Specialist

There are some specific conditions where incontinence can be a symptom. And, in some cases, these conditions present their own challenges for the management of incontinence. Some of these conditions are described below.

Dementia and incontinence

Dementia is a progressive condition that causes cognitive symptoms. Problems with memory loss, mood changes, communication and orientation can have an effect on continence in people with dementia.

Incontinence is not an inevitable consequence of dementia and people with dementia should always be assessed for alternative reasons for their incontinence (for example a UTI, constipation or enlarged prostate) and these should be treated appropriately.

The skills required for successful toileting identified by Getliffe and Dolman highlight the complexity of going to the toilet. If any of these skills are disrupted by cognitive impairment such as dementia, a person may experience continence issues.

Skills Required for Successful Toileting (Getliffe and Dolman):

  • recognise the need to use the toilet
  • be motivated to use the toilet
  • identify an appropriate place
  • locate an appropriate place
  • have the physical ability to get there
  • hold on until an appropriate place is reached
  • maintain goal-orientated behaviour
  • able to adjust clothing and use toilet once reached

A thorough assessment of urinary incontinence can identify which specific issues are causing the problem and individualised care should be given to help people maintain or improve their continence levels.

Good bladder and bowel habits will help an individual to maintain their continence for longer and basic advice should be given, such as good fluid intake, avoiding constipation and reducing caffeine.

Practical tips to help individuals manage incontinence include:

  • regular toileting programmes – prompting someone to use the toilet or taking them on a regular basis
  • clear signs on the toilet door – both words and a picture of a toilet can help
  • ensure there are suitable handrails in the toilet
  • make the toilet easily identifiable – people may find a white toilet with a black seat easier to identify
  • make clothing easier to take off – for example, elasticated waists rather than button fly.
  • using a urinal instead of a toilet.

Carers often report that incontinence is the most challenging aspect of caring for a relative with dementia, and is regularly cited as the reason for a relative going into a care home. When caring for a person with dementia and incontinence, the needs of the carer should also be taken into account and whether a carer’s assessment is needed to ensure they have enough support.

For further information go to www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=136

Older people and incontinence


Older men may develop an enlarged prostate gland, which can cause difficulty in passing urine and voiding the bladder fully. They may experience difficulty in initiating a flow of urine and experience “dribble” after they feel they have finished.

Older women may have weak pelvic floor muscles following childbirth and experience urinary incontinence on exertion or after sneezing or coughing.

Both men and women may have an altered dietary intake as they get older, which can trigger changes in bowel habits. They may become constipated or suffer from looser stools.

Medication can affect appetite, ability to wake up in the night for the toilet and the number of visits to the toilet required. Diuretics are designed to cause more frequent urination; therefore older people may become anxious about going out. Laxatives, used to treat and prevent constipation, loosen stools and increase bowel movements so anxiety can develop about leaving the house in case of accidents.

Older people may be less active, which can cause constipation.

The older generation tend to be very private about toilet habits so they may not seek advice about symptoms until a serious problem has developed. Their spouse may cover for them by doing additional washing, buying pads, waterproof sheets. They may think that it is a normal consequence of old age or fear that it is a symptom of a serious illness such as bowel or bladder cancer.

Communication problems may develop in older adults – eyesight, hearing and speech may be affected by age and illnesses such as stroke or dementia.

Older people are more likely to experience mobility problems, as well as physical frailty and falls.

Sensory and motor impairment and conditions such as arthritis make fastenings on clothes harder to manage.

Urinary incontinence can also be difficult for carers to manage, and a cohort study of about 6000 patients found that urinary incontinence was second only to dementia as a reason for admission to long term care.4

Neurological problems

Bladder
For most people, nerves in the bladder signal when it is time to urinate. People get the feeling that they need to go and must find a toilet. The urge to urinate becomes more urgent the longer time passes, but most people make it to the toilet in time.

Neurogenic bladder is the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem (Urology Care Foundation 2016).

People who are born with spinal cord birth defects, such as spina bifida, can have this type of bladder problem. Examples of brain disorders that can cause neurogenic bladder include Parkinson’s disease and multiple sclerosis. It can also be caused by trauma or infection of the brain or spinal cord, pelvic surgery, strokes and diabetes.

Symptoms include:

  • urinary incontinence
  • frequency and urgency
  • difficulty emptying the bladder (underactive bladder or obstructive bladder)

Complications include:

  • urinary retention
  • urinary tract infection
  • hydronephrosis
  • autonomic dysreflexia (patients with high thoracic or cervical spinal cord lesions) life-threatening syndrome due to unregulated sympathetic hyperactivity
  • bladder cancer
  • sepsis

A full assessment should be performed by a health professional and may include:

  • physical examination including a full neurological examination
  • urodynamic studies
  • urinalysis / monitor renal function
  • renal ultrasound scan (cystoscopy/cystometrography)

Bowel

Any damage to the brain and spinal cord can have a major impact on the function of the large bowel and maintenance of faecal continence.

Sensory and motor control of the anorectum (the distal portion of the digestive tract, including the entire anal canal and the distal 2cm of the rectum) may be impaired leaving the individual with reduced or absent voluntary control of defecation. Stool transit may be slowed, which may result in constipation.

Neurogenic bowel is the term used to describe dysfunction of the colon (constipation, faecal incontinence and disordered defecation) due to loss of normal sensory and/or motor control or both3.

Complications:

  • haemorrhoids or bleeding from constipation.
  • faecal incontinence
  • faecal impaction, where dry hard stools collect in the rectum and anus
  • rectal prolapse from repeated straining
  • megacolon – dilation of the colon
  • anal fissure or tear.

Bowel management is essential for people with spinal cord injuries. They tend to become experts in managing their own bowel regime and know exactly what works for them. However, if there is a change in routine, or the routine is disrupted, problems can occur.

Treatment and management
Communication is key to managing complications. It is important to ask the individual, their family and carers what works for them and discuss the various treatment options. This may well include interventions such as the manual evacuation of faeces.

"What is their ‘normal’ routine? What works and what doesn't work?"
"Do we need to order any medications or enemas?"

Ensure adequate fluids are provided and a healthy diet is maintained.

It is important to maintain patient dignity and privacy at all times.

References

If you would like to read more about this subject the following resources may be useful.

(1) Getliffe and Dolman (2003) Promoting continence: a clinical research resource (2nd edition), London: Baillière Tindall.

(2) Chung AL, Emmanuel AV (2006): Gastrointestinal symptoms related to autonomic dysfunction following spinal cord injury. In Weaver LC, Polosa C, editors. Progress in Brain Research, Elsevier: p.327-33.

(3) For further information go to www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=136

(4) NICE guidelines (2012) Urinary incontinence in neurological disease: assessment and management.

(5) Hwadmin, Thirugnanasothy S. Managing urinary incontinence in older people. Clinical Review. 9 August 2010.

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