Managing Incontinence

Welcome to the educational program Managing Incontinence. Incontinence is a common condition that is stigmatizing, embarrassing and can significantly affect a person’s lifestyle and confidence. Many people experience weekly, even daily incontinence. Fortunately, many incontinence problems can be controlled, if not cured.

This program will help you to identify the different types of incontinence and learn about the various interventions and treatments.

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You may view the topics in order as presented, or click on any topic listed in the main menu to be taken to that section.

We hope that you enjoy this program and find it useful in helping both yourself and those you care for. There are no easy answers when it comes to the care of another, as every situation and person is different. In addition, every caregiver comes with different experiences, skills, and attitudes about caregiving. Our hope is to offer you useful information and guidelines for caring for someone with dementia, but these guidelines will need to be adjusted to suit your own individual needs. Remember that your life experiences, your compassion and your inventiveness will go a long way toward enabling you to provide quality care.

Let’s get started.

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Urinary Incontinence

Urinary incontinence is the inability to control urination. There are five main types of urinary incontinence: stress, urge, overflow, functional, and mixed.

Functional incontinence is incontinence that occurs when a person has the urge to urinate but is unable to reach the toilet in time because of physical, mental, or communication limitations. This is the most common type of incontinence among people with Alzheimer’s disease, Parkinson’s disease, or arthritis. Dementia can cause confusion that may prevent the person from recognizing the need to urinate or finding a bathroom and disrobing in time. The reduced mobility associated with Alzheimer’s can also hinder the person’s ability to reach the toilet and manipulate handles, seats, and garments in time to control the bladder.

Stress incontinence is the leakage of urine due to sudden pressure on the bladder from increased abdominal pressure. Stress incontinence can happen when someone coughs, sneezes, lifts something, exercises, laughs, or gets up from a sitting or lying position. It is the most common type of incontinence among women, and may be due to weakened pelvic muscles or changes in the position of the bladder or uterus, often due to childbirth. Other causes of stress incontinence include weakening of the bladder muscles, damage to nerves controlling the bladder, weakening of the sphincter muscles that close the tube connecting the bladder to the outside of the body, menopause, and prostate issues.

Urinary Incontinence (Continued)

Urge incontinence is sometimes referred to as reflex incontinence or an overactive bladder. It is the uncontrolled loss of urine associated with a sudden, strong urge to urinate. Urine can leak the instant the person feels the urge to urinate. Even the sound of running water can trigger this type of incontinence. The urge occurs frequently, especially while sleeping or drinking. Urge incontinence is most common among the elderly, and may be a symptom of a urinary tract infection. Other causes include stroke, diseases involving the brain or nerves, inflammation of the bladder or prostate, or surgery in the pelvic region.

Overflow incontinence is the leakage of urine that occurs when the urinary bladder’s capacity is exceeded. People with this type of incontinence cannot empty their bladders and so the bladder is often full, causing frequent urination with weak and small amounts of urine output. Some

Fecal Incontinence

Fecal incontinence, also known as bowel or stool incontinence, is the inability to control bowel movements, causing stool to leak at unexpected times.  The incontinence can range from a small leakage of stool to a complete loss of bowel control. 

Common causes of fecal incontinence include constipation, diarrhea, and muscle or nerve damage. Muscle damage is involved in most cases of incontinence.  A common cause of muscle and nerve damage is childbirth or surgery.  Other causes of nerve damage include diabetes, multiple sclerosis, and injury to the spinal cord.

Fecal incontinence caused by severe diarrhea is usually due to infection, irritable bowel, medication side effects, ulcerative colitis, Crohn’s disease, diverticulitis, cancer or radiation therapy.

Poor diet can also contribute to fecal incontinence. Diets should be rich in fiber but not to the point where it causes diarrhea. A balanced diet is important to maintain health bowel movements. As the body ages it can become more sensitive to certain foods, so caregivers should monitor the diet and look for food triggers of incontinence.  

Incontinence and Aging

There are also many physical changes due to aging that can contribute to urinary and fecal incontinence. Aging is associated with overall decreased muscle tone due to the replacement of muscle and elastic tissue with weaker connective tissue, which can reduce the ability to control the bladder and bowel. As muscles grow weaker and the supporting structures in the pelvis relax and loosen, the risk of developing urinary or fecal incontinence increases.

Aging also decreases bladder capacity, causing more frequent urination and a decrease in the force of the urine stream, which makes it difficult to cut off the flow once a stream is started.

