CONTINENCE - CAN WE DO BETTER? Continence Advisory Service Inverurie Hospital 01467 672748

ROLE OF CONTINENCE ADVISOR Clinical caseload Education/training on continence promotion, enuresis, encopresis, catheter’s, equipment etc. to professionals and the public Advice on equipment and products Resource Centre Audit and Research

Joint Continence Clinic Weekly Thursday at City hospital Monthly at Alford, Inverurie and Peterhead Patients can self refer Nurses – community/practice/Gp etc can refer Complete Referral form

FACTS AND FIGURES Urinary incontinence is a symptom resulting from one or more underlying conditions. 70% of patients with urinary incontinence can be improved or cured. Urinary incontinence in older females may be associated with an increased risk of falls and fractures. Estimate that 210,000 - 335,000 adults in Scotland have significant problems with urinary incontinence.

FACTS AND FIGURES An estimated 1:3 women in the UK have symptoms of stress urinary incontinence. SUI is the most prevalent type of urinary incontinence. Only 25% of women in the UK have consulted their Doctor. Over 25% of women with urinary symptoms wait more than 5 years to seek advice.

FACTS AND FIGURES 53 million people in Europe have bowel control problems or faecal incontinence – more prevalent than asthma/diabetes 1.4% of the population over 40 years old in the UK affected by faecal incontinence Constipation affects between 3% and 15% 1 in 5 people over 40 – overactive bladder (Bladder and Bowel Foundation – October 2009)

WHO WILL SUFFER FROM URINARY INCONTINENCE WHO WILL SUFFER FROM URINARY INCONTINENCE? (Royal College of Physicians 1995) Women living at home 15-44years 5 - 7% 45-64years 8 - 15% over 65years 10 - 20% Men living at home 15-64years 6% over 65years 7 - 10% Men/women living in Residential homes 25% Nursing homes 40% Long stay hospitals 50 - 70%

ECONOMIC COST £737,000 per year based on 100,000 patients Drugs cost - £48,000 Appliances - £122,000 Pads cost - £144,000 Staff cost - £395,000 Surgery cost - £28,000 Estimate by Continence Foundation (2001)

COST OF INCONTINENCE Consultant/ laboratory services Diagnostic procedures Surgery Physiotherapy Medication Nursing time Supplies/products Skin breakdown Falls Additional care home admissions Longer hospital stays Lost productivity

IMPACT OF INCONTINENCE Go to the toilet just in case/know all the toilet’s Wear pad just in case Fear of coughing etc. Embarrassment Feel dirty Social exclusion Restrict employment, education, leisure, opportunities Don’t talk about it Loss of confidence Avoid new relationships Stop having sex Don’t go out

REASONS FOR NOT SEEKING HELP Embarrassment Belief that it is a common part of ageing Availability of products Poor knowledge of treatments available Low expectations of treatment Fear of surgery

ASSESSMENT TOOLS Evidence that patient care could be improved by enhanced training. Effective treatment depends on thorough assessment and diagnosis. Assessment, treatment and referral should be offered to all patients with urinary incontinence problems. Scottish Intercollegiate Guidelines Network Management of Urinary Incontinence in Primary Care - SIGN 79 www.sign.aca.uk

ASSESSMENT TOOLS CONT Quality Improvement Scotland - Continence Adults with Urinary Dysfunction www.nhshealthquality.org NHS Grampian Continence Resource Pack NHS Guidelines on Completion of Assessment Form

DEFINITIONS - TYPES OF URINARY INCONTINENCE Urinary Incontinence - is the complaint of any involuntary leakage of urine. SUI - Stress Urinary Incontinence - is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. UUI - Urge Urinary Incontinence - involuntary leakage accompanied by or immediately preceded by urgency.

DEFINITIONS - TYPES OF URINARY INCONTINENCE Incomplete bladder emptying - in the past referred to as Overflow Incontinence Detrusor Overactivity Incontinence - Incontinence due to an involuntary detrusor contraction (in the past referred to reflex)

STRESS URINARY INCONTINENCE - SIGNS AND SYMPTOMS Leakage of urine e.g. coughing, sneezing, increase in physical activity. Amount of urine passed can be small. May have urinary frequency and urgency.

URGE URINARY INCONTINENCE SIGNS AND SYMPTOMS Urgency Frequency Nocturia Incomplete emptying Incontinence Nocturnal enuresis

VOIDING SYMPTOMS SIGNS AND SYMPTOMS Urgency Frequency Slow stream Hesitancy Straining Nocturia UTI Incomplete emptying of the bladder

FUNCTIONAL INCONTINENCE Individuals who cannot cope with their bladder function suffer functional incontinence, factors that can contribute are: impaired mental status impaired mobility impaired dexterity unsupported environment

ASSESSMENT CONTINENCE ASSESSMENT Complete continence assessment form Detailed history of symptoms M.S.Q. Score Quality of life Urinalysis Fluid intake Review mobility & dexterity Review medication Bowel pattern - use Bristol Stool Chart Post void residual

ASSESSMENT FREQUENCY VOLUME CHART Intake/output Bladder capacity Frequency of voids Frequency of incontinence episodes Nocturia Pattern of voiding

TREATMENT Review environment/clothing Fluid intake of 1500-1800mls per day Avoid fluids that contain caffeine Discourage smoking Advice on weight loss Double voiding Individualised toileting Bladder retraining Treat UTI’s Treat constipation & review diet Pelvic floor exercises Review medication/anti-cholinergics I.S.C./Catheter Referral to other agencies

REFER TO G.P. Exclude/treatment for vaginal atrophy Exclude/treatment for enlarged prostate Exclude/treatment for prolapse Treat infection Review of medication Prescription of anti-cholinergics Referral to consultant

Medication – Side-Effects on Bladder/Bowel Remember to check and exclude that medication side-effects are not causing or exacerbating problem Use BNF or www.bnf.org to check side effects such as difficulty with micturition, dry mouth, constipation, diarrhoea, urinary frequency etc. Check which over the counter medication used Are drugs appropriate for problem? e.g. too low a fluid intake for prescribed laxative? Request medical staff/nurse practitioner to review

Medications Which Can Cause Incontinence SEDATIVES – Lorazepam, Diazepam ANTIPSYCHOTICS – Chlorpromazine, Flupentixol (Depixol), Quetiapine ANTIDEPRESSANTS – Amitriptyline, Citalopram, Fluoxetine ANTICHOLENERGICS – Oxybutynin, Tolterodine LAXATIVES – Movicol, Lactulose DIURETICS – Furosemide, Spironolactone

EQUIPMENT AND PRODUCTS Commode and urinals Urinary sheaths/retracted penis pouch Washable pants/bed protection Disposable pads - correct sizing Intermittent self-catheterisation Indwelling catheter - urethral/supra-pubic/catheter valves Specialist companies

REFERRAL FOR ADVICE Link nurse within your clinical area Continence Advisor Continence Clinic Urologist Gynaecologist Physiotherapist Occupational Therapist Dietician Pharmacist Speech Therapist Horizons Other specialist nurses

YES - WE CAN Health Professional should have a positive attitude to continence problems All patients should undergo a continence assessment before product use. Issue of products should not take the place of therapeutic interventions. SIGN 79 2004