Incontinence 101

Having spent 3 years in various wards, community areas, clinics etc., there has always been one problem which many of my patients have been affected by; incontinence!

Incontinence can be urinary, faecal or both. Incontinence is not a disease, rather a sign of a lifestyle problem, or a symptom of a medical condition. It affects between 3 and 6 million people (!!!!), and many do not seek help until much later. This needs to change!

Types of incontinence

Stress incontinence -not actually related to stress! It means that there is pressure on the bladder due to pregnancy, being overweight, sneezing, lifting heavy objects and some medical conditions (such as prostate cancer). It happens because the pelvic floor and urinary sphincter are weakened.

Overactive bladder- this is when you feel a strong urge to urinate, as your bladder is not relaxed. This means your bladder doesn’t like any amount of urine, so is constantly telling you to get rid of it! This can be caused by the type of fluids you drink, like caffeine or alcohol. It may be due to dehydration, as small concentrated amounts of urine in the bladder will irritate it. A urinary tract infection (UTI) can also cause an overactive bladder, but this is easily ruled out through a urine dip.

incontinence

Functional incontinence- This means that the incontinence is occurring as they are unable to reach the toilet on time, often due to immobility but also caused by Dementia or other physical/mental illnesses.

Mixed incontinence- As the name suggests, this is when there are two causes of incontinence. For example, a mix of stress and overactive bladder. Very common in women!

Total incontinence- This is the most severe, as there is no control over the bladder so there is constant leakage. This can be due to bladder abnormalities, spinal cord damage or bladder fistulas.

Faecal incontinence

Faecal incontinence can be harmless or serious, so it’s important to know all the details! Diarrhoea and constipation are the most common causes. Chronic constipation can lead to a weakening of rectal and intestinal muscles, causing faecal leakage. This is common in people with Parkinson’s.

How can you prevent incontinence?

  • Avoid/cut down on “bladder unfriendly” things such as caffeine, alcohol and spicy/acidic foods
  • Regular exercise (the answer to everything!)
  • Regular pelvic floor exercises
  • Treat any constipation and diahorrea quickly
  • Don’t strain during bowel movements, as this can weaken the muscles which control your bowel movements and only allow small amounts of faeces to pass

Treatments

There are so many options, and it depends upon the persons health and mental capacity, as well as the type of incontinence they have.

Pelvic floor exercises– These strengthen the pelvic floor muscles, which is the most effective treatment for stress or childbirth related incontinence. They are undertaken for 12 weeks, and must be completed 3 times a day (8 contractions each time).

Bladder training- This is a method I’ve been doing accidentally in all my years as a waitress/student nurse (2 professions where emptying you bladder needs to be precisely scheduled with your many other tasks). It involves delaying the passing of urine for 5-10 minutes, in order to force the bladder to wait. Techniques to achieve this include crossing you legs, standing on your toes, distracting yourself or applying pressure to your perineum.

Medicinal- I won’t go too far into detail, as I’m not an expert just a keen observer. Medicinal treatment of incontinence only works for overactive or mixed incontinence, and it is not the first-line of treatment (in nurse-led services). Drugs such as Oxybutynin, Tolterodine, Darifenacin and Festoterodine. These drugs are either immediate or extended release, with extended release causing less side effects but interacting with more drugs. They work by inhibiting the parasympathetic nerve impulses, relaxing your bladder. However, it is highly important to educate your patients about the possibility of urinary retention with these drugs, and a bladder scan is required 4 weeks after starting these treatments.

So that’s your one stop blog about continence! I can highly recommend spoking with your local continence service, whether in hospital or community, as you learn so much!

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Student Nurse Advocate

images.jpegAdvocating for patients, in my opinion, is one of our most privileged roles and one we should take very seriously. I have often found, our position as Student Nurses affords us a certain advantage when it comes to patient’s openness right from day 1. Because we are often very hands-on, we know our patients very intimately and they feel more able to open-up to us about smaller concerns they may not feel were important enough to raise with their doctor or consultant for example. This carries a responsibility for us to make sure we take all patient’s concerns seriously and act on/escalate anything that, using our theoretical knowledge, may be of importance to their care. This also takes a pinch of courage to have confidence in your instincts and “back yourself” as we say on the Rugby pitch.

