Preventing and treating incontinence

Continence interventions can reduce or minimise functional decline and promote social continence and good bladder habits and strategies.

In hospital, there are many barriers to maintaining continence and many factors contribute to incontinence. These include:

• medical factors – such as the person’s existing medical conditions, acute illness and medications
• environmental factors – such as poor signage on doors, inadequate lighting, shared bathrooms and an unfamiliar environment
• need for assistance to toilet.

We are all responsible for helping older people to maintain continence in hospital. This requires an individualised approach at the patient level, but needs to also include policy, systems and environmental design.

There are many things we can do to support continence and treat incontinence. Here are some recommendations.

Treat incontinence immediately

Immediately treat any conditions that are causing the person’s incontinence, for example:

• delirium
• infection
• fluid intake
• faecal impaction
• depression.

Urge incontinence

Consider:

• bladder re-training (refer to physiotherapy)
• anticholinergics (monitor residuals, not in dementia)²
• vaginal oestrogen.

Stress incontinence

• Discuss weight reduction.
• Address coughing and sneezing.
• Recommend pelvic floor exercises (refer to physiotherapy).
• Consider vaginal oestrogen.

Nocturia

If the person is getting up to go to the toilet more than twice a night:

• encourage them to get out of bed to use the toilet or a commode next to the bed
• ask them if they are reducing the amount they drink to reduce getting up at night. If they are, tell them that this can lead to dehydration, which causes swallowing problems, malnutrition, falls and delirium.

Dementia

If the person has dementia, consider:

• timed toileting according to their voiding pattern determined from the bladder diary regular toileting
• continence products, such as disposable pull ups or washable continence pants
• the person’s body cues that indicate they need to use the bathroom, such as fidgeting or pulling at their clothes.

Faecal incontinence

If the person's stool is too hard, consider:

• increasing water consumption
• increasing dietary fibre (note: for older people this can add to faecal loading and increase the risk of urinary incontinence and flatulence; seek advice from a dietitian)
• using laxatives using titrate aperients according to stool pattern (as per Bristol Stool Chart)
• encouraging regular mobilisation around the ward.

If the person’s stool is too soft, consider:

• searching for the underlying cause, such as irritable bowel syndrome or inflammatory bowel disease
• using loperamide
• using an enema or suppositories to help the person empty their bowel at a predictable time and prevent soiling.

Modify the environment

The environment can make it difficult for a person to access the toilet. Modify the environment so the person can toilet independently and to minimise the risk of falls.

• Orientate the person to their new environment, showing them where the bathroom is and where the call bell is.
• Consider moving the person to a bed closer to the toilet.
• Consider if using toilet substitutes (non-spill urinals, bedside commodes, bedpans) would be appropriate.
• Eliminate hazards (obstacles on the path to the bathroom, inadequate lighting, lack of handrails, restraints such as bed rails and bed height).
• Provide adequate lighting and lit signage to toilets at night.
• Consider altering the person’s clothing to make toileting easier (for example, use Velcro fasteners and pants with elastic waist bands rather than buttons and zippers).
• Refer the patient to Occupational Therapy for gait aids, such as a bed stick. Make sure these aids are easy to reach at all times.

Develop a continence management plan

An individualised continence management plan should be developed and implemented in conjunction with the older person. It should be regularly reviewed and adjusted as needed.

The plan should be based on information provided by the patient, their family or carer, and their residential care facility if they are not living at home.

The plan should be comprehensive and include the following elements.

A toileting plan

• Find out when the person normally uses their bowels. Encourage them to go to the toilet when they get the urge because this is the most effective time to completely empty their bowels (for most people, it is usually first thing in the morning after breakfast³).
• Encourage the older person to get out of bed and use a commode next to the bed or walk to the toilet if possible.
• Show the older person and their family how to use the call bell if they need assistance to use the toilet.
• Encourage the patient to completely empty their bladder with each void.
• Discourage the use of bedpans and urinals in the bed if possible.
• Do not place, or leave in place, indwelling catheters for urinary incontinence or convenience or for monitoring of output for non-critically ill patients.
• Review the indication for catheterisation – question the reasons, note the date it is inserted, and plan for review by an expert (including trial of void).

Educate the patient and their carers

• Provide education about bladder and bowel function.
• Discourage the use of known bladder irritants (such as coffee, alcohol and soft drinks).
• Provide education on continence products if required and:
  • check and assist the older person to change their disposable pads after each episode of incontinence if necessary
  • monitor and protect the patient’s skin integrity (with particular attention to the perineum, inner thighs and buttocks)
  • limit the use of continence pads ‘just in case’, especially large ones that may reduce a patient’s ability to self-toilet. These can be difficult to remove, particularly for patients with arthritis or poor vision. Look at strategies so ‘just in case’ is not required.

Refer to other health professionals

Refer the person to:

• a dietitian for fibre and fluid advice, to ensure adequate hydration and fibre intake to maintain optimal bladder and bowel function
• a physiotherapist for functional mobility and strengthening advice, gait aids, bladder and bowel re-training, and pelvic floor exercises
• a continence service or specialist for advice on continence products, behavioural therapy, medication treatment or surgery.^4,5

Practise person-centred care

Person-centred practice and clear documentation are the keys to managing continence issues. It is important to respect the dignity and privacy of the older person and to involve them in every aspect of care. Communicating the care plan with the rest of the healthcare team, including the patient and family or carer, is also vital in providing a consistent person-centred approach to continence management.

1. Society of Hospital Medicine. Five Things Physicians and Patients Should Question. 2013 [cited 2015 March 26]; Available from: http://www.choosingwisely.org/doctor-patient-lists/society-of-hospital-medicine-adult-hospital-medicine/.

2. Kim, S., S. Liu, and V. Tse, Management of urinary incontinence in adults. Australian Prescriber, 2014. 37(1): p. 10-3.

3. Continence Foundation of Australia, The Continence Guide - Bladder and Bowel Control Explained, 2014, The Continence Foundation of Australia: Melbourne.

4. Deakin University/Eastern Health, A continence resource guide for acute and subacute settings, 2008, Melbourne: Deakin University/Eastern Health.

5. Deakin University/Eastern Health, Assessing urinary incontinence and related bladder symptoms educational resource, 2008, Eastern Health: Melbourne.