1. Definition & Prevalence
1.1 Incontinence of urine is defined as “objective involuntary loss of urine” by the International Continence Society and faecal incontinence as “involuntary loss of solid or liquid faeces. These conditions are at their most prevalent in older people and, for urinary incontinence, they appear to experience the most severe disease. Up to 24% of women and 15% of men over the age of 65 suffer with the condition. The prevalence of other lower urinary tract symptoms which do not involve incontinence is higher in both sexes. Faecal incontinence appears to affect 4-6% of community dwelling over 65 year olds. Prevalence of both conditions is at its highest in institutional care.
1.2 Despite being one of the geriatric giants, it is not always seen as a priority by geriatricians. Management of this condition must improve. There is a definite role in the detection and initial management of continence problems for all geriatricians, particularly as continence has an impact on all of the other geriatric “core” conditions (delirium /dementia, falls, stroke, movement disorder). The BGS wishes to encourage the interest of geriatricians such that there is a continence lead within every general hospital and PCT. Training in continence care is an essential part of training for any geriatrician, regardless of eventual career.
1.3 The documents in this paper aim to define the core skills and abilities that a generalist in continence care should have to allow progression within specialist training and provide links to guidelines, articles and internet sites which contain the relevant information to allow practitioners to learn what to do.
2. Policy & Guidelines
2.1 The Department of Health’s National Service Framework for Older People (http://www.dh.gov.uk/en/Publicationsandstatistics/PublicationsPolicyAndGuidance/DH_4003066 ) called for integrated continence services to be established for older people by April 2004, and its document Good Practice in Continence Services (http://www.dh.gov.uk/en/Publicationsandstatistics/PublicationsPolicyAndGuidance/DH_4005851 ) highlighted the need for proper assessment and management of incontinence, and regular audit of services.
2.2 In an effort to improve the identification and management of urinary incontinence, clinical guidelines have been developed, notably by the International Consultation on Incontinence (ICI) and the European Association of Urology (EAU). The recently updated urinary incontinence guidelines of the EAU (http://uroweb.org/fileadmin/user_upload/Guidelines/16%20Urinary%20Incontinence.pdf ) also include a recommendation for the use of SNRIs for stress incontinence. Considerable effort has gone into recent updates of these guidelines, and it is hoped that their recommendations will improve standards of care, and help dispel the nihilistic attitude to continence that is common amongst the physicians as well as patients. The 3rd ICI, organised by the International Continence Society, 2004 updated the guidelines and the management of urinary incontinence in frail older men and women is summarised in a series of algorithms, tailored to the needs of primary and secondary care.
2.3 The National Institute for Health and Clinical Excellence (NICE) has issued guidance on the management of urinary incontinence in women (http://www.nice.org.uk/page.aspx?o=CG40 ) and faecal incontinence (http://www.nice.org.uk/page.aspx?o=CG49 ). Guidance on the management of lower urinary tract symptoms (LUTS) in men is planned. The Scottish Intercollegiate Guideline Network (SIGN) guidelines on the management of urinary incontinence in primary care were published at the end of 2004 (http://www.sign.ac.uk/sign79.pdf ). Recommendations for the treatment of urge, stress and mixed urinary incontinence are comparable with those in the updated ICI and EAU guidelines.
3.1 The largest audit of continence care worldwide, the national audit of continence care in England , Wales and Northern Ireland (http://continenceaudit2006.rcplondon.ac.uk ) showed variations in service provision, a widespread failure to establish the cause of incontinence, with inadequate use of routine assessments, such as bladder diaries and the measurement of residual bladder volumes. The audit report concluded that an emphasis on containment (through pads and catheters), rather than cure of incontinence, was expensive, and suggested a missed opportunity to assess, treat and reduce the numbers of incontinent people. The site contains the audit tools which can be downloaded for local use.
4. Identification and assessment
4.1 There is a need therefore for opportunistic case finding and wherever possible a screening question relating to bladder (and bowel) should be asked of people presenting for medical care regardless of the condition. If a positive response is gained, then an assessment of the problem by an appropriately trained individual should be offered. The use of a self completion questionnaire, measuring symptoms and bother has been validated for use by women and could provide impetus to those seeking care ( Basra R, Artibani W, Cardozo L, Castro-Diaz D, Chapple C, Cortes E, de RidderD, Espuna-Pons M, Haab F, Hohenfelner M, Kirby M, Milsom I, van Kerrebroeck P, Vierhout M, Wagg A, Kelleher C. Design and valdation of a new screening instrument for lower urinary tract dysfunction: The Bladder Control Self-assessment Questionnaire (B-SAQ) European Urology 2007 Jul;52(1):230-7)
4.2 A storage symptom and voiding symptom history should be taken. This should be supplemented by relevant history of prior interventions related to continence, a dietary history (FI) and a drug history. Relevant red flag symptoms should be sought and appropriate action taken in response to these. Definitions of urinary incontinence symptoms and terms can be found at: http://www.icsoffice.org/default.asp?ReturnUrl=documents/Search/Index.asp. Elements of the history which are thought to be important are contained within the relevant national guidelines.
Key symptoms : Please remember to ask for the following:
- Difficulty passing urine (hesitancy / straining / poor stream)
- Frequency of passing urine by day or night
- Wetting or leakage or unable to reach the toilet in time
- A feeling of incomplete bladder emptying
- A need to rush to the toilet (urgency)
- Pain on passing urine and presence of blood
- Leakage of urine preventing normal activities
- Frequent urinary tract infections
- A leakage of urine on laughing, sneezing and coughing.
