Continence issues are rarely the reason for hospital admission. Older people who experience incontinence or constipation, or develop these issues during their stay, are at risk of poorer outcomes than those who do not.
Incontinence and constipation are often signs that an older person is experiencing other health conditions.
Targeted screening, assessment and intervention can have a positive impact on the patient’s ability to participate in all recommended activities in hospital, reduce the person’s risk of experiencing a range of cascading problems such as infection, wounds and delirium, and have a lasting effect on their social and functional quality of life when they are discharged.
Continence and ageing
As a person ages, their bladder and bowel changes, which affects their function.
Bladder changes include1:
- the elastic tissue of the bladder wall becomes tough and less stretchy and unable to hold as much urine
- weakening of the bladder muscles
- increases in involuntary bladder contractions
- urethral blockage:
- in women this can be due to weakened muscles causing the bladder or vagina to prolapse
- in men this can be due to an enlarged prostate gland
- increases in post-voiding residual volume (50–100 mL)
- increases in fluid excretion at night.
Bowel changes include2:
- sphincter weakness (for example, due to childbirth stretch injury)
- loss of anal sensation
- impairment of gastrocolic reflex
- softening of stools.
Incontinence has a big impact on health and quality of life
Incontinence has an enormous impact on an older person’s quality of life. It adds significant burden on family and carers and is a major factor in deciding to go into residential care.
Incontinence also puts people at greater risk of health issues such as falls and pressure injuries.
Incontinence has financial implications due to the cost of continence aids. It can affect a person’s general wellbeing and make them socially isolated due to embarrassment.
Continence problems can develop with other issues
In older patients, incontinence is usually caused by a combination of factors, including age-related changes to the urinary tract.
Continence problems can develop or become more severe if an older person is experiencing:
- Reduced mobility – can lead to falls when attempting to reach the bathroom. This is the single most predictive factor for incontinence, and urge incontinence has been identified as a high falls risk for men and women and as a major contributing factor to hip fractures in older women.3
- Impaired cognition – including delirium, dementia and depression, limit a person’s ability to self-toilet, particularly in an unfamiliar environment. Incontinence may add to the burden of depression.4
- Under nutrition (hydration and fibre) – adequate hydration and fibre intake is essential in maintaining bladder and bowel function. Many older people report limiting their fluids to avoid getting up to go the toilet while in hospital. This can contribute to constipation and urge incontinence.
- Medication side effects (particularly diuretics, sedatives, caffeine and alcohol) – medications can cause constipation and drowsiness, which can increase the risk of falls. Diuretics can increase frequency. Caffeine and alcohol are bladder irritants and can also increase urinary frequency.
- Skin integrity problems – exposure to urine and faeces can cause skin breakdown and leave the skin susceptible to damage from friction and pressure, dermatitis, and bacterial and fungal infections.
- Frailty – people who are frail and functionally impaired need accessible, safe toilet facilities and often benefit from assistance or supervision in hospital.
Identifying continence issues
Incontinence is rarely the reason a patient is admitted to hospital; however, it plays an important part in their recovery. Continence issues are often treatable and, in some cases, reversible.
Hospital admission presents an excellent opportunity to investigate continence issues and develop a management plan. This could improve the patient’s experience and recovery, and have lasting positive impact after discharge.
In addition to following health service policy and procedures, the following actions can help identify patients with continence issues and risks.
Screening questions
Continence is a sensitive issue. Even though we might talk about this topic with patients every day, we need to be mindful to:
- actively listen to the patient and avoid making judgements
- respect the patient’s right to choose the most appropriate treatment option.
While there are no validated screening tools available, when a person is admitted it is useful to establish their usual bowel and bladder habits. Ask these screening questions:
- Do you leak urine before you get to the toilet?
- Do you have to wear pads?
- Do you suffer from constipation or diarrhoea?
- Do your bowels or bladder ever cause you embarrassment, pain or concern?
- Are you rushing to the toilet or looking for the toilet all the time?
- Are you going to the toilet every half an hour? (in addition to leaking urine, overflow incontinence can also be identified by frequency)
- Was this an issue before you were ill or has it become worse?
If a patient answers YES to any of these questions, they should be assessed for incontinence.
