2. Continence - What are we aiming for?!! Dr Tammy Angel

6. Why is it important? Curable!

7. QOL Occupational Physical Social Psychological Sexual Domestic

8. Topics for today..  What’s normal?  What are the NICE guidelines for each types of incontinence?  Local services and National initiatives  Working example..

9. Normal? Bladder stores and voids Usually sense ‘urge’ to PU at 2-300mls At socially convenient time and place Reflex relaxation of external sphincter Bladder muscle contracts

10. Types of incontinence Stress Urge Overflow Functional Cognitive/neurological/psychiatric Mixed

11. NICE Rx UI At initial ax-SUI/UUI/ Mixed Hx is suffficient to inform non invasive 1st line Rx options (3 day) bladder diaries Invasive Ix NOT recommended before conservative Rx

12. Stress incontinence.. Pelvic floor exercises.. ‘of at least 3 months duration’ –Digital ax PFM contraction- at least 8 contractions tds - consider electrical stimulation/ biofeedback for pts unable to actively contract PF Duloxetine : ‘Not be routinely used 2nd line, may be offered as alternative to surgical Rx’ Urodynamics +/- surgical intervention (TVT TOT; injectables colposuspension)

14. Urge incontinence Rx UTI’s and stop unnecessary diuretics OAB : Caffeine reduction and Bladder retraining.. ‘at least 6 weeks’ Anticholinergics ‘ non-proprietary oxybutynin due to cost effectiveness rather efficacy - if not tolerated tolterodine; solifenacin, trospium Intravaginal oestrogens for atrophy Botulinium toxin A (willing to self catheterise); sacral nerve stimulation; augmentation cystoplasty; urinary diversion intravesical oxybutynin,

15. Overflow incontinence Clear bowels Alphablockers eg tamsulosin Stop anticholinergics Intermittent self catheterisation ?prostatic surgery

16. Functional incontinence Physiotherapy Move closer to toilet REGULAR TOILETTING Neuropsych  REGULAR TOILETTING

17. How should we assess pts - history? MOBILITY DRUGS BOWELS COGNITION INFECTION MEDICAL COMORBITIES PSxH

18. Continence Assessment Examination: Abdomen/ Pelvis Perineal/ cough Rectal Post micturition bladder scan +/- Neuro/ Gait Investigation Fluid volume charts Urinalysis/ MSU Creatinine PSA AXR +/- USS Renal tracts

19. Hemel initiatives.. Weekly ward round : “the dry, the wet and the catheterised”! Rolling Educational Programme for All Assessment of patients in Day Hospital and RAU Management Algorithims and care plan Participation in National Continence Audit Local Catheter Audit + Identify HCA + Trained on each ward + Weekly screening--> see referrals + rationalise pad usage

22. 1725 Bleep 1725

23. Shape of new service MondayTuesdayWednesdayThursday Friday Hemel F/U Watford Wards SACH RAU/OPD Watford F/U Hemel Clinic/ WR WardsTA/ AC WR ? Community Admin/ Audit

24. Service Objectives.. Patients identified, comprehensively assessed, and appropriately managed Patients receive written information about their condition Better follow up for patients Improve transfer of information into community Promote education

26. My interpretation.. Community Continence Advisors

27. Working example 70 yr old woman; C/O: severe urgency, UI, nocturnal frequency..needs radioactive iodine! PMH : ‘CCF’, HT, OA awaiting THR DH: BFZ, Frusemide, Diltiazem, doxazosin tramadol PSH: N and no previous ix

28. Further hx and ix O/E: well in self, mild SOA, abdo NAD, PV N, PR loaded Urinalysis = clear Bladder scan when ‘desperate’ = 60 mls and PMRV = 0 mls WHAT NEXT?…

29. Assessment.. 1.Overactive bladder with small capacity 2.Exacerbated by diuretics, 3.Reduced mobility due to OA, 4.SOA ? Diltiazem/Gravity/RVF 5.Constipation

30. Plan and outcome Stopped BFZ, doxazosin Frusemide at 5pm then fluid restrict Detrusitol XL 4 mg od Bladder retraining exercises – holding on Senna and docusate Leg elevation during the day DRY!!.. Rx radioiodine

31. Conclusions Dispel 2 urban myths: 1.Incontinence is not normal for age 2.It is curable… A continence nurse specialist will dramatically improve quality of service and community integration!

33. Any questions ?