4.3 An initial assessment for continence problems should follow a standardised form. An assessment of toileting ability should accompany any examination for incontinence. Older people may have no lower urinary tract pathology but the impact of other disabling conditions may serve to render them incontinent. Mobility and manual dexterity (for dressing and undressing) are paramount.
- A urine analysis to exclude symptomatic infection should be done and any active infection treated.
- A standing stress test can be employed to demonstrate stress incontinence in the outpatient clinic, but this does have its limitations, as a full bladder can “kink” the urethra hiding the underlying problem.
- Examination should also take into account the presence of vaginal atrophy and prolapsed. As a general rule, a patient with a prolapse reaching to the introitus or causing symptoms should be referred appropriately.
- The role of the rectal examination in women complaining of urinary incontinence is contentious. There are no data to suggest that performance of a rectal examination alters outcome from treatment, but anecdotally, a loaded rectum may be the cause of frequency and voiding difficulty.
- Rectal examination for men should be mandatory as assessment of prostate size is important. However, the association between prostate size on rectal examination and outflow tract obstruction is variable.
- When making a diagnosis of overactive bladder (OAB) other conditions which might lead to similar symptoms need to be excluded, and the complaints of bladder pain or haematuria need to be appropriately investigated.
- A three day bladder diary is an extremely useful diagnostic aid
- There is no need for cystometry to confirm a diagnosis prior to conservative treatment in women. For more information see NICE Guidance: (http://www.nice.org.uk/page.aspx?o=CG40)
4.4 A structured history for bowel problems needs to be taken. Elements of this history should include:
- Assessment of normal bowel habit and the presence of either blood or mucus
- Assessment of the usual consistency of stools (Refer to stool chart such as the Bristol Stool Chart to assist the patient/carer to describe)
- Need to strain at stool, ability to delay emptying, the presence of pain or bloating
- Assessment of incomplete emptying after an attempted bowel evacuation
- Need for digital evacuation for successful emptying
- Passage of faeces without awareness
- Frequency of incontinence, presence of faecal urgency, precipitating factors
5.1 There is good evidence that older people do just as well as younger people following conservative and drug treatment for their urinary problems. However, older people are often undertreated. The British Geriatrics Society supports a proactive approach to treatment in this group.
5.2 Older women are also under-represented in the groups receiving surgery for stress incontinence despite advances in surgical techniques which minimise operating, in hospital and recovery time. Surgery for older men predominantly involves the relief of outflow tract obstruction.
5.3 There is a dearth of data on older men with Lower Urinary Tract Symptoms. The few studies of drug treatment for men suggest that a combination of antimuscarinics and alpha- blockers are effective in an unselected group of men with Overactive Bladder. There is no role for alpha-blockers in women.
5.4 Nocturia is a common symptom and has many causes. The treatment of nocturia is an important component of geriatric practice and although not licensed in people over the age of 65 people with nocturnal polyuria (>35% of 24h urine production during sleeping hours) respond to DDAVP. http://guidance.nice.org.uk/CG40/niceguidance/pdf/English/download.dspx Estimation of serum sodium concentration should be made three days after starting therapy. All cases appear to occur in the initial period of dose titration. A meta-analysis has reported that the incidence of significant hyponatraemia in older women is 14%. All cases appear to occur in the initial period of dose titration.
5.5 The use of pads, appliances and catheters for containment should only follow assessment and reversal of identified factors underlying the incontinence. Their use is not treatment of the condition. Sheath drainage for men where possible is preferable to the long-term use of urethral catheters. The use of suprapubic catheters is more convenient; they are easier to change and avoids the urethral complications such as recurrent urinary tract infections and sepsis associated with urethral catheters.
6. Integrated Continence Services
6.1 The Department of Health document “Good Practice in Continence Services” sets out a vision for the delivery of care in an integrated fashion. There is evidence of progress towards this nationally but it is slow. The current NHS organisational changes make it necessary for there to be clear organisational arrangements between provider organisations. Commissioners should be encouraged to view services in an integrated fashion. Tariffs should be “unbundled” to allow this to happen.
7. The way forward
7.1 The BGS strongly supports all attempts to raise the profile of continence care. Geriatricians should ensure that training is provided for their junior staff and that there is a clear pattern of referral for their patients to local continence services where there is no local geriatrician with a specialist interest
7.2 The BGS wishes to see a geriatrician with a specialist interest in continence management all Districts and encourages the development of this interest within job plans and service development plans
7.3 The BGS recognises continence care as a key part of ensuring privacy and dignity in care for older people and encourages members to take an active role in its “Behind closed doors” campaign.
- Abrams PH, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U et al. The standardization of terminology of lower urinary tract function: Report from the standardization sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21: 167-178.
- Perry S, Shaw C, McGrother C, Matthews RJ, Assassa RP, Dallosso H et al. Prevalence of faecal incontinence in adults aged 40 years or more living in the community. Gut 2002, 50(4):480-4.
- Perry S, Shaw C, Assassa P, Dallosso H, Williams K, Brittain KR, Mensah F, Smith N, Clarke M, Jagger C, Mayne C, Castleden CM, Jones J, McGrother C. An epidemiological study to establish the prevalence of urinary symptoms and felt need in the community: the Leicestershire MRC Incontinence Study. Leicestershire MRC Incontinence Study Team. J Public Health Med. 2000 Sep;22(3):427-34.
- Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence Plymouth : Plymbridge Distributors Ltd; 2004.