Features

Childbirth, menopause, ageing and stress incontinence: dispelling the myths

How nurses can explain that pads are not the answer and need not be inevitable

How nurses can explain that pads are not the answer and need not be inevitable

  • Women are more likely than men to experience involuntary loss of urine when they laugh, cough, sneeze or lift a heavy weight
  • Getting the message across that stress incontinence is preventable can be a challenge, say nurse specialists
  • Read tips for how to begin with an honest conversation and why terms like bladder weakness are unhelpful
Picture: iStock

If theres one thing that frustrates Alison Wileman, it is the implication that stress incontinence is somehow inevitable or even normal.

As chair of the RCN bladder and bowel forum and Southern Health NHS Foundation Trust continence service

...

How nurses can explain that pads are not the answer and need not be inevitable

  • Women are more likely than men to experience involuntary loss of urine when they laugh, cough, sneeze or lift a heavy weight
  • Getting the message across that stress incontinence is preventable can be a challenge, say nurse specialists
  • Read tips for how to begin with an honest conversation – and why terms like ‘bladder weakness’ are unhelpful
Picture: iStock

If there’s one thing that frustrates Alison Wileman, it is the implication that stress incontinence is somehow inevitable or even ‘normal’.

As chair of the RCN bladder and bowel forum and Southern Health NHS Foundation Trust continence service lead, she is on a mission to assure women in particular – and nurses – that stress incontinence need not be seen as inevitable.

The problem with normalising incontinence

Alison Wileman: ‘It could be one in
three women who have it’

There are things you can do to stop it, and even prevent it happening in the first place. Getting that message out there is a challenge, she says, partly because of the myths that persist in the general population and even among some health professionals.

Adverts that some might interpret as normalising the use of pads do nothing to dispel these myths, she says. In fact, she believes they reinforce them.

‘I had a lady in the virtual clinic yesterday. She’s got a toddler and she’s proactive, and she said she was talking to her friends about having a referral and coming to see me because she wasn’t going to put up with stress incontinence.

‘She said they were surprised and saying things like: “Oh, you can do something about it?” She was shocked that her friends – she’s 30 – were accepting it as normal, when it just isn’t.’

Sending the wrong message: the incontinence pad advert problem

Wendy Preston: ‘Too many will be living with
something they could get help with’

An important message for nurses to communicate is that leaking isn’t inevitable – not even after childbirth or when a woman gets older – and that a pad should not be a first port of call.

Last year, the RCN wrote to the Advertising Standards Authority (ASA) to complain that adverts for incontinence products inaccurately portrayed urinary incontinence as ‘normal’ post-childbirth.

The ASA found that the company did not breach any rules, but the company did agree to amend its advert ‘following feedback from health professionals’ to direct people to seek healthcare advice.

RCN head of nursing practice Wendy Preston says that far too often women do not report incontinence because of embarrassment.

‘It is important that adverts for products to help with incontinence make it clear it is not something that should be just covered up and that there is treatment available,’ she adds.

‘It may not be a comfortable conversation but unless we do talk about it, far too many will be living with something they could get help with.’

What is stress incontinence, who is more likely to experience it, and how can nurses help?

Stress incontinence is the most common type of incontinence, affecting more women than men, probably because it can be related to childbirth and the menopause. Essentially it is an involuntary loss of urine when you laugh, cough or sneeze, or lift something heavy – anything that involves putting pressure on the pelvic floor.

Numbers of those affected are probably under-reported.

‘It could be one in three women who have it, but who actually puts their hand up and admits at one time or another that they will leak urine,’ says Ms Wileman.

‘I’ve had patients say “Oh, I’ve only got bladder weakness”, but when you have a conversation, they’ll say they leak a bit of wee. It’s a different label and it sounds as if it’s something that’s not as bad’

Alison Wileman, chair, RCN bladder and bowel forum

There are factors that put you at higher risk. ‘You could have stress incontinence because you have constipation – you resolve the constipation, and you’re not having symptoms of stress incontinence. You could be having issues around your asthma being poorly managed – you’re coughing loads and you end up leaking urine. Your asthma is better managed, and you’re not incontinent. You lose weight – it’s amazing, you have women who come back to clinic and they’ve lost a stone and they say they can’t believe the impact it’s had on their symptoms.’

Is it ‘pure’ stress incontinence?

When patients do ask for help, they might be treated in primary care or specialist services depending on the protocol and availability in their area. Generally, specialist continence nurses like Ms Wileman will do an assessment to see if the individual has ‘pure’ stress incontinence or if they have other issues such as an overactive bladder or inability to void.

‘We send patients a quality of life questionnaire to understand how they’re managing. A fluid chart is such a good support as an assessment tool to find out what’s going on,’ says Ms Wileman. ‘So, when we’ve found that the person has pure stress incontinence, we’d be giving them advice around their weight and their diet to make sure that constipation wasn’t an issue. We’d be giving them advice tailored to their circumstances.’

Effects of the menopause and advice on pelvic floor exercise

Oestrogen therapy may be appropriate
for older women Picture: iStock

Stress incontinence is familiar to many perimenopausal or post-menopausal women.

‘Oestrogen can affect the pelvic floor so oestrogen therapy might be appropriate for the older woman when they’ve got thin, dry tissue – atrophic vaginitis – because it might improve their pelvic floor exercises,’ says Ms Wileman.

‘Or if they’ve got any scar tissue or the muscle is damaged, the exercises might be more of a struggle for them to achieve. We give advice about pelvic floor exercises and how women can slot them into their day-to-day activities – trying to keep tools as simple as possible, and achievable.

‘If they feel they don’t have time to do their pelvic floor exercises, I suggest that it’s like brushing your teeth – it might be when they watch a particular television programme, or listen to a radio station.’

