Bladder and Bowel Control Dr Sue Woodward Lecturer, Florence Nightingale School of Nursing and Midwifery
2 Why do we need to understand anatomy?
Normal physiology Normal adult bladder capacity = 450-500mls Normal Urinary frequency = 6-7 times per day Normal frequency at night depends on age. Older people can get up once at night & be within normal limits Fluid intake = 2.5-3L per day Normal bowel habit = Not more than 3 times per day & not less than once every 3 days 3
Prevalence & Impact of Urinary Incontinence Urinary incontinence is common in the general population (more so among women) Prevalence increased following stroke 31-60%, most frequently reported 2 weeks after stroke (Pilcher & McArthur, 2012) QoL decreases with increasing severity, impacting on emotional health Increased risk of falls and poorer outcomes from stroke Dissatisfaction with bedpans and catheters 4
Defining incontinence The involuntary or inappropriate passing of urine and/or faeces that has an impact on social functioning or hygiene. It also includes enuresis (bedwetting).` (DH, 2003) Urinary Incontinence is the complaint of any involuntary leakage of urine (Abrams et al, 2002) 5
Types of bladder problems Problems with storage (neurogenic detrusor overactivity) Frequency Urgency Voiding with some element of voluntary control Problems with emptying (Retention/DESD) Supra-conal lesions likely dyssynergia Hesitancy Frequency Incomplete emptying/high residual volume Both Pre-morbid condition? 6
Continence assessment Trigger questions (DH, 2011) Does your bladder or bowel ever/sometimes cause problems? How often do you empty your bladder during the day/night? Do you ever have to rush to the toilet urgently to empty your bladder? Detailed continence assessment using evidence-based assessment tools (Woodward, 2006) 7
Initial assessment History (urgency, UI, frequency, nocturia) Examination Investigations Screen for UTI Post-void residual, preferably using bladder scan (>100ml) Urodynamics? 8
Simple strategies Remember patient choice, privacy and dignity Prevention of constipation Prevention of urinary tract infection Functional, call bell at hand, assess patient s mobility, manual dexterity, comfort 9
Management - storage Antimuscarinics Oxybutinin/Tolterodine Trospium, solifenacin et al.. Tolerability? Pelvic floor exercises Containment Skin care 10
Management - emptying ISC the gold standard? No comparative studies Upper tract surveillance Many published guidelines, but few make specific surveillance recommendations Protocols (European Association of Urology, 2010; Sèze, 2007) 11
Lifestyle modification/ Containment Lifestyle modification Fluid intake (volume and type of fluids) Containment Pads Sheaths Indwelling catheter (suprapubic vs urethral) Patient choice/disability 12
Indwelling products: urinary catheters Indwelling catheters should be a last resort due to significant risks: Infection (6% of patients develop CAUTI) Trauma/urethral erosion Pain and bleeding Latex allergy Blockage and bypassing 13
Prevalence & Impact of Constipation/FI Constipation is common affecting <20% UK population at some point in their lifetime More prevalent among women Wide variation in symptoms Impacts on quality of life and associated with anxiety and depression 14
Bowel problems following stroke Constipation experienced by 30-60% following stroke FI affects 56% of individuals acutely after stroke, 11% at 3 months, and 22% at 12 months (Harari et al, 2004) Bowel problems linked with modifiable factors, e.g: Toilet access Lifestyle Diet Fluid intake Physical activity Simple/acute constipation Not eating Environmental issues Drugs 15
Assessment of constipation Symptom review Frequency Urge Consistency (BSFS) Mucus Blood Incomplete evacuation Straining Digitation (PR/PV) Laxative use 16
Assessment of faecal incontinence 33% of Hospitalised patients develop faecal incontinence Need to identify and treat Infective causes Faecal impaction with leakage of faecal liquid 17
Management of constipation Dietary manipulation Fluid manipulation Exercise Positioning Develop good habits/ routine Privacy Laxatives Stimulant Faecal softeners Bulking agents Biofeedback 18
Management of FI Dietary Anti diarrhoeal or constipating drugs Biofeedback therapy Rectal irrigation Surgical 19
Indwelling products: faecal management systems External faecal collectors cause further damage to skin when removed Indwelling devices can prevent deterioration and improve skin integrity in IAD (Padmanabhan et al, 2007) For use with critically ill/immobile patients only Can be used for up to 29 days Disadvantages: Risk of rectal bleeding Can cause trauma Contraindicated in some patients 20
Conclusions Bladder and bowel problems are common among people following stroke Symptoms are distressing, unpredictable and affect QoL Very limited evidence for most interventions Further research is needed 21
Further reading Chapter 18! NICE guidelines (August 2012) 22