The International Continence Society (ICS) (2002) has coordinated the publication of a consensus document defining the terminology associated with the lower urinary tract, in which it defines urinary incontinence as ‘a condition in which involuntary loss of urine is a social or hygienic problem’. However, it is only when the specific type and cause of the person’s incontinence are known that appropriate treatment can be offered.

The prevalence of urinary incontinence in the UK is difficult to ascertain. Some estimates suggest that between 3 and 6 million people have some degree of urinary incontinence. Interestingly, the Bladder and Bowel Foundation (2008a) estimates that around one third of women are affected by stress urinary incontinence.

It is recognised that although urinary incontinence affects all age groups, male and female, its prevalence is greatest amongst women, particularly older women. In response to this fact the National Institute for Health and Clinical Excellence (NICE) (2006) developed guidelines on the management of urinary incontinence in women.

Types and causes of urinary incontinence

Faecal incontinence

According to NICE (2007), faecal incontinence is a not a diagnosis but is a symptom or sign. Reaching a consensus on a definition of faecal incontinence is difficult, but it can be classified by the symptom, such as faecal leakage. The prevalence of faecal incontinence in the UK is difficult to ascertain as it remains a taboo subject and people are reluctant to discuss their problems or seek help, due to embarrassment, anxiety and fear. It is estimated that faecal incontinence is experienced by 1–10% of the adult population living at home (NICE 2007). However, prevalence rates vary, from up to 13% for minor incontinence in the community, to up to 95% in nursing homes (Black 2007). It is known that faecal incontinence is more common in older people, particularly frail older women.

While urinary incontinence is more prevalent in the population than faecal incontinence, the latter is the more distressing problem. Faecal incontinence is socially even less acceptable than urinary incontinence and raises strong emotions among carers who have to deal with it. It is a source of discomfort and acute embarrassment for the sufferer, and contributes to feelings of helplessness, loss of self-esteem and social isolation.

Faecal incontinence, like urinary incontinence, is a symptom of an underlying pathology and with appropriate assessment and treatment many people will regain continence (Kenefick 2004).

Types and causes of faecal incontinence

The causes of faecal incontinence must be determined before treatment is instigated. Other than simple constipation, faecal impaction with overflow diarrhoea (spurious diarrhoea), the main cause of faecal incontinence is usually damage to the pelvic floor and anal sphincters (such as during childbirth, rectal prolapse or surgery), resulting in an inability to recognise that the rectum is full or to distinguish between flatus and faeces.

Causes of faecal incontinence in adults include:

• faecal impaction with overflow diarrhoea in very frail older people and often those with dementia and physical disability

• diarrhoea/intestinal hurry caused by gastroenteritis, inflammatory bowel disease (IBD) (see Ch. 4), and medications such as antibiotics, excessive use of laxatives and some foods

• neurological disease which may include spinal nerve injury, spina bifida, stroke and diseases such as Parkinson’s and multiple sclerosis

• anal sphincter damage due to direct trauma caused during childbirth or surgery.

Rao (2004) states that many people who experience faecal incontinence refer to themselves as having diarrhoea or urgency as this seems more tolerable. Rao refers to faecal incontinence being graded in relation to its severity:

• Passive – involuntary discharge of faecal matter or flatus without awareness. The person may have impaired perception or impaired reflexes. There may also be sphincter dysfunction.

• Urge – involuntary discharge of faecal matter or flatus, in spite of active attempts to retain the bowel contents. This is usually related to sphincter disruption.

• Seepage – undesired leakage after a normal bowel movement. Mostly this is due to incomplete evacuation of the bowel contents and/or impaired rectal sensation. The sphincter function and the pudendal nerve are mostly intact.

Faecal incontinence or soiling in children is termed ‘encopresis’ and is defined as the passage of a normal consistency stool in a socially unacceptable place. The prevalence of children with faecal incontinence decreases from 1 in 30 children at age 5 years to 1 in 100 by the age of 12 years (Department of Health [DH] 2000).

Epidemiology of incontinence – prevalence studies

Seminal research into the prevalence of incontinence by Thomas et al (1980) found that whilst incontinence was most prevalent among older women, its occurrence was significant across all age groups. Stress incontinence was reported less often by nulliparous than by parous women of all ages, and was especially prevalent among those who had borne four or more children. Urge incontinence also occurred more commonly among parous than nulliparous women. No significant class differences were found among men or women, but individuals of African Caribbean or part African Caribbean descent were more likely to have some form of incontinence than those of Asian descent.