Older people also have decreased kidney function, so they are not able to concentrate the urine as well.  Therefore older people generally produce more urine and fill their bladders more quickly than younger people. The urethra, which is a tube through which urine travels from the bladder to the outside of the body, loses its closing pressure due to weakening of the muscle that closes off this tube.  This makes it more difficult for the urethra to stop urine leakage. 

Aging is also associated with diminished estrogen secretion, which makes muscles of the pelvic region weaker. 

With aging, prostates also become weakened and/or enlarged, which can block urine outflow.  All of these changes reduce urine control.

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Case Study 1

Here is an example with Mary and her husband, Robert, who has Alzheimer’s disease.

What could be causing Robert’s incontinence?
  • A. Chronic illnesses.
  • B. Medications.
  • C. His environment.
  • D. Cognitive changes due to Alzheimer’s disease.
  • E. All of the above.
 

Case Study 1 Answers:

Choice A: “Chronic illnesses” is a good possibility. 

Illnesses such as diabetes, congestive heart failure, arthritis, Parkinsons Disease, multiple sclerosis and Alzheimers Disease can all cause incontinence.

Diabetes can lead to an increase in urinary tract infections and a sense of urinary urgency.

Heart problems can cause an increase in nighttime urination and hinder the ability to get to the bathroom quickly.Arthritis makes jointsstiff and sore, making it more difficult to move around and get to the bathroom.

Disorders of the nervous system such as Parkinson’s Disease, multiple sclerosis, stroke, spinal cord injury, brain cancer, structural abnormalities, as well as dementia can cause incontinence and reduce mobility. Alzheimers Disease can also make it difficult to remember where the bathroom even is at times.

Because many medical conditions can cause incontinence, it is important to have a healthcare professional investigate the cause.

Choice B: “Use of medications”is another good choice.

Some medications, such as those taken for the heart and high blood pressure, make it difficult to make it to the bathroom in time, leading to urgency incontinence. Other medications, such as those taken for colds and depression, make it difficult to empty the bladder, causing retention incontinence. Some medications can have the side effect of decreasing a person’s awareness of the urge to go to the bathroom.These include sleeping medications and medications given for behavior problems.

Choice C: “His environment”is another possibility.

Environmental factors that can lead to incontinence include the availability of bathrooms and the distance to them. The lighting and obstructions along the pathway to the bathroom can also affect a person’s ability to reach the toilet in time.

Restrictive or complex clothing can also make it difficult for the person to undo them before losing control of bowel or bladder.

In addition, language itself can be a factor, as the bathroom can be called by many different names in different cultures.This can lead to confusion and difficulty communicating the need to use the toilet.

Choice D: “Cognitive changes due to Alzheimer’s disease”is also another possibility.

People with Alzheimers may not be able to find the toilet due to visual and perceptual changes or memory loss.They may become confused about how manipulate clothing or bathroom fixtures. They also might not recognize the physical urge to urinate, though these symptoms often do not appear until the later stages of the disease.

Choice E: Because all of these choices are possible factors that can put Robert at risk for incontinence, choice E, “all of the above,” is the best answer.

Consequences of Incontinence

There are a host of consequences that surround the unpleasant problem of incontinence, which effect everyone involved.

Some of the medical problems that are attributed to incontinence include skin infection and breakdown, urinary tract infections, which can lead to blood infections, impaired mobility, and falls and fractures.

Psychological consequences include feelings of guilt, anger, embarrassment and uselessness. Incontinence can also effect a persons self-image, which can lead to depression and sexual difficulties.

People with incontinence issues often isolate themselves from others.  They might withdraw from family & friends and avoid social activities. Incontinence also requires dependence on others and is one of the major reasons for placement in long term care facilities, as caregivers find themselves unable to tend to these needs.. Another consequence can include the need for additional medications.

Gathering Information

In order for healthcare providers to assess the incontinence, they will need to complete a physical examination, take a medical history, and talk to the person and caregiver.  It is helpful to keep a record of the severity of the symptoms and a history of the problem.

A good way to gather the necessary information is by keeping a journal or diary. The incontinence diary should include a record of when the person goes to the bathroom and the amount of output. The diary should keep track of incontinent episodes, the times that they occur, the output amounts, and what the person was doing at the time that they happened. It should also include a record of fluid and food intake and their times of consumption. This food intake diary is especially important for gathering information on fecal incontinence.

Keep a list of what the person eats for a week. This can help identify any connections between certain foods and bouts of incontinence. If a potential food trigger is suspected, have the person stop eating that food and see if the incontinence improves.

The diary is an essential tool in helping people overcome incontinence, because it provides healthcare professionals with information about severity, frequency, and patterns of incontinence, and possible causes. It is the basis for planning a treatment program. 

