Continence Management in the Community

Approximately five million Australians are living with a form of incontinence.

To break down this number in terms of age group, incontinence affects 1 in 166 people under 65; 1 in 14 people over 65; and 1 in 4 people over 85 (Bostock 2019).

What is Incontinence?

Incontinence is the name given to the condition in which a person experiences any accidental or involuntary loss of urine from the bladder (urinary incontinence) or bowel motion, faeces or wind from the bowel (faecal or bowel incontinence).

Living with incontinence can be both challenging and exhausting. Generally, the physical effects of incontinence are non-life threatening, however, consequences such as the sequelae of falls, UTIs and delirium may have life-shortening effects (Bostock 2019).

Incontinence affects both men and women, and people of all ages and backgrounds and many of the complications of this disorder are not visible, but are very capable of hindering an individual’s quality of life.

Thankfully, incontinence can be treated, managed and in many cases, cured.

Types of Incontinence

There are different types of incontinence and each has a number of possible causes. The most common are:

• Stress incontinence – caused by activities that increase pressure inside the abdomen and push down on the bladder;
• Urge incontinence – a sudden and strong need to void;
• Incontinence associated with chronic retention, and;
• Functional incontinence – issues relating to physical, intellectual or environmental impediments.

(Continence Foundation of Australia 2019)

The following health professionals are best positioned to treat patients living with incontinence:

• Continence nurse advisors;
• Continence physiotherapists;
• Community healthcare;
• Bladder or bowel medical health specialists;
• Practice nurses; and
• Pharmacists.

(Continence Foundation of Australia 2019)

How Serious is Incontinence?

Incontinence is a distressing, symptom-based disorder. If left untreated it can result in a profound loss of quality of life, affect sexuality and relationships, mental health and wellbeing, and cause social isolation and institutionalisation.

Creating a Continence Management Plan

Creating a management plan with the patient and their family is the first step to addressing incontinence. The following should be taken into account:

• A comprehensive medical history;
• Food and fluid consumption;
• Bowel health;
• Level or mobility and function;
• Bladder function; and
• Hormonal balances.

(Bostock 2019)

The success of the management plan hinges on the strength of the patient’s trust and confidence in the continence advisor. Once this is established, this lends validity and value to the delivery of the management plan (Bostock 2019).

Management Plan Considerations

The management plan coordinates nurse expertise with an individual’s needs; offers clear guidelines, milestones and progress measurements; provides support and encouragement.

Careful consideration will ensure that the individual and/or their family will have ownership of the outcomes, direct the course of the plan and decide which modifiable risk factors can be ameliorated, and which are non-negotiable. Non-negotiable may include the type of food and drink they consume, or the medications they take (Bostock 2019).

In the assessment phase, discuss which aspects of incontinence are the most bothersome to the patient. Ask them to consider the following:

• Social isolation;
• Embarrassment;
• Cost of continence aid;
• Amount of laundry;
• Changes in quality of life;
• Changes to sexual health and intimacy; and
• The inability to engage in an activity that causes incontinence.

(Bostock 2019)

Management Strategies

Keep in mind that every patient will need individualised strategies to account for factors such as age, gender, state of health, fluid restrictions, level of activity, function and mobility, among others (Bostock 2019).

Fluid

Water should form the majority of fluid intake. Caffeine-based drinks such as coffee, tea and soft drinks should be restricted to a maximum of three per day (Bostock 2019).

Alcohol should only be consumed in moderation as it can contribute to the incidence of urinary incontinence. This is because alcohol acts as a diuretic and bladder stimulant (Bostock 2019).

Advise patients to reduce fluids one hour before sleep (Bostock 2019).

Bowel health monitoring

Constipation is known to contribute to the incidence of urinary incontinence. The pressure of an impacted rectum against the bladder causes over-activity and possible leakage, therefore it is important to include management of bowel health in the management plan (Bostock 2019).

The following is indicated as promotive to optimal bowel health:

• Five vegetables and two fruits daily (different types/textures);
Wholegrains;
• Consuming up to 35 grams of fibre (soluble and insoluble);
• Lean, red meat;
• Up to three fish meals per week; and
A balance of fluids for hydration.

Exercise and physical health

Activity, exercise and energy expenditure are very important. Exercise promotes strength and mobility and the ability for the person to access the toilet independently is important for maintaining quality of life (Bostock 2019).

Comorbidities

Take into consideration any other health issues the patient may be living with. Any comorbid condition has the potential to impact the chance of a patient regaining continence, particularly:

• Diabetes;
• Cardiac disease;
• Renal disease; and
• Pelvic floor dysfunction.

