Posted 26 April 2021 - 01:00
Posted 26 April 2021 - 01:00
Analysis
Urinary incontinence: it’s common in nurses, but are you ignoring the symptoms?
Demographic and occupational factors increase the risk, but it’s important to seek help early
Demographic and occupational factors increase the risk for nurses, but it’s important to seek help early
- Studies suggest stress and urge incontinence are relatively common among nurses
- Incontinence can have a big impact on physical and psychological well-being, but many nurses find it difficult to discuss as it is still seen as a taboo subject, experts say
- The steps that can improve and reduce symptoms, including lifestyle changes, pelvic floor exercises and better hydration
Addressing patients’ continence needs is an important aspect of many nursing roles, but a significant proportion in the profession are also likely to be struggling with their own bladder problems.
An estimated 14 million men, women, young people and children are living with bladder problems, according to NHS England.
Different types of urinary incontinence and who they affect
About 61% of men in the general population experience lower urinary tract symptoms (LUTS), which includes needing to urinate more often, overactive bladder and a sudden need to urinate urgently.
About a third (34%) of women are living with urinary incontinence (UI), according to the Excellence in Continence Care guide.
Although it is rarely life-threatening, UI can have a big impact on the physical, psychological and social well-being of those affected.
While there are different types of UI, the most common are stress incontinence – when leakage occurs during periods of abdominal pressure, such as coughing, sneezing, lifting and straining – and urge incontinence – leakage that follows a strong, sudden urge to pass urine.
Incontinence issues common among nursing professionals
International research suggests incontinence may be a significant issue for the nursing profession, with 48% of 322 nurses and midwives in a 2017 Australian study reporting UI. In a similar study in Brazil, 28% of 291 female nursing staff reported experiencing UI at least once a month.
In addition, a number of studies suggest that rates of LUTS could be more prevalent in nursing than in the general population. One study of 1,070 nurses in China in 2013 found that almost 90% reported symptoms of LUTS.
These apparently high rates of UI and LUTS among nurses are linked to both the demographic of the profession and the nature of nurses’ work – with age, female gender, overweight and lack of hydration all factors in UI.
Learning to talk about personal experiences of incontinence
Elaine Hazell, clinical nurse specialist in functional urology at Guy’s and St Thomas’ NHS Foundation Trust in London, says UI remains a taboo subject that healthcare staff are often reluctant to talk about.
‘Staff joke about it, but no-one actually says that they are affected and asks us what steps they could take for improvement,’ Ms Hazell says. ‘We really need to talk about it more. We are getting better at discussing the impact of the menopause at work, so some nurses may bring up continence concerns as part of this discussion.
‘I worry that a lot of nurses must have incontinence, but are not seeking help and are just using pads. It is more common as we age, but it is not a “normal” part of ageing.’
Ms Hazell says nurses who seek help should be offered appropriate care and support to help improve their symptoms. ‘With proper care, there is so much that can be done to help. We have a brilliant specialist physiotherapy service and we would always seek out options to help people, not dismss their symptoms.’
‘Nurses need breaks to drink some water and use the bathroom to prevent or manage any symptoms of UI. But things like being overworked and wearing personal protective equipment don’t help with this’
Lucia Berry, pelvic health physiotherapist
She adds that nurses’ knowledge in relation to continence and incontinence can vary considerably, and bladder and bowel care only became a required part of preregistration courses in 2018.
‘Many aspects of how the urinary system works seem to be widely misunderstood,’ she says.
UI and nurses: the demographic and occupational factors
Nine out of ten UK nurses are female and, while UI affects men and women, it is more common in women.
Stress incontinence is usually the result of weakness in the pelvic floor muscles or the sphincter in the urethra, which carries urine.
Increasing age is a factor and more than 250,000 of the 675,000 nurses on the register– more than 1 in 3 – are aged 51 or over, according to Nursing and Midwifery Council data. In the UK, 51 is also the average age of the menopause, which itself is a risk factor. Falling oestrogen levels due to the menopause and hysterectomy can cause stress incontinence, as the hormone helps keep tissues supple.
Being overweight can increase the risk of having stress incontinence, and research suggests that many nurses are overweight. A study published in the BMJ in 2018 found that a quarter of UK nurses are obese.
Another risk factor is childbirth, with the risk higher for a vaginal birth and higher again if instruments were needed. If a woman experienced UI during pregnancy, this puts her at higher risk of problems in the future.
Smoking is also risk factor, as it causes coughing, which can be difficult for a weakened pelvic floor to cope with.
Urge incontinence is generally caused by the detrusor muscle – a muscle in the wall of the bladder which relaxes to allow the bladder to fill with urine, then contracts to let urine out – contracting too frequently, according to the NHS.
This creates an urgent need to go to the toilet in a problem known as overactive bladder.
Drinking too much alcohol or caffeine and not drinking enough liquid (which can lead to concentrated urine that irritates the bladder), constipation, urinary tract infections and some neurological conditions can cause or contribute to an overactive bladder.
The importance of seeking help with incontinence
Too many women put up with UI rather than seeking help, says Lucia Berry, pelvic health physiotherapist and a trustee of Pelvic Obstetric and Gynaecological Physiotherapy (POGP) professional network.
A number of factors that affect the way nurses work put them at higher risk of UI, she says. The physical aspect of many nursing roles, including being on your feet a lot and moving and positioning patients, puts more pressure on the pelvic floor.
Add to this that many nurses, in hospital and the community, may struggle to get breaks or go to the toilet. The resulting over-filling of the bladder can lead to more pressure on the pelvic floor muscles and the urethral sphincter. If a nurse has problems with constipation, or simply hasn’t had time to use the toilet, this also compounds the problem, with additional weight and pressure from stool in the bowel.
