service providers should establish integrated continence services by April 2004

The audit found only limited action toward this and that service provision remains extremely variable

Only 59% of primary and 32% of secondary care sites had a written policy which covers continence care for older people

Each care setting should have a written policy covering continence care

Nearly all settings asked a screening question relating to bladder and bowel care, but only 64% of primary and 44% of secondary sites had a basic assessment protocol. Each care setting should have a written protocol of basic assessment in addition to a screening question. Integrated continence services were only present in 53/138 of primary care, 50/195 secondary care sites and 10/27 care homes taking part in the audit.

On further inspection many of the services said to be integrated were missing vital elements
Only 49% of secondary care trusts offer structured training on the management of continence
Each care setting should provide structured training on the management of continence
Only 49% of secondary care trusts offer structured training on the management of continence
Each care setting should provide structured training on the management of continence
80% of services had a written policy that pads should be available on the basis of clinical need

However 81% of primary care and 76% of care home services limited the maximum number of daily pads for patients. 60% of primary and 70% of secondary care patients received pads as a way of managing their condition rather than treating the underlying problem

There are ethical and financial implications for correctly assessing all service users

A proper assessment would eliminate this ethical dilemma ensuring that pads were available to those who need them

Inadequate assessment of incontinence with an emphasis on containment rather than cure is expensive, from both a financial and health perspective

Dealing with continence care correctly will:

Reduce the numbers of incontinent service users in your care
Provide a higher standard of care
All settings should have a written policy
All settings should have a screening question and basic assessment protocol
All staff should receive training

All staff should be clear on the fact that they are part of the ongoing process of assessment and review.

Stress Incontinence

Stress incontinence is the involuntary leakage of urine

It can occur when a person:

Laughs

Exercises

Coughs

Sneezes

Why Does Stress Incontinence Occur?

If the muscles controlling the bladder become weakened urine can leak

It is more common just after childbirth and during the ageing process

The Urinary System

Some of you will have knowledge of the urinary system
It will be useful to look at how the urinary system works to better understand incontinence
Urine is produced in the kidneys, It passes down to the bladder (a muscular organ) via the ureter
The valve controlling the bladder is called the urethral sphincter

This valve opens to allow urine to flow out of the bladder, It closes to hold urine in.

The pelvic floor muscles help support the bladder
They assist in the retention of urine in the bladder

Stress incontinence can occur if either the sphincter muscle or the pelvic floor muscles become weakened, When these muscles become weakened they cannot contract (tighten). Once weakened they are unable to cope with any extra pressure (e.g. a cough, sneeze etc)

Men and urinary incontinence

The elderly experience the same bladder problems as other adults

Where the elderly differ, though is in their ability to respond and to compensate for problems which a younger adult may find trivial

Evidence suggests that the presence of urinary incontinence alone increases the chance of an elderly person becoming institutionalised earlier than a continent elderly person. With people living longer the expanding proportion of the elderly will place an increasing burden on services delivering continence care. However, incontinence should never be viewed as a normal consequence of ageing

Age Related Effects

Studies have shown that:
Detrusor contractile function
Bladder capacity
Urinary flow rates

All decline in association with greater age. As well as incomplete emptying of the bladder. In men, the progressive enlargement of the prostate with age tends to dominate the behaviour of the urinary outflow tract

As enlargement increases, the bladder requires a greater contractile effort to overcome the effects of the obstruction

The overactive bladder is the commonest cause of urinary incontinence in the elderly, regardless of sex

In many cases the cause of an overactive bladder is not known, However it is commonly associated with progressive enlargement of the prostate 

Detruser Instability (Overactive Bladder)

It is also associated with neurological injury or disease
E.g.
Spinal cord injury
MS
Cerebrovascular disease

Parkinson’s or Alzheimer’s disease

Individual symptoms are extremely important in making a diagnosis of detrusor overactivity

Not everyone will experience all symptoms and many go to great lengths to avoid experiencing incontinence  E.g. restricting fluid intake or increasing urinary frequency

Diagnosing Detruser Instability- Getting the True Picture

In addition to taking a relevant history it is useful to get the service user to complete a diary

If the service user is unable to do this alone help can be given by the care professional/member of the family

Continence Care

The diary would record:
Urinary frequency
Volumes passed
The number of incontinence episodes
Fluid intake

Urinalysis

Urinary tract infection and calculi may cause urinary urgency and urge incontinence and should be excluded at an early stage

The simplest method to exclude infection is to use a rapid urinalysis dipstick

Absence of Infection

In the case of reoccurring infections or haematuria (in the absence of infection) further investigation is needed. Referral to the GP is required

Drug Treatments

Antimuscarinic drugs are still the most widely used treatment in the UK though the side effects have limited their tolerability:

Dry mouth
Constipation
Blurred vision

Oesophageal reflux

Oxybutynin

The most commonly prescribed treatment for the overactive bladder in the UK is Oxybutynin
Oxybutynin is both antimuscarinic, a direct muscle relaxant and a local anaesthetic agent
Studies have shown that high dose oxybutynin (5mg tds) increases the incidence of side effects

The withdrawal rate has varied between 22-40% with up to 80% suffering significant adverse reactions

More recent studies, using lower doses of the drug has shown a reduction in adverse effects and an enhanced level of tolerability

Bladder Retraining

Most drug therapy has conventionally been used in combination with bladder retraining

This technique involves the simple maxim “hold on” (simple to say but requiring much motivation and will power). Even in the most motivated patient, bladder retraining can take months to achieve a lasting change in habit. There is a high relapse rate.

Clean Intermittent Catheterisation

In combination with antimuscarinic drugs, many elderly men who would not be candidates for surgical treatment can be successfully managed by this technique

Surgery

Surgery is most applicable for those with detrusor overactivity associated with other conditions such as outflow tract obstruction

There are several techniques that can be used

Post Prostatectomy Incontinence

The incidence of incontinence following prostatectomy varies between 1-15% depending upon the procedure used . In late life, pre-existing bladder problems may co-exist

Nocturnal Frequency

Nocturnal frequency is deemed to be excessive if greater than twice nightly

There are several physiological changes, which lead to an increasing likelihood of developing nocturnal frequency. Normally, adults produce two thirds of their twenty-four hour urine output by day and the other third by night . In older individuals this changes and there is a redistribution of fluid at night. In addition, some older adults have a delayed diuresis (increased formation of urine by the kidneys). Together these factors mean that the kidneys are working harder overnight to produce greater quantities of more dilute urine. The amount of which may be in excess of functional bladder capacity. For highly dependent men in a care setting nocturnal incontinence requires a major effort to manage effectively. The use of pads and barrier creams can minimise the disruption of sleep patterns

Cognitive Impairment

For those patients who are cognitively impaired (where there is little chance of active participation in behavioural methods of treatment) drug treatment may help. However there is little evidence that drugs can be effective

Strategies:

Scheduled voiding (toileting at regular intervals)
Individualised toileting programmes  (toileting is planned around known voiding habits)
Prompted voiding programmes (prompting to visit the toilet at regular intervals)

Prompted voiding programmes requires the care professional to know whether the patient is wet or not and depends upon the ability of the patient to request toileting

All 3 strategies been found to be effective in reducing incontinence episodes in nursing home patients

All methods are very labour intensive but there is evidence that (for regular toileting regimens) a four hourly interval is as effective as a two hourly one

Containment

For some elderly males the only option available for the treatment of their urinary incontinence is containment 

The main aims of containment devices:

Protection of skin and clothing
Prevention of malodour

Devices include condoms, clamps, absorbent underwear, single use and reusable pads