Last week while assisting a patient with his wash (which is often a time when I learn the most about a patient) he told me he hadn’t slept well that evening as he had visited the bathroom over 10 times in the night. This patient was due for discharge in the coming days so this was concerning for me. As an elderly gentleman with hypertension, heart disease and other comorbidities, he was at risk of Falls and if he is going up and down to the bathroom so regularly, especially in the night, he may sustain a serious injury such as a fractured neck of femur. I looked through his drug kardex and found he was on very high doses of furosemide, a loop diuretic that is often prescribed to patients with Heart failure to prevent oedema.Renal_Diuretics.gif

I asked the patient if he was happy for me to discuss this with his doctors and a specialist continence nurse to see if something could be done to help either reduce this frequency or make provisions for his discharge so he isn’t at an increased falls risk, he agreed and I approached his doctor.

This encounter wasn’t entirely successful. When I proposed reducing his diuretics to the doctor, initially his response was “Do you want him to die of heart failure?” – in front of the patient…

keep-calm-and-back-yourself-4Not exactly the response I was hoping for, but I explained my concerns from a Nursing point of view and emphasised I am aware that his furosemide was prescribed for a reason and it is entirely his decision, I just wanted to advocate my patient’s best interests.

This exchange I felt didn’t end on a particularly positive note, so later in the day I apologised to the doctor saying “I didn’t mean to question his treatment I just wouldn’t feel comfortable if I didn’t make you aware of his concerns to see if we could work together towards a solution”. The doctor was much more amicable and smiled and said he understood and would consider what could be done.

Not long after this, the same doctor stopped me and said he had written a letter to the patient’s GP to recommend reducing his diuretics in the community and observe his response. He felt changing his medications the day before discharge might impact on his fitness for discharge. He also suggested trialling Oxybutynin. When I recognised Oxybutynin as an anti-muscarinic (which would improve his feelings of urgency), his face lit up. I have a feeling, he may not have expected me to possess such knowledge.

ghozt_tramp_-_business_communication_duplicat_model

So many speech bubbles but 1 shared goal – patient’s wellbeing

Only upon writing this have I realised just how many units of study went into this encounter; Communications, Anatomy and Physiology, Pharmacology, Applied Pharmacology, Nursing Therapeutics, Recovery focused care and Medicines Management all informed my actions in this case. Reflecting on this scenario I am really pleased with the outcomes we achieved. Not only was the gentleman’s GP made aware of our concerns and recommendations but I managed to speak to the Trust’s continence specialist nurse and get her recommendations for interim provisions to help the patient transition into community. I fed all this back to the patient who was visibly relieved and so grateful we had pursued his concerns and formulated an action plan he understood and would work for him.

Advocating for patients is a vital part of the Nursing role and we can see advocacy in the NMC code in various different guises (see 3.4, 4.1, 8.6, 8.7 & 9.3).

Incontinence IPL – So good I just couldn’t hold it in!

Last week I attended an amazing IPL (Inter Professional Learning) seminar all about continence issues across the age span. First I’d like to highly recommend going to as many IPLs as you can as they offer a really useful insight into specialist areas of nursing, you may not realise you have a particular interest in. Continence may not be a topic that particularly grabs you but having spent a fair few hours on a gastro ward I have experienced up close what its impact on a patient can be.

All the goodies

All the goodies

The continence specialist nurse who spoke (let’s call her Liz for confidentiality’s sake) truly was a specialist. She brought a whole table-full of gadgets and aids available through the Trust to help patients both in community and in hospital with continence needs. It isn’t uncommon for continence issues to arise following a hospital stay as patients catheterised for a prolonged period of time can have depleted control of their urethral sphincter. This has led to a worrying culture of nurses in hospital and community thinking that incontinence is just a symptom of old age. THIS IS NOT THE CASE. If a patient is losing control of their bladder or bowels there are things that can be done or services we can provide, like consultations with specialist nurses such as Liz.

There are dozens of conditions that can lead to continence issues and they don’t just affect the elderly!! Stress incontinence or urge incontinence can affect anyone at any age, for example urinary incontinence is quite common directly following vaginal birth especially traumatic births involving use of forceps or indeed vaginal tearing (this however should not last longer than a day or two).

Did you know a large pad can absorb 500ml of liquid in under 10 seconds?

Did you know a large pad can absorb 500ml of liquid in under 10 seconds?

The best solution we have to continence issues is to try and avoid them ever existing. Pelvic floor exercises for example only take a minute or so and can be done anytime, anywhere. In fact I’m doing them now as I write this post. Strengthening your pelvic floor allows better control of your bladder and a better sex life – according to Liz. Taking good care of your bladder and bowels with a healthy diet, plenty of fluids and regular strengthening should be far more commonplace than it is because, believe me, you’ll miss them when they’re gone.