Urinary incontinence affects approximately 300 million people globally—a number so high that it forms 5% of the entire global population (Incontinence UK, 2022). Incontinence UK (2022) states that at least 7 million people in the UK are living with urinary incontinence—around 5–10% percent of its population. The number may, of course, be much higher, given the stigma that prevents people from actively seeking help for the condition.
Physiology of urinary incontinence
The National Institutes for Health (NIH) (2023) explains that the bladder tightens in order to move urine into the urethra while the muscles surrounding it relax to allow the urine to pass out of the body. If the muscles are not working, urine may leak and incontinence may become an issue. There are various reasons for this complex problem to occur: urinary tract infections, vaginal irritation and constipation (in the short term) (NIH, 2023). However, the problem is often for the longer-term. Where the issue does not resolve, the underlying physiology may indicate a weak bladder or weak pelvic floor muscles, overactive bladder muscles, nerve damage from multiple sclerosis, diabetes or Parkinson’s disease, arthritis (due to mobility issues) and pelvic organ prolapse. In men, the most common issue is prostatitis, causing inflammation of the prostate gland, enlarged prostate gland leading to benign prostate hyperplasia, or male urinary incontinence, which may also be caused by damage or injury to nerves or muscles from surgery (NIH, 2023).
There are various types of urinary incontinence:
- Stress incontinence occurs when urine leaks due to pressure is being placed upon the bladder (such as when someone is exercising, coughing, sneezing, laughing, or lifting something heavy). It is the most common bladder control issue in younger and middle aged women, although it can develop later on following menopause
- Urge incontinence happens as a result of someone not being able to get to the toilet on time, and because the person cannot hold their urine for long enough, therefore becoming incontinent before reaching the bathroom. This is very common among patients with diabetes, Alzheimer’s disease, Parkinson’s disease, multiple sclerosis or stroke (NIH, 2023)
- In men, where the prostate is enlarged and blocks the urethra, the bladder does not empty properly. As a result of being full, urine can leak in small amounts, which is known as overflow incontinence. Sometimes this problem can result from spinal cord injury or diabetes
- When someone cannot mobilise effectively, and therefore, simply cannot get to the bathroom, they may have functional incontinence, resulting from their physical issues with mobility, rather than an underlying disordered pathophysiology of the bladder.
Management of women with urinary incontinence
The National Institute for Health and Care Excellence (NICE) (2019) guideline that covers the management of urinary incontinence and pelvic organ prolapse in women recommends the non-surgical approach in the management of the condition. NICE (2019) also recommends advice to reduce caffeine intake and to modify fluid intake such that it is not too high (causing urinary frequency), nor too low (causing dehydration and various complications in relation to dehydration). The guideline also recommends patients with a high BMI (>30), to reduce it in a healthy way. Social prescribing to exercise groups may, for example, be a healthy way to encourage weight loss, and where someone is very overweight and they are able to be referred, a dietitian may be able to advice on the most appropriate diet plan for the patient.
A supervised trial should be offered for 3 months, as a first line of treatment for women with stress or missed urinary incontinence, with the pelvic floor training programme consisting of at least eight contractions three times a day (NICE, 2019). Women with an overactive bladder may also benefit from Transcutaneous electrical nerve stimulation (TENS) in combination with pelvic floor muscle training. This may be most suited to women who are unable to contract their pelvic floor muscles. NICE (2019) recommends continuing bladder training for a minimum of 6 weeks as a first line of treatment for women with urgency or mixed incontinence, and that where there is no benefit, a combination of medication and bladder training may be the preferred modality of treatment. TENS is not recommended for an overactive bladder, and in some cases, botox may be an option. The continence specialist nurse and a consultant may decide on exactly which is best, but as a nurse, it is important to have a good general knowledge of the topic.
NICE (2019) makes it clear to not offer any absorbent containment products, hand-held urinals or toileting aids for the treatment of urinary incontinence, unless only as a coping strategy while waiting for treatment, or to be used as an adjunct to continuing therapy, or for long-term management of urinary incontinence. These should be prescribed only after treatment options have been tried and were of no good effect. People using incontinence products should be reviewed every year. It is important to assess the patient’s skin in the review and at any other clinical opportunity, as urinary incontinence can often affect and damage it. The issue of continence should be assessed and the efficacy of continence products should also be examined at the review (NICE, 2019).