If the person has a pre-existing cognitive impairment or is experiencing delirum, confirm their answers with their family or carer. If applicable, contact the patient’s residential care facility to obtain their continence plan. This information will help identify the risk of episodes of incontinence during their stay.
Assess contributing factors
As a first step, we should seek to eliminate as many contributing factors to incontinence as possible.
Use DIAPPERS to screen for reversible causes5:
- Delirium
- Infection--urinary (symptomatic)
- Atrophic urethritis and vaginitis
- Pharmaceuticals
- Psychological disorders, especially depression
- Excessive urine output (for example, from heart failure or hyperglycemia)
- Restricted mobility
- Stool impaction
Also ask about:
- decreased fluid intake
- urinary retention
- lack of toilet access
- whether the patient is emptying their bladder, especially if they have a neurological condition.
Use the Urinary Distress Inventory to check for symptoms of incontinence on admission.
Once you have identified an issue and treated underlying causes, further assessment may include physical examination, taking a brief targeted history, gathering more information on the person’s usual baseline functional abilities and using standardised tools to gather more evidence.
Take a history
A person may have a mixture of continence types, which can make the underlying cause more difficult to work out. Take a brief and targeted history, gathering the following information.
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- urge
- stress
- voiding difficulty - hesitancy, intermittency, weak stream, incomplete emptying
- blood in the urine (haematuria)
- waking at night to go to the toilet (nocturia)
- pain or difficulty urinating (dysuria)
- postmenopausal/prostatism
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- malaena
- rectal bleeding
- anaemia
- loss of weight
- unexplained change in bowel habits
- nocturnal diarrhoea
- abdominal or pelvic mass.
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- >during the day or during the night
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Women
- gynaecological/obstetric history (the most common cause of stress urinary incontinence in women is childbirth).
Men
- urologic history (the most common cause of stress urinary incontinence in men is benign prostatic hypertrophy).
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- arthritis and related disorders
- musculoskeletal conditions
- neurological conditions such as Parkinson’s Disease, Multiple Sclerosis
- stroke
- diabetes
- dementia.
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- diuretics
- high blood pressure medications
- antidepressants and sedatives
- muscle relaxants and sleeping pills
- calcium channel blockers (can cause constipation)
- non-prescribed drugs.
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How they are managing
- mobility
- using toilet facilities
- continence aids
- the social and routine activities. Some people report a restriction on their ability to lead their lives6 and stigma about incontinence can be a barrier to seeking help.7
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If needed, check the following:
- Fluid status and signs of dehydration
- Abdominal examination and rectal and genital examination, looking for
- palpable bladder
- incontinence associated dermatitis
- for women
- signs of vaginal atrophy or prolapse
- pelvic floor muscle contraction
- for men
- prostate shape, size and consistency
- pelvic floor muscle strength.
- Cardiac and respiratory examinations:
- cardiac failure history and treatment
- obstructive sleep apnoea (can lead to nocturnal polyuria and nocturia)
- Neurological examination to include cognition and function/mobility.
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The following investigations can help us better understand urinary tract function, other conditions, patient management and the degree of continence to aim for (dependant, social, independent).
- Two-day bladder chart:
- include voided volumes for two consecutive days and nights
- note if incontinent and the degree of leakage (damp/wet/soaked).
- Urine full ward test (dipstick): refer the patient to medical staff if nitrite/leucocyte/blood positive.
- Bowel chart: Bristol Stool Chart©.
- Post-void residual scale: is collected using a bladder scanner
- if 100 mL - no action
- if > 100 mL - refer to medical staff. Incomplete bladder emptying leads to urinary stasis and increases risk of UTI
- if >500 mL – refer to medical staff as soon as practicable. This may imply urinary retention requiring catheterisation.
- Note: When using the scanner select male or female setting; for female with hysterectomy, select male setting.
- Abdominal X-ray
- May be recommended to rule out abdominal masses and can be useful in identifying faecal impaction.
- Two-day bladder chart:
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.
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Immediately treat any conditions that are causing the person’s incontinence, for example:
- delirium
- infection
- fluid intake
- faecal impaction
- depression.