Ms Wileman tends to steer people towards the NHS resources on pelvic floor exercises because they are kept up to date, she says. ‘We also produce our own booklet on promoting continence that has male and female pelvic floor exercises, but there’s also information about caffeine, overactive bladder, things like that. It’s about opening conversations and encouraging people to think about it.’

Pelvic floor exercises can be built into day-to-day activities Picture: Alamy

Why euphemisms and terms often used about the condition don’t help

One of the things that upsets Ms Wileman is that terminology appears to be changing – instead of ‘stress incontinence’, terms such as ‘bladder weakness’ or ‘bladder sensitivity’ are used.

She believes these mask the seriousness of the condition.

‘I’ve had patients, non-continence colleagues and friends say: “Oh, I’ve only got bladder weakness.”

‘But when you start to have conversations with them, they’ll say they leak a bit of wee. It’s a different label and it sounds as if it’s something that’s not as bad.’

Gill Davey: ‘People talk about it as if it’s
part of the ageing process’

Proactive about preventing incontinence

Gill Davey, a freelance clinical nurse specialist who until recently was continence services manager with the Dudley Group NHS Foundation Trust in the West Midlands, has worked in continence services for almost 25 years.

She believes women should be taught proactively how to prevent stress incontinence and warns that it is only going to become more of an issue in the future.

‘Women who become pregnant should be taught to look after their pelvic floor,’ says Ms Davey.

‘Obviously, babies are getting bigger and obesity is becoming even more of a problem, so that’s more extra weight on our bodies, and there is menopause as well, which is another area.

‘It’s trying to dispel these myths – actually, it’s not normal to wet yourself after you’ve had a baby. You need to get that pelvic floor functioning better’

Gill Davey, freelance clinical nurse specialist

‘One problem is that a lot of people talk about it as if it’s part of the ageing process, or they say that their mother wet herself when she had a baby so it’s expected that they will too.

‘It’s trying to dispel these myths, that actually, it’s not normal to wet yourself after you’ve had a baby. You need to get that pelvic floor functioning better. And you don’t want to be wearing pads. Learn the skill young – we don’t want to be wetting ourselves, we want to be kept dry and clean.’

Tips for talking to patients about stress incontinence

Clinical nurse specialist Gill Davey advises:

Do not assume stress incontinence is normal or inevitable and challenge the notion that a pad or similar product is the answer

Ask gentle questions such as ‘do you leak urine when you cough or sneeze?’ or ‘how long can you hang on when you need to go to the toilet?’. You might follow up with ‘can you count to five, or can you hang on for 10 minutes?’

Ask ‘trigger’ questions relating it to someone’s life, such as ‘are you leaking when you’re running to the toilet or when you’re hoovering?’

Check whether there are other issues that could be causing stress incontinence symptoms – such as excess weight, constipation, excess caffeine or poor fluid intake – and offer lifestyle advice

Refer women to reputable advice on pelvic floor exercises, such as the NHS website

Familiarise yourself with local resources such as specialist continence services, so that you know where to signpost patients (or seek advice yourself) when necessary

Discussing lifestyle changes with patients

One of the challenges for services is persuading patients to make the necessary lifestyle changes to improve symptoms.

‘Nurses who are in this field are obviously passionate about what we do and what we believe in, because we know we can make a lot of difference,’ says Ms Wileman.

‘It’s nothing technically difficult, but what can be difficult is getting the person to take on board and make some lifestyle changes. It could be as simple as doing more pelvic floor exercises or stopping drinking loads and loads of coffee to make the difference, and the bladder will be back in harmony again.’

Health visitors, midwives and practice nurses should be equipped to talk to women about stress incontinence, she says. ‘For example, if they’re doing smears, practice nurses could check at the same time – ask the woman to cough, ask if there are any leakages, or asking if they’re having problems,’ she says.

‘It is personal, and it may have taken quite a bit of courage to speak to the nurse or health visitor or midwife, but they can ask some quite gentle questions. If someone says that when they cough they leak a little bit, well that’s the time to nip it in the bud and get something done about it.’

Most issues relating to stress incontinence could be handled at this level, unless there are ‘red flags’ such as excessive bleeding, prolapse or pain, in which case a referral to an appropriate secondary care service would be in order, she says.

‘If there’s no red flag symptoms they could quite easily be managed in primary care,’ she adds. ‘If the practice nurse is confident about managing this, then they can, or they could pass them to the continence services, and involve specialist physiotherapists as well for more one-to-one pelvic floor management.’

Removing the taboo about discussing incontinence

Ms Wileman doesn’t entirely blame advertising for the misconception that urinary leakage is inevitable. It is partly, she says, because incontinence traditionally has not been discussed openly.

‘Our parents and our parents’ parents didn’t talk about it, and because it is such a taboo subject it’s heavily under-reported,’ she says.

‘The positive is that women in adverts are talking about it, but the messages are normalising it. I’d want them to push the challenge that actually, this isn’t acceptable, this isn’t normal, I can do something about it.

‘It’s like having a weepy leg. You wouldn’t go around with a weepy leg ulcer for six years and think “Oh, it’s because I’m old” or “Oh, it’s because I’m 40” or “Oh, it’s because I smoke”.

‘You’d have a different attitude to it and you’d do something about it. Putting a plaster on it – which is how I describe reaching for a pad – masks the impact.’


Jennifer Trueland is a health journalist


Further information

Want to read more?

Subscribe for unlimited access

Enjoy 1 month's access for £1 and get:

  • Full access to primary healthcare.com
  • Bi-monthly digital edition
  • RCNi Portfolio and interactive CPD quizzes
  • RCNi Learning with 200+ evidence-based modules
  • 10 articles a month from any other RCNi journal

This article is not available as part of an institutional subscription. Why is this?

Jobs