Once a treatment is started, the diary should be maintained in order to tract the effects of the treatment, whether beneficial or not. It is a useful tool for both home caretakers and staff to use.

Assessment

Your healthcare professional can use the diary for both the assessment and the evaluation of the effectiveness of the treatment plan.  Assessment acknowledges the problem, gives clues to causes and contributing factors and establishes a baseline, or history by exploring such factors as onset, duration, frequency, severity, associated symptoms and aggravating or ameliorating factors.

Assessments may have to target a number of causes to find an effective solution. These can include improving the person’s mental state, reducing confusion, identifying any illness, injury, or disease, reviewing dietary and fluid intake, the appropriate use of constipating drugs, toilet training and exercises.

Other assessments may also be used such as a functional assessment, which looks at how well the person can manage mobility, such as disrobing and getting up and down from a toilet.  Physical assessments are also standard and should include an abdominal, rectal, prostate and urologic exams.  The physician should examine sensation and the ability to tighten pelvic muscles.  Special tests can also measure urine flow, output, and retained urine to help determine the type of urinary incontinence the person has. The physician may check the persons B12 levels, because a deficiency of B12 can cause nerve problems that can lead to incontinence.

A mental status evaluation may be given to see if the person can recognize the urge to go, or remember where the toilet is.

Strategies for Managing Incontinence

Treating incontinence partly depends upon the cause.  However, there are several strategies that can be used to manage the problem of incontinence. though all should begin with some everyday practical tips for caregivers.

First, caregivers should take a backpack or bag containing cleanup supplies and a change of clothing with them whenever they leave the house or residence.  Before leaving home, have the person use the toilet.  While away from the house, make sure to locate public restrooms before they are needed, and schedule regular trips to the restroom. If an episode of incontinence is likely, have the person wear disposable undergarments, adult diapers or pads, and consider the use of fecal deodorants to add to their comfort.

One strategy for decreasing episodes of incontinence is Habit Training or Scheduled Toileting, which involves scheduling toileting on a planned basis. This is done by matching the trips to the bathroom to person’s natural voiding, or expelling schedule. This strategy can be used with people who are cognitively impaired as well as those who are not.

Prompted voiding or expelling, is a supplement to habit training, This intervention attempts to teach people awareness of their urges and to request toileting assistance. The three major elements include monitoring, prompting and praising.

Monitoring includes teaching the person to pay attention to their own urge to go.  In prompting, the person  is prompted every 2-3 hours to actually use the toilet. Individuals also receive praise for controlling their bowel and bladder and appropriately using the toilet.

The best candidates for prompted voiding include those who are more cognitively intact and can recognize the urge to go, those who are capable of asking for the toilet and using the toilet when prompted, those who are able to have bowel movements when given toileting assistance, and those with the ability to move around independently.   Some of the drawbacks include the constant need for communication and support from caregivers and the need to constantly monitor the person to assure that the program is being carried out. This can become especially difficult in programs with either too many, or not enough staff.

Strategies for Managing Incontinence (Continued)

Another strategy is pelvic muscle exercise, which is used to improve bladder control through active exercise of the muscles that help to close the urethra and prevent leakage.  Exercises should be performed 30-80 times per day for 6 weeks and can be used for stress, urge or mixed incontinence problems.

Men can also try using a penile clamp, or incontinence clamp, which is a device that is placed around the penis to prevent urine leakage.

Another option is intermittent catheterization, or using a catheter to empty the bladder on a regular basis. This can be used for overflow incontinence problems. Treatment for individuals in the later stages of Alzheimer’s often includes the “check & change” approach, where disposable pads are used as a method for managing urinary and fecal incontinence.

Medications can supplement any of the strategies for managing incontinence. Anticholinergic agents are the first line of pharmacologic therapy for urge incontinence. Medications for treating fecal incontinence depend upon the cause. If diarrhea is causing fecal incontinence, the health care provider may recommend some anti-diarrheal drugs.  Some anti-diarrheal drugs decrease the spontaneous motion of the bowel (known as bowel motility) while others work by decreasing the water content of the stool. 

If chronic constipation is the cause of incontinence, the healthcare provider may recommend the temporary use of laxatives or stool softeners to prevent stool impaction and restore normal bowel movements.  Before taking any over the counter medications, talk to a healthcare professional.

Some medications can actually cause or worsen incontinence.  Talk to a health care professional about the person’s medications to see if this is the case and whether changes can be made to reduce this side effect.

Another treatment option is surgery.  Different surgical procedures can treat urinary and fecal incontinence. However, given the complex medical problems that elderly people with Alzheimer’s disease often have, surgery may not be a good option for many of them.

