Problems of the bladder, bowel or both are common in the community setting and are challenging issues for affected individuals, carers and healthcare staff to manage. Within the UK, an estimated 14 million individuals have urinary incontinence (NHS England, 2018), and over 6.5 million adults have bowel control problems (Yates, 2017; NHS England, 2018), with 1 in 10 affected by faecal incontinence. Nearly two thirds of people with faecal incontinence also have urinary incontinence, a condition known as ‘double incontinence’ (NICE, 2015b). Faecal incontinence is closely associated with age, and it is more prevalent in residential or nursing homes, with 1 in 3 individuals in residential homes and 2 in 3 individuals in nursing homes affected (NICE, 2015b; NHS England, 2018). However, these statistics are probably an underestimation given the stigma associated with the condition and its consequent under reporting (Bedoya-Ronga and Currie, 2014). Although the incidence of incontinence is known to increase with age, it is not an inevitable part of the ageing process (Day et al, 2014). Older people may be more prone to continence issues for a number of reasons, for example, multiple morbidies such as stroke and dementia, mobility problems, or polypharmacy, which can affect both bowel or bladder function. Additionally, the muscles of the bladder age and begin to malfunction, the prostate enlarges in men and weak pelvic floor muscles result in proplapse. These can have negative effects on an individual's physical and emotional wellbeing and can contribute to anxiety, depression and loss of personal relationships (Yates, 2017); increase susceptibility to urinary infections and falls; and can cause incontinence-associated dermatitis. There is certainly scope to address and improve or manage some of these issues more appropriately. This article looks at these points in depth.
Bladder and bowel function in the older person
The causes of incontinence in the older population are usually multifactorial (Table 1) and consequently require a number of different interventions for treatment. There are significant age-related physiological changes within the bladder, lower urinary tract and bowel. For the urinary tract, these changes include a decrease in detrusor contractions, reduction in bladder capacity and urinary flow rates and increase in prevalence of incomplete emptying and progressive enlargement of the prostate gland (Asian et al, 2009; Yates, 2016). Individuals may present with frequent micturition (over eight times in 24 hours), urgency to void (inability to hold on), stop/start flow and hesitancy (inability to initiate a void), or they may void only small amounts because of incomplete emptying. For women, there is a higher risk of pelvic floor dysfunction because of previous childbirth and decease in oestrogen levels due to menopause, which can contribute to reduced urethral closing pressures and prolapse (Lucas et al, 2012; Yates, 2016).
| Changes in bladder function | Changes in bowel function | Medical conditions |
|---|---|---|
| Decline in ability to contract, decreased capacity, decreased flow, and reduced ability to concentrate urine | In a healthy adult, there is no significant change in normal digestion, absorption and elimination | Menopause or hysterectomy |
| Urinary tract infections | More prone to develop diverticular disease | Prostatectomy |
| Prostate problems in men | Insufficient diet or dietary fibre can cause constipation | Dementia |
| Insufficient fluid intake can cause bladder urgency or urinary tract infections | Insufficient fluid intake can contribute to constipation | Diabetes |
| Pelvic floor dysfunction |
Pelvic floor, anal sphincter or squeeze pressure dysfunction | Heart failure |
| Constipation or faecal impaction can cause voiding difficulties | Constipation or faecal impaction | Musculoskeletal problems, e.g. arthritis, affecting mobility/dexterity |
| Mobility, dexterity and mental capacity issues Difficulty getting to the toilet or recognising the toilet | Mobility, dexterity and mental capacity issues. Difficulty getting to the toilet or recognising the toilet | Neurological problems, e.g. multiple sclerosis, cerebrovascular accidents and Parkinson disease |
Changes in the bowel normally associated with a long-term lack of fibre include diverticular disease, constipation, faecal impaction, pelvic floor dysfunction and diarrhoea. Both the bladder and bowel are affected by mobility or dexterity and mental capacity issues as well as polypharmacy, for example, diuretics, anticholinergics or antimuscarinics, opioids, calcium channel blockers, cholinesterase inhibitors, alpha-agonists, antihistamines, laxatives and antibiotics.
Basic assessment in the community
A first-level continence assessment should be undertaken by community health workers or district nurses who have been deemed competent in the skill in line with recommended minimum standards (United Kingdom Continence Society (UKCS), 2015). Health professionals should receive multi-disciplinary accredited education in basic continence assessment to promote continence care. The outcome should be the diagnosis of the problem and offering of treatments, but if this is not achievable, other management options may be required (UKCS, 2015). The assessment should include a complete medical, surgical and obstetric history; all medication, including over-the counter-medication, herbal remedies and recreational use; a completed 3-day bladder and/or 1-week bowel diary or an observational chart completed by carers/professionals; and any environmental factors, that is, access to toilets, room sharing, chair or bed height, toilet height, sufficient space in the toilet to accommodate equipment such as walking aids and wheelchairs, floor surfaces and unambiguous signage that may affect continence (NICE, 2015a; NICE, 2015b; Staskin et al, 2013; Yates, 2018).
Questions the health professional should ask include:
Treatment
Age should never be a barrier to initiating treatments; the only concerns should be whether the individual can physically or mentally comply with or carry out the treatments. Thus, advanced treatments such as bladder retraining, pelvic floor rehabilitation, anal irrigation, etc. should still be considerations. However, it is advisable to start with simple conservative therapies (Table 2), as these are less invasive and disruptive for the patient.
| Bladder | Bowel |
|---|---|
| Identify fluid intake (aim for 6–8 glasses daily) | Identify fluid intake (aim for 6–8 glasses daily) |
| Discourage consumption of caffeine-based fluids | Discourage consumption of caffeine-based fluids |
| Discourage consumption of excess fluid before bedtime | Encourage a balanced diet |
| Review medication | Review medication |
| Encourage individual toileting programmes | Encourage individual toileting programmes |
| Pelvic floor rehabilitation | elvic floor rehabilitation |
| Toileting assistance/equipment (commode, bottom wipers, etc.) | Toileting assistance/equipment (commode, bottom wipers, etc.) |
| Environmental changes (clear signage on doors, adaptations like hand rails and clothes) | Environmental changes (clear signage on doors, adaptations like hand rails and clothes) |
| Containment products |
Containment products |
While there are few products to manage incontinence in women other than pads, the choice of product used to manage urinary incontinence in men depends on the individual's preference and confidence in the product's effectiveness (Chartier-Kastler, 2011; Yates, 2016). This includes sheaths, pubic pressure devices and a range of urine directors.
Absorbent pad products are frequently used but can cause skin damage (incontinence-associated dermatitis) if they are not absorbent enough or too absorbent. The risk of this skin damage can be mitigated by using barrier creams. Ideally, all-in-ones (wraparound brief style) should not be used for mobile individuals who can be toileted, as they can be difficult to manage and can reduce independence and dignity (Cottenden et al, 2013; Yates, 2016). Users also tend to keep them on for prolonged periods of time (Lekan-Rutledge, 2004). These products should be used mainly for immobile or bed-bound individuals.
Conclusion
Continence care within a community setting is multifactorial and requires the healthcare worker to have knowledge of basic continence assessment, simple conservative therapies and management options. If these strategies are implemented in an organised way, the continence status in patient may see some degree of improvement. If this is not achievable, their dignity and quality of life with regard to the continence problems can and should be maintained.