The most important finding of the study, however, was the 1:10 ratio of known to unknown cases of incontinence. This suggests that for every incontinent person who is known to health or social services professionals, there are 10 others who are unidentified. As further in-depth interviews revealed, many people try to ‘cope’ with moderate to severe problems of incontinence without professional support. These findings identify the need for health care workers to take advantage of all appropriate opportunities in all care settings to identify those who require assessment and treatment for incontinence.

The Essence of Care Benchmark for Bladder, Bowel and Continence Care recommends that nurses use a ‘trigger’ question to initiate conversation that may lead to further assessment of a person’s continence, bladder and bowel status (DH 2010). It is recognised that the nurse asking a question provides an opportunity for the person to talk about this sensitive subject. An open question offers the opportunity for an in-depth answer, for example ‘Tell me about any difficulties you have maintaining continence or with your bladder or bowel function’.

An audit of first assessments by community nurses found that district nurses were primarily assessing people with incontinence for absorbent products rather than assessing their incontinence with a view to improved management or regaining continence (Audit Commission 1999). There is a need not only to identify people who are incontinent, but also to improve public and professional understanding of incontinence, to evaluate services available for those requiring assessment and to improve methods of treatment and management (Scottish Intercollegiate Guidelines Network [SIGN] 2004). However, continence care seems to remain low on the list of nursing priorities, with a focus on containment rather than interventions to improve continence and QoL (Box 24.1).

Box 24.1 Evidence-based practice

Do nurses promote continence in hospitalised older people? An exploratory study

Dingwall & McLafferty (2006) explored whether nurses working in older peoples’ medicine and in acute medical settings promote urinary continence in older people or in reality use containment strategies.

The study demonstrated that untreated urinary incontinence in older adults can result in prolonged hospital admission and increased risk of admission to long-term care. It was recognised that little qualitative investigation into how nurses promoted urinary continence in older people was available.

Data were collected using focus groups and one-to-one semistructured interviews in two NHS regions in Scotland. Registered and non-registered nurses were invited to participate. Data were analysed thematically.

Their findings indicated that some nurses believe older people accept urinary incontinence as a result of ageing. Lack of assessment resulted in older people being labelled as incontinent of urine. Assessment strategies for older people tend to focus on product identification and management of incontinence, rather than identifying the cause. The study identified that although all nurses know the importance of promoting continence, the problem continues to be contained rather than treated.

Competing clinical priorities, varying staff approaches and deficits in education were cited as barriers to promoting continence.

Resource

Dingwall L, McLafferty E: Do nurses promote continence in hospitalized older people? An exploratory study, J Clin Nurs 15(10):1276–1286, 2006.

Sociological factors in underreporting of incontinence

That incontinence remains to such a large extent a hidden problem among the general population can be attributed in part to the embarrassment felt by many people, leading to reluctance to admit to incontinence and seek treatment (Mason et al 2001). Several authors agree that the more severe the incontinence, the more likely a person is to seek medical help (Roe et al 1999, Shaw 2001). However, the severity of the symptoms is only one factor that influences the person in their choice to seek professional help or not. Shaw (2001) identifies other factors that influence this decision:

• lack of knowledge of causes, not considering incontinence to be a medical problem

• lack of knowledge of treatment options, not aware that incontinence is treatable

• belief that incontinence is a long-term condition related to age and parity

• previous experience or experience of friends/family

• cultural background and attitudes to discussing such intimate problems

• personality of the person and their relationship with members of the health care team.

Many people prefer not to mention their incontinence to others (Roe et al 1999).

Incontinence may restrict employment, and educational and social activities, which in turn may compromise both physical and mental well-being.

It may also be true that, in women, the private nature of and, to some degree, secretiveness surrounding menstruation gives an easily transferable model of management to follow should incontinence develop. Many women conceal the leakage of urine as they have concealed menstruation previously.

For many people, incontinence is a source of embarrassment or shame rather than a signal to seek medical help. The dysfunction is seen mainly in terms of its social consequences rather than as a symptom of a possible underlying illness or disease process.