Strategies for Managing Fecal Incontinence

An effective strategy for managing fecal incontinence should start with changes in the person’s diet. Foods that can cause diarrhea or gas and worsen fecal incontinence should be eliminated. These include spicy foods, fatty and greasy foods, cured or smoked meat, carbonated beverages, and dairy products if the person is lactose intolerant. Caffeine, alcohol, sugar-free gum and diet sodas that contain artificial sweeteners, can also act as laxatives.

Try having the person eat several, smaller meals throughout the day, rather than three large ones. Large meals sometimes trigger bowel contractions that may cause diarrhea.

Have the person eat more fiber. Fiber helps make stool soft and easier to control. Fiber is present in fruits, vegetables, and whole-grain breads and cereals. Aim for 20 to 30 grams of fiber a day, but add it to the diet slowly. Too much fiber all at once can cause bloating, gas or even diarrhea.

Have the person drink more water to keep stools soft and formed.

In addition to managing fecal incontinence through changes in diet, help avoid further discomfort by keeping the person’s skin around the anus as clean and dry as possible. To relieve anal discomfort and eliminate any possible odor associated with fecal incontinence, have the person gently wash with water after each bowel movement — do this by using wet toilet paper, incontinence wipes or other disposable wipes, showering or, better yet, soaking in a bath.  Keep in mind that soap can dry and irritate the skin as can rubbing with dry toilet paper.

Make sure these areas are dried thoroughly after cleaning. Allow the area to air-dry after washing. If you’re short on time, you can also gently pat the area dry with toilet paper or a clean washcloth.

After drying, apply a barrier cream or powder. Moisture-barrier creams help keep irritated skin from having direct contact with feces.  Be sure the area is clean and dry before you apply any cream. Nonmedicated talcum powder or cornstarch also may help relieve anal discomfort.

Continence Programs

In residential facilities Continence Programs are often in place, where staff are responsible for the follow-through of a plan of care using techniques that include self-monitoring, supervisory monitoring and a sharing of feedback.

Continence program regulation has shifted from the idea of containment and management measures to nursing measures to restore and rehabilitate bladder function.

The staff involved in these programs usually include a registered nurse, or RN, a LPN and a CAN. These people are responsible for doing an initial assessment of severity and type of incontinence. This information will be used for the development of a plan of care with other team members, who give their input. This plan should be discussed with the residents before implementation. The staff are responsible for gathering data to evaluate the effectiveness of the plan and to modify it as needed. They are also responsible for observing and encouraging the residents in the plan of care by offering incentives and constant feedback.

Summary

In summary, there are five main types of urinary incontinence: Functional incontinence is caused by inability to reach the toilet in time because of physical, mental, or communication limitations. This is the most common type among those with Alzheimer’s disease. Stress incontinence is caused by sudden pressure on the bladder as when someone coughs, sneezes, lifts something, exercises, laughs, or gets up from a sitting or lying position. Urge incontinence is the uncontrolled loss of urine associated with a sudden, strong urge to urinate. Overflow incontinence occurs when the urinary bladder’s capacity is exceeded. Mixed incontinence refers to the presence of two types of incontinence at the same time, which is commonly found among those with Alzheimer’s. Aging, medical conditions, medications, diet, and Alzheimer’s disease can all increase the risk of incontinence.  Keeping a diary of the person’s bladder and bowel habits and diet can help assess the problem and evaluate treatments. Strategies for managing incontinence include behavior modification using habit training and prompted voiding,  modifying the diet, and medications. Surgical treatment is usually a last resort. Caregiver tips include carrying cleanup supplies and a change of clothing, scheduling regular trips to the bathroom, using pads or diapers, and keeping the pelvic region clean and dry using mild products and a gentle technique.

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Written by: Janet K Pringle Specht, PhD, RN, FAAN (University of Iowa College of Nursing)

Edited by: Mindy J. Kim-Miller, MD, PhD (University of Chicago School of Medicine)

 

References:

  • Urinary Incontinence. Mayo Clinic. Retrieved on Jan 15, 2009 from http://www.mayoclinic.org/urinary-incontinence/.
  • Fecal Incontinence. Mayo Clinic. Retrieved on Dec 19, 2008 fromhttp://www.mayoclinic.com/health/fecal-incontinence/DS00477.
  • Fecal incontinence. (2000). FamilyDoctor.org. Retrieved on Jan 15, 2009 from http://familydoctor.org/online/famdocen/home/seniors/commonolder/067.html.
  • Fecal Incontinence. (2007) National Digestive Diseases Information Clearinghouse. Retrieved on Dec 19, 2008 from http://www.digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/.
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