Management of men with urinary incontinence
The standard advice should be given to modify lifestyle and arrange regular follow up. Men can also receive pelvic floor muscle training and bladder training, with advice to manage fluid intake and avoid constipation, reduce body weight, and referring the man, as you would refer a woman, to a continence nurse or physio.
Where the man has moderate to severe voiding symptoms, with a score of 8 or more on the International Prostate Symptom Score (IPSS), an alpha blocker is recommended by the NICE (2015) guideline on lower urinary tract symptoms in men. Alfuzosin, doxazosin, tamsulosin or terazosin are all alpha blockers recommended for this problem in men. Once commenced on this drug, the individual should be reviewed at 4–6 weeks, and then every 6–12 months.
With an enlarged prostate and high risk of progression, NICE (2015) recommends a 5-alpha reductase inhibitor such as dutasteride or finasteride. A mixed presentation of storage and voiding symptoms may warrant for further medical intervention through use of antimuscarinic drugs such as oxybutynin, tolterodine or darifenacin. A urologist may recommend catheterisation or prostate surgery if the medical interventions have not worked.
Apps to aid self-management of urinary incontinence
Rygh et al (2021) published their research in the British Medical Journal, which looked into the efficacy of app-based treatment for stress urinary incontinence. The researchers carried out a prospective cohort study with the objective of comparing the results to the randomised controlled trial that had already demonstrated good efficacy of the app ‘Tät’. The researchers looked at a large sample of patients. The study period was 17 months and in that time, 24602 non-pregnancy non-postpartum women over the age of 18 downloaded the app and responded anonymously to the questionnaire. A total of 2672 (11%) of these then also responded to the 3-month follow up. The main outcome measure was the change in symptom severity. This was measured through use of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and subjective improvement (Patient Global Impression of Improvement (PGI-I)).
The participants evaluated their use of Tät over the period of 3 months. The app provided the user with information, a pelvic floor muscle training programme and lifestyle advice.
The researchers concluded that the app showed good efficacy for aiding the self-management of urinary incontinence in the ‘real world’. Compared with the randomised controlled trial, the reduction in incontinence symptoms was less; however, two-thirds of users found they improved. The researchers commented on the usefulness of an app as it reaches potentially more women; this is because it is easy to download and used anonymously, avoiding the potential stress of arranging an appointment. The app may be something that makes its way into the field of urinary incontinence management, especially for those with shorterterm issues or milder, longer-term issues, that do not require a specialist and medical intervention. This may help with NHS waiting lists and with accessing the necessary advice and resources with far greater ease.
Mental health considerations
Cheng et al (2020) analysed the relationship between urinary incontinence and depression or anxiety, searched well-reputed databases and included 12 articles in their analysis, comprising a total of 31462 participants. The researchers found the urinary incontinence group had significantly higher levels of depression and anxiety at all ages analysed. The mental health impact of incontinence can be significant due to the social issues surrounding the condition, especially where it is not well-managed. Some patients may hardly leave their house for fear of losing control of their bladder or may severely dehydrate themselves in order to avoid passing urine. This, in itself, can also be damaging to the mental health of the patient. It is important to ensure their wellbeing by recommending any relevant support groups they could try online, while also advising on the relevant route to accessing talking therapies—such as through Improving Access to Psychological Therapies. A continence nurse can also counsel the patient on the condition, which may reassure the patient and motivate them to self-manage their condition.
Conclusion
Overall, the area of continence is fairly complex. Both men and women may experience different types of continence problems, for a variety of reasons that could result in the issue being either short- or long-term. There are recommended routes of management, including through pelvic floor muscle exercises, use of medication, surgery or catheterisation for men, or continence aids for women (but only as a last resort when nothing else has helped). The impact on mental health is significant and therefore, the assessment of your patient will be holistic and may result in contact or referral with the continence nurse or specialist, as well as meeting the psychological needs of the patient through counselling support group referrals. An app to help patients self-manage their condition has also emerged and may be helpful to the patient.