Personal and social attitudes towards incontinence are not, however, the only factors that account for the underreporting of this widespread health problem. The way that particular health services are marketed or presented can also influence an individual’s decision whether to seek help or cope on their own. In the words of one person, ‘I would find it too embarrassing to go to a special clinic…perhaps a home visitor would be more helpful’ (Association for Continence Advice 2000).

It is therefore important that continence services reflect positive attitudes and approaches to promoting continence, and progress on this is demonstrated in the setting of standards by nurses and monitoring of services and treatment. It is vital that people and carers affected by incontinence are given every opportunity to regain their continence, to be empowered and to be involved in the development of targeted services. To this end, a Charter for Continence was developed by several professional organisations in 1995 (Box 24.2). Various government initiatives and other publications have assisted in the process.

Box 24.2 Information

Charter for Continence

The Charter for Continence presents the specific needs and rights of people with bladder or bowel problems. It outlines the resources available and the standards of care that can be expected.

As a person with bladder or bowel problems you have the right to:

• Be treated with sensitivity and understanding

• Become continent if achievable

• Receive a thorough individual assessment of your condition by a doctor or nurse knowledgeable in this aspect of care

• Request specialist advice about continence care

• Be provided with a clear explanation of your diagnosis

• Participate in a full discussion of treatment options, their advantages and disadvantages

• Be provided with full, impartial information on the range of products which are available and how to obtain them

• Expect products to have clear instructions for use

• Receive regular reviews of treatment and be given the opportunity to change treatments if your condition has changed

• Be made aware of any treatments or products as they become available

• Be provided with a personal contact point able to give you ongoing advice and support.

Developed by The Continence Foundation, InconTact, Association for Continence Advice (ACA), the RCN Continence Care Forum, Education and Resources for Improving Childhood Continence (ERIC), the Spinal Injuries Association and the Multiple Sclerosis Society. (Produced by an educational grant from Bard Ltd, March 1995.)

In England and Wales, the DH (2000) issued guidance on continence services to the NHS. This provided targets for both inpatient and community care. The guidance also influenced the content of the 10-year programme of the National Service Framework (NSF) for older people (DH 2001). A supporting system redesign for older people is now underway to build on the progress of the NSF (DH 2009). The Essence of Care (DH 2010) benchmark statements ensured that specific areas of care, such as continence, could be audited and improved.

In Scotland, various guidance was published, for example, NHS Quality Improvement Scotland (NHSQIS) (2004), Nursing and Midwifery Practice Development Unit (NMPDU) (2002) and SIGN (2004).

In the last few years NICE has produced guidelines for both urinary and faecal incontinence and related treatments (NICE 2006, 2007).

The participation of those most affected by incontinence has been further strengthened by the inclusion of patients/carers on all the working parties for national continence publications, and including sections on patient information in those publications.

Factors contributing to incontinence

Incontinence is basically due either to a delay in achieving continence, or loss of established continence.

Delay in achieving continence

In childhood, the acquisition of the skills necessary to achieve continence may be delayed. Nocturnal enuresis may present as a primary or secondary feature; its cause is not known. Although it often spontaneously resolves, it is sometimes not resolved during childhood. In such cases, if it remains untreated, it may be a problem throughout life (Hjalmas et al 2004). Its impact on both individual and family has been researched by Morrison et al (2000).

Learning disability may also prevent a person from attaining continence. Professionals working with people who have learning disabilities should base their interventions on the assumption that, although the process of toilet training may be slow, continence will eventually be achieved provided interventions are tailored to the individual and their family’s requirements (Rogers 1998). Physical difficulties can hinder the acquisition of continence. Some children cannot become continent without medical intervention, such as in some types of spina bifida. An infant or child who is continuously wet should always be investigated for either congenital fistula or failure to empty the bladder. Such symptoms should be taken seriously as failure of bladder emptying (with stasis of urine) can lead to vesicoureteric reflux (VUR). There is reflux of urine up the ureters following a rise of pressure within the bladder during voiding. The urine later runs back to the bladder and is not immediately voided, which in turn increases the risk of urinary tract infection (UTI). The constant reflux of infected urine into the ureters can lead to chronic pyelonephritis (reflux nephropathy) (see Ch. 8).