-
Consider:
- bladder re-training (refer to physiotherapy)
- anticholinergics (monitor residuals, not in dementia)9
- vaginal oestrogen.
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- Discuss weight reduction.
- Address coughing and sneezing.
- Recommend pelvic floor exercises (refer to physiotherapy).
- Consider vaginal oestrogen.
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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.
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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.
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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.
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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.
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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.
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- 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 breakfast10).
- 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).
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- 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.
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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.11,12
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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.
Continence and discharge planning
People experiencing continence issues may have difficulty managing their continence, particularly outside the home, or feel embarrassed by their condition. They may feel reluctant to seek help due to social stigma. This can cause them to restrict their activity, increasing their risk of experiencing social isolation.7 We can help patients make a smooth transition from the hospital to their home or care facility by finding out what they understand about their condition, acknowledging their concerns, demonstrating sensitivity and developing a care plan that addresses the person’s ongoing continence management needs:13
- Do they need a referral to a continence clinic?
- Should their GP be advised of continence issues identified in hospital?
- Do they need written materials and resources to help manage continence? Refer to Continence Foundation of Australia website.
- Are they eligible for government funding support for the cost of continence aids?
- Do they need referrals for aids and specialist services?
- Would they benefit from a continence nurse follow up phone call or assessment in the community?
- Would they benefit from a referral to a dietitian for advice on maintain healthy bowels?
- Where is the person going after discharge – their own home, supported accommodation (with or without stand-up staff overnight) or residential care?
- If the person is going home, will they be alone or have help? Do they have a carer who can assist them?
- Can they afford the cost of aperients (mild laxatives) and continence appliances?
- Are they eligible for an aids assistance scheme, for example, from the Department of Veterans’ Affairs, Continence Aids Assistance Scheme or the Department of Health and Human Services’ Aids and Equipment Program?
Your organisation can develop a discharge kit that includes resources and contact details specific to your local area.
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- Keane, D.P, O'Sullivan S, Urinary incontinence: anatomy, physiology and pathophysiology. Best Practice & Research Clinical Obstetrics & Gynaecology, 2000. 14(2): p. 207-226.
- Cooper, Z.R, Rose S, Fecal incontinence: a clinical approach. The Mount Sinai journal of medicine, New York, 2000. 67(2): p. 96-105.
- Gray, M., The importance of screening, assessment, and managing urinary incontinence in primary care. Journal of the American Academy of Nurse Practitioners, 2003. 15(3): p. 102-107
- Trantafylidis, S.C.-A., Impact of urinary incontinence on quality of life. Pelviperineology, 2009. 28(28): p. 51-53.
- Resnick, N.M. and S.V. Yalla, Management of Urinary Incontinence in the Elderly. The New England Journal of Medicine, 1985. 313: p. 800-804.
- Mitteness, L.S. and J.C. Barker, Stigmatizing a normal condition: urinary incontinence in late life. Medical Anthropology Wuarterly, 1995. 9: p. 188-210.
- Heintz, P.A., C.M. DeMucha, M.M. Deguzman, R. Softa, Stigmas and microagression experienced by older women with urinary incontinence: A literature review. Urologic Nursing, 2013. 33: p. 299-305.
- Society of Hospital Medicine. Five Things Physicians and Patients Should Question. 2013 [cited 2015 March 26]; Available from Choosing Wisely
- Kim, S., S. Liu, and V. Tse, Management of urinary incontinence in adults. Australian Prescriber, 2014. 37(1): p. 10-3.
- Continence Foundation of Australia, The Continence Guide - Bladder and Bowel Control Explained, 2014, The Continence Foundation of Australia: Melbourne.
- Deakin University/Eastern Health, A continence resource guide for acute and subacute settings, 2008, Melbourne: Deakin University/Eastern Health.
- Deakin University/Eastern Health, Assessing urinary incontinence and related bladder symptoms educational resource, 2008, Eastern Health: Melbourne.
- Elstad, E. A., S. P. Taubenberger, E. M. Botelho, S. L. Tennstedt, Beyond incontinence: the stigma of other urinary symptoms, Journal of Advanced Nursing, 2010. 66: pp. 2460-2470.
Reviewed 17 July 2024