A nurse is providing privacy for a client who has incontinence

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 causes1:

• D elirium
• I nfection--urinary (symptomatic)
• A trophic urethritis and vaginitis
• P harmaceuticals
• P sychological disorders, especially depression
• E xcessive urine output (for example, from heart failure or hyperglycemia)
• R estricted mobility
• S tool 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.

Bladder and bowel symptoms

• 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

Exclude

• malaena
• rectal bleeding
• anaemia
• loss of weight
• unexplained change in bowel habits
• nocturnal diarrhoea
• abdominal or pelvic mass.

When the problem occurs

• >during the day or during the night

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).

Other medical conditions or chronic diseases

• arthritis and related disorders
• musculoskeletal conditions
• neurological conditions such as Parkinson’s Disease, Multiple Sclerosis
• stroke
• diabetes
• dementia.

Medications

• diuretics
• high blood pressure medications
• antidepressants and sedatives
• muscle relaxants and sleeping pills
• calcium channel blockers (can cause constipation)
• non-prescribed drugs.

Fluid and fibre intake

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 lives2 and stigma about incontinence can be a barrier to seeking help.3

Examine relevant systems

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.

Investigate the evidence

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.

1. 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.

2. Mitteness, L.S. and J.C. Barker, Stigmatizing a normal condition: urinary incontinence in late life. Medical Anthropology Wuarterly, 1995. 9: p. 188-210.

3. 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. 299305.

Assisting patients with elimination is an essential aspect of the nurse's role and has important medical significance as well as psychosocial effects on the client's quality of life.[1]  As the pattern of healthy bowel movements and urination vary in different patient groups, the management for each patient population may differ. Nurses need to assist with healthy elimination patterns to ensure patients are having regular soft bowel movements and adequate urination and to identify abnormal patterns such as flatulence, constipation, diarrhea, incontinence, fecal impaction, hemorrhoids as well as polyuria, anuria, and other abnormalities which can be signs of underlying medical conditions. 

While there are pharmacologic alternatives to assist with elimination issues, assistance by nurses is often required. For instance, in abdominal pain syndrome and constipation, studies show that abdominal massage appears to increase bowel function, but without the negative effects of laxatives.[2] 

Conversely, certain medications can cause constipation, diarrhea, and hinder or exacerbate elimination. Opioids, NSAIDs, antibiotics, anticoagulants, can all induce constipation.[3] It is vital nurses know which patients are at risk for bowel and bladder disruption and monitor them for these issues. 

The nursing team must provide strong supportive communication when assisting clients with elimination. A study found that the nurse's attitudes toward excretion-related nursing care strongly influenced the use of a toilet and physical functions of the elderly.[4] Patients may be reluctant to discuss their bowel and bladder problems due to embarrassment. It is vital that nurses maintain open communication and empathy with their clients and ask questions as well as physically assess patients for signs of bladder and bowel irregularities.[5][6]

Elimination issues may occur due to a variety of different medical conditions; for instance, post-surgical patients are at risk for ileus, congenital malformations in infants can cause bowel and bladder disruption, and cancer patients and the elderly can have altered elimination secondary to drugs and therapy.[7][8]

The inability to effectively eliminate waste products from the bowel and bladder may lead to serious medical conditions and can be a psychosocial factor contributing to decreased quality of living.[5] Special consideration is necessary for patients at risk for bowel and bladder dysfunction such as patients with decreased fiber or fluid intake, or those with decreased bulk in their diet, patients on bed rest, those with kidney, CNS, or heart disease, the elderly, infants and cancer patients.[6]

Management may differ based on the diagnosis of the patient. For instance, a study found that enterally fed preterm infants would benefit from abdominal massage twice a day, whereas cancer patients with elimination issues may benefit from Sitz baths.[9][7][10]

Non-invasive interventions such as repositioning the patient, providing counseling in regards to a high fiber diet rich in prunes, stool softeners, removing drugs that may be causing gastrointestinal or genitourinary side effects, and abdominal massage can aid the patient in elimination. Additionally, more invasive interventions such as the use of suppositories, urinary catheters, enemas, bowel and bladder training, and management can also help clients who have failed initial interventions.[6]

Urinary catheterization for retention is possible with the use of ointments such as zinc oxide and topical agents to keep the skin protected. A recent meta-analysis found that periurethral cleaning with water before urinary catheterization is as effective as using anti-septic agents and does not increase the risk of UTI's.[11] Bladder, colostomy, and urinary catheter irrigations can also be performed to assist with elimination.[11] 

Various enemas can also be used depending on the issue; cleansing enemas are used before procedures like colonoscopies to clean the colon of fecal material for optimal visualization, retention enemas may help lubricate the rectum and deliver medication, and lastly, return-flow enemas are often used after anesthesia to stimulate peristalsis.[12]

If less invasive techniques are unsuccessful, colostomies, or urostomies are options. However, given that these are invasive procedures, there is an increased risk of complications such as infections, B12 deficiency, dehiscence, and necrosis, and these patients require thorough monitoring.[13]

Invasive methods may lead to long term adverse outcomes. A study found that decreasing the use of the invasive practices routinely adopted in nursing homes (laxatives, enemas, rectal exploration) improved constipation in nursing home residents.[14] Thus, empathetic nursing care, counseling, and non-invasive methods are ideal for improving excretion issues.