‘Many nurses work long shifts, often on consecutive days,’ says Ms Berry. ‘They will not have time to hydrate properly and use the toilet frequently.
‘Having breakfast is important, as this gets the bowel moving and is more likely to prompt a bowel action at home. Lots of people don’t like pooing at work, so if that opportunity is missed, it can be a long time, with that extra weight bearing down on the pelvic floor, leading to more opportunities of UI.
‘Nurses need breaks to drink some water and use the bathroom to prevent or manage any symptoms of UI. But things like being overworked and wearing personal protective equipment don’t help with this.’
Community nursing: ‘I turn down drinks if it’s hard to access a toilet’
Rachel (not her real name), a mental health nurse in the South West of England, is 48 and has experienced symptoms of stress incontinence since she had her first child 14 years ago.
She finds that running, jumping, sneezing and coughing can all cause involuntary leakage and it is worse around the time of her period.
Rachel did visit a specialist physiotherapist but found the associated intimate examination difficult. The symptoms persisted despite Rachel’s attempts to carry out the pelvic floor exercises recommended.
‘I did find them exhausting, despite being physically fit, and probably didn’t do them enough,’ she says.
Her work as a community mental health nurse can mean that she thinks twice about drinking in case she is not near a toilet.
‘Some days I’m visiting patients at home all day,’ she says. ‘On those days I do think about where the public toilets are and will turn down drinks as it can be hard to access facilities.’
Rachel is a keen runner and found that this activity made it worse. ‘I always wear a pad for running and did get to the point where I needed to wear a panty liner all the time,’ she says.
‘But an injury stopped me running about a year ago and the symptoms have improved since then, including when I am not running. While it won’t stop me running, it does show that it contributes.’
Inadequate opportunities for breaks and hydration
Research confirms that over-stretched nurses struggle to access water and have breaks.
In a 2017 RCN survey on safe and effective staffing, 59% of survey respondents said they did not get to take sufficient breaks on their last shift. This was more pronounced in community settings, where 69% of nursing staff did not take sufficient breaks.
And a 2019 Nursing Standard survey of almost 2,250 nurses found eight out of ten respondents had gone an entire shift without a single drink of water, with more than half saying it happened at least once a week.
The term ‘nurses’ bladder’ was coined by Danish researcher AL Bendtsen in reference to infrequent voiders’ syndrome, after he found a large proportion of nurses suppressed the need to void during their shift.
He observed that the syndrome can lead to overextension of the bladder, urinary tract infections and stress incontinence.
The concerning findings of the RCN’s 2017 survey prompted the college to launch the Rest, Refuel and Rehydrate campaign, calling for nurses to be able to access essential breaks during their work.
Non-surgical approaches to treat UI in women
- Trial caffeine reduction in women with overactive bladder
- Women with a BMI of over 30 should be advised to lose weight
- Women should be offered a trial of supervised pelvic floor muscle training of at least three months' duration as first-line treatment for stress or mixed urinary incontinence. This should comprise at least eight contractions, performed three times per day
- Offer bladder training (techniques to train the bladder to hold more urine and empty less frequently) lasting a minimum of six weeks as first-line treatment for women with urgency or mixed urinary incontinence
- Do not offer pads to treat urinary incontinence, only as a coping strategy pending definitive treatment, as an adjunct to ongoing therapy and for long-term management of urinary incontinence only after other treatment options have been explored
Source: NICE guidance - Urinary incontinence and pelvic organ prolapse in women: management
Lifestyle advice and specialist care for urinary incontinence
The approaches to manage UI can be divided into two main areas, says Ms Berry.
The first is offering lifestyle advice; losing weight, if the individual is overweight and particularly if they are obese, increasing activity and stopping smoking can all have a significant effect.
‘While the research isn’t clear yet if high-impact sports like running affect UI, we generally feel that any activity is good and can improve bladder control,’ she says.
The second is specialist care from a continence healthcare professional. Experts and the National Institute for Health and Care Excellence (NICE) agree that approaches such as pelvic floor exercises should be a first-line treatment for stress and mixed incontinence, but that this needs to be supervised by a trained healthcare professional.
‘About 20% of people can do their pelvic floor exercises properly without professional input, so we know that the majority can’t,’ says Ms Berry. ‘I often use ultrasound scans when teaching an individual about this, so they can see and feel what happens when a pelvic floor contraction is done correctly.’
Ways to access treatment for incontinence
8 out of 10
nurses have gone an entire shift without a drink of water
(Source: Nursing Standard survey 2019)
Professionals can also advise on bladder training, and there are also intravaginal devices that can be prescribed to help women with a pelvic organ prolapse and UI. ‘It may be that a nurse is fine on day one of 12-hour shifts but they may find that by day two, using such a device will help them remain dry,’ Ms Berry says.
NICE is clear that a pad should never be offered as a treatment for UI, only as a short-term coping strategy or alongside ongoing therapy when all other treatments have been explored.
Some continence services are self-referred, or individuals can be referred by their GP. Nurses can also access support through occupational health at work, but experts say that staff often feel embarrassed seeking such care in their workplace.
What’s important is that nurses act early and seek help as soon as they experience symptoms, Ms Berry says.
‘A lot of it comes back to self-care, trying to give yourself time to hydrate and go to the toilet properly,’ she adds. ‘It is important with a stressful job that these aspects of looking after ourselves don’t go out of the window.’
Further information
- NHS England: Excellence in continence care
- RCN bladder and bowel forum on Twitter
- NHS: What are pelvic floor exercises?