(Bostock 2019).

Continence Aids and Equipment Available

Ensure the patient has all the aid, equipment and appliances required to fully support their mobility and function.

It is very important that this equipment is regularly serviced and maintained. The services of an occupational therapist or a physiotherapist may be required to do a home and equipment assessment (Bostock 2019).

Aids and equipment required by the patient may include:

• A walking frame;
• A toilet raise;
• Grab rails;
• Non-slip mats;
• Containment products;
• Bed or chair protection; and
• Urine collection devices.

(Bostock 2019)

Toileting, Bladder and Bowel Programs

Toileting programs are useful to regulate voiding patterns, they can act as a prompt for people with a loss of cognition (as well as for people with full cognitive abilities) to visit the toilet at set intervals. The program should be based on the outcome of a bladder diary, a person’s patterns and their fluid intake (Bostock 2019).

Bladder and bowel retraining programs can be used by any person living with incontinence. The program will be developed in conjunction with the individual and their family. The program will encourage the person to extend the time in between voids; may include pelvic floor therapy; bowel retraining therapy aimed to increase anal sphincter tone, and encourage routine emptying of the bowel (Bostock 2019).

Pelvic floor therapy is a conservative treatment option. The program aims to develop or further support, the tone and flexibility of the pelvic musculature, ligaments and viscera, to decrease episodes of urinary incontinence (Bostock 2019).

What Does Optimum Bladder and Bowel Health Look Like?

Habits of a healthy bladder:

• Empties 4-8 times each day (every 3-4 hours).
• A person is able to hold up to 400-600ml of urine (the sensation of needing to empty occurs at 200-300 ml).
• May wake up once at night to pass urine and twice if they are older (i.e. over 65 years of age).
• Lets them know when it is full but gives them enough time to find a toilet.
• Empties completely each time they pass urine.
• Does not leak urine.

(Continence Foundation of Australia 2019)

Habits of a Healthy Bowel:

• A person can hold on for a short time after they feel the first urge to go to the toilet - this allows time to get there and remove clothing without any accidental loss of faeces.
• Pass a bowel motion within about a minute of sitting down on the toilet.
• Pass a bowel motion easily and without pain - ideally, they shouldn’t be straining on the toilet or struggling to pass a bowel motion.
• Completely empty their bowel when they pass a motion - they don’t have to go back to the toilet soon after, to pass more.

(Continence Foundation of Australia 2019)

Conclusion

Incontinence is a relatively common, treatable condition. Dignity and privacy should be key considerations in developing a management plan intended to aid a patient in achieving continence.

Your intervention could make a considerable improvement to a patient’s continence management and in effect, make a drastic improvement to their overall quality of life.

Additional Resources

Aged Care Quality Standards: https://www.myagedcare.gov.au/aged-care-quality-standards

Ausmed, 'A Quick Guide to Paediatric Urinary Incontinence': https://www.ausmed.com/cpd/articles/paediatric-urinary-incontinence

The Continence Foundation of Australia Resources: https://www.continence.org.au/resources

The National Continence Helpline on 1800 33 00 66 is a free and confidential service and is staffed by continence nurse advisors who can provide practical information, a wide range of resources and details of local continence services.

References

• Bostock, N. 2019, 'Management of Urinary Incontinence in the Community', Ausmed, 29 July, viewed 13 August 2019, https://www.ausmed.com/cpd/courses/urinary-incontinence.
• Continence Foundation of Australia 2019a, About Your Bladder, Continence Foundation of Australia, Surrey Hills, viewed 13 August 2019, https://www.continence.org.au/pages/about-your-bladder.html.
• Continence Foundation of Australia 2019b, About Your Bowel, Continence Foundation of Australia, Surrey Hills, viewed 13 August 2019, https://www.continence.org.au/pages/about-your-bowel.html.
• Continence Foundation of Australia 2019c, Managing Bladder Problems, Continence Foundation of Australia, Surrey Hills, viewed 13 August 2019, https://www.continence.org.au/pages/managing-incontinence.html.
• Continence Foundation of Australia 2019d, Managing Bowel Problems, Continence Foundation of Australia, Surrey Hills, viewed 13 August 2019, https://www.continence.org.au/pages/managing-bowel-problems.html.
• Continence Foundation of Australia 2019e, What is Incontinence?, Continence Foundation of Australia, Surrey Hills, viewed 13 August 2019, https://www.continence.org.au/pages/what-is-incontinence.html.

(Answers: b, a, b.)