Any patient without a bowel movement for several days requires assessment for constipation or small bowel obstruction. Nurses may assess bladder function by measuring the amount of residual urine. On average, adults urinate 30 mL each hour.[4]

Secondary complications of disrupted elimination such as delirium secondary to UTI’s, or a positive FOBT secondary to ulcers or hemorrhoids also need monitoring.[15]

It is also essential to monitor elimination to prevent the spread of hospital-acquired infections such as Clostridium difficile and to isolate the client and use hand hygiene and gown and glove precautions when assisting the patient.[16]

Thus, by following these methods and being knowledgeable about elimination and the complications associated with patient elimination, nurses can adequately assist with this fundamental aspect of patient care. 

Review Questions

1.

Coggrave M. Neurogenic continence. Part 3: Bowel management strategies. 2008 Aug 14-Sep 10Br J Nurs. 17(15):962-8. [PubMed: 18983017]

Lämås K, Lindholm L, Stenlund H, Engström B, Jacobsson C. Effects of abdominal massage in management of constipation--a randomized controlled trial. Int J Nurs Stud. 2009 Jun;46(6):759-67. [PubMed: 19217105]

Sharma A, Rao S. Constipation: Pathophysiology and Current Therapeutic Approaches. Handb Exp Pharmacol. 2017;239:59-74. [PubMed: 28185025]

Tanaka K, Takeda K, Suyama K, Kooka A, Nakamura S. Factors related to the urination methods of elderly people with incontinence who require at-home nursing care. Nihon Ronen Igakkai Zasshi. 2016;53(2):133-42. [PubMed: 27250220]

Cauley CE, Savitt LR, Weinstein M, Wakamatsu MM, Kunitake H, Ricciardi R, Staller K, Bordeianou L. A Quality-of-Life Comparison of Two Fecal Incontinence Phenotypes: Isolated Fecal Incontinence Versus Concurrent Fecal Incontinence With Constipation. Dis Colon Rectum. 2019 Jan;62(1):63-70. [PubMed: 30451749]

Pellatt GC. Clinical skills: bowel elimination and management of complications. 2007 Mar 22-Apr 11Br J Nurs. 16(6):351-5. [PubMed: 17505389]

Wickham RJ. Managing Constipation in Adults With Cancer. J Adv Pract Oncol. 2017 Mar;8(2):149-161. [PMC free article: PMC5995490] [PubMed: 29900023]

Powell M, Rigby D. Management of bowel dysfunction: evacuation difficulties. Nurs Stand. 2000 Aug 9-15;14(47):47-51; quiz 53-4. [PubMed: 11974378]

Tekgündüz KŞ, Gürol A, Apay SE, Caner I. Effect of abdomen massage for prevention of feeding intolerance in preterm infants. Ital J Pediatr. 2014 Nov 14;40:89. [PMC free article: PMC4236471] [PubMed: 25394549]

Tseng YL, Lin SY, Tseng HC, Wang JY, Chiu JL, Weng KT. Stress and other factors associated with colorectal cancer outpatients with temporary colostomies. Eur J Cancer Care (Engl). 2019 Jul;28(4):e13054. [PubMed: 30993754]

Huang K, Liang J, Mo T, Zhou Y, Ying Y. Does periurethral cleaning with water prior to indwelling urinary catheterization increase the risk of urinary tract infections? A systematic review and meta-analysis. Am J Infect Control. 2018 Dec;46(12):1400-1405. [PubMed: 29778430]

Peate I. How to administer an enema. Nurs Stand. 2015 Dec 02;30(14):34-6. [PubMed: 26639291]

de Oliveira AL, Boroni Moreira AP, Pereira Netto M, Gonçalves Leite IC. A Cross-sectional Study of Nutritional Status, Diet, and Dietary Restrictions Among Persons With an Ileostomy or Colostomy. Ostomy Wound Manage. 2018 May;64(5):18-29. [PubMed: 29847308]

Palese A, Granzotto D, Broll MG, Carlesso N. From health organization-centred standardization work process to a personhood-centred care process in an Italian nursing home: effectiveness on bowel elimination model. Int J Older People Nurs. 2010 Jun;5(2):179-87. [PubMed: 20925719]

Kobayashi Y, Watabe H, Yamada A, Suzuki H, Hirata Y, Yamaji Y, Yoshida H, Koike K. Impact of fecal occult blood on obscure gastrointestinal bleeding: observational study. World J Gastroenterol. 2015 Jan 07;21(1):326-32. [PMC free article: PMC4284352] [PubMed: 25574108]

Read ME, Olson AJ, Calderwood MS. Front-line education by infection preventionists helps reduce Clostridioides difficile infections. Am J Infect Control. 2020 Feb;48(2):227-229. [PubMed: 31515098]