19. Management of urinary incontinence in primary care
In this series featuring information for patients and professionals taken from SIGN’s evidence-based guidelines we reproduce the information for discussion with patients and carers from SIGN guideline number 79, on management of urinary incontinence in primary care.
Urinary incontinence is not an illness or a disease. It is a symptom that something is wrong with the ability of the bladder to store urine. Urinary incontinence can affect every aspect of life and must be taken very seriously. Those affected often report feeling anxious, ashamed, inadequate, embarrassed or dirty. It is essential that when people with urinary incontinence seek help, there is a pathway for them to receive immediate support, followed by the necessary steps to receive further consultations and investigations appropriate for their individual needs.
Depression, relationship and sexual difficulties, low self-esteem and lack of confidence affect many of the people living with continence issues. These problems need to be assessed and treated. Professionals must be able to provide patient-friendly information leaflets. Back-up information for patients must also be available to enable them to make contact with others experiencing similar problems, if they wish. In general it is very difficult for patients to ask for help, especially on their first visit to the GP. Many people who are living with continence issues will visit their GP with a different complaint and just happen to mention continence as if it were not really a huge problem for them. It is important that they are taken very seriously, treated with dignity and empathy and given positive feedback that their problem can, in a very high percentage of patients, be cured or at least managed more effectively enabling them to have a better quality of life.
The following points were drawn up by the guideline development group to reflect the issues likely to be of most concern to patients and carers following a diagnosis of urinary incontinence. These points are provided for use by health professionals when discussing urinary incontinence with patients and could form a basis for locally produced patient information materials.
Symptoms people with urinary incontinence experience include:
- Leaking urine on coughing, sneezing, exercise, rising from sitting and lifting
- Not reaching the toilet in time
- Frequent urination during the day/night
- Dribbling urine after leaving the toilet
- Loss of bladder control
- Bladder spasms
- Feeling of incomplete bladder emptying
- Pain on passing urine
- Burning sensation on passing urine.
Getting appropriate help
Contact GP, Continence Adviser/Nurse Specialist, Community Nurse or Specialist Continence Physiotherapist.
Self referral can normally be made to a Community Continence Adviser – contact your local health centre or NHS 24.
Other professionals you may be referred to:
- Urologist – a specialist in the field of bladder problems, prostate problems and male sexual organs
- Urogynaecologist – a specialist who works in the field of women’s bladder and reproductive organ problems
- Neurologist – a specialist who deals with the nervous system throughout the body
- Elderly care physician/geriatrician – a specialist in the field of medicine for older people.
What should I expect from a continence assessment?
On your first visit for a continence assessment you can expect to discuss your medical history and have a urine test. You may receive a pelvic floor examination at this assessment or during a subsequent consultation. Prior to a pelvic floor examination the procedure will be explained to you and consent sought. You will be asked if you wish a chaperone. Questions you can expect to be asked during your assessment may include:
- How often do you go to the toilet?
- How often do you leak or have accidents?
- When you have leaked how bad is it? Are your pants damp, wet through to your clothes or soaked to the floor?
- When do you leak or have accidents?
- What medicines do you take?
- What do you normally eat and drink?
- Is it painful or uncomfortable when you pass urine?
- How often do you get up at night to pass urine?
Frequently asked questions
Questions that you may like to ask during a continence assessment include:
- Why do I leak?
- Why do I have to go to the toilet so often?
- Why am I sometimes unaware that I need to go the toilet? Often I am wet when I get there.
- Why do I leak when coughing, sneezing, or doing exercise?
- On visiting the toilet I only pass small amounts of urine and feel as though my bladder is not completely empty. Why is this?
- I have pain when passing urine, why is this?
- Sometimes I have blood in my urine – what should I do?
- Why do I leak urine when I am having sexual intercourse?
Tests and investigations to diagnose causes of urinary incontinence
- Testing of a urine sample to rule out infection or other conditions (urinalysis)
- Voiding diaries (frequency and volume charts) to assess and diagnose some bladder problems. Using these involves filling in a diary-type form noting everything you drink, the amount of urine you pass and when you are wet, damp or soaking. Some diaries also record if the leakage is associated with coughing, sneezing or moving. This is done over a period of at least three days. An example of this type of chart is shown in Annex 2 of the guideline.
- Pelvic floor muscle examination – the pelvic floor muscles are checked by vaginal examination (women) or by examination of the back passage (men)
- Bladder scan – this is to find out if there is any urine left in your bladder after you have passed urine. It is a simple procedure where gel is put on to your abdomen and then your bladder is scanned
- Urodynamics – this test can help to find out the cause of bladder problems. It involves putting one catheter into the bladder through the urethra, (the tube that carries urine out of the bladder) and another into the back passage. This can be a little uncomfortable but can be a very useful test to find out what is going wrong with your bladder
- Cystoscopy – this procedure is normally carried out in a urology department by a physician. It can be done under local or general anaesthetic. An instrument similar to a catheter with a camera is inserted into the urethra going up into the bladder and allows the doctor to detect abnormalities.
Treatment – physiotherapy
There are many different forms of physiotherapy available to help with bladder problems. These include pelvic floor muscle exercises, biofeedback, electrical stimulation and use of vaginal cones.
Pelvic floor muscle exercises can help strengthen the muscles in the pelvic floor, giving more control over your bladder. They are very helpful for stress incontinence problems.
Your continence adviser and/or specialist continence physiotherapist can advise you how to do these properly. Leaflets and booklets to support ongoing therapy are available.
Biofeedback uses simple devices and techniques to enable the patient to improve pelvic muscle function through increasing muscle awareness.
Electrical stimulation therapy usually involves using a vaginal or rectal probe to assist in rehabilitation of pelvic floor muscles by strengthening them and increasing awareness of their use. Sometimes machines can be borrowed or purchased to allow treatment to continue at home. Electrical stimulation can be used where people have very weak pelvic floor muscles.
Vaginal cones are small cone-like devices that are inserted into the vagina to help strengthen the pelvic floor. Patients have their own individual set (usually two to three with different weights). After insertion you will be encouraged to keep them in place, using your pelvic floor muscles for an increasing period of time until you can hold on to them for 10 to 15 minutes. Cones are unsuitable for anyone with more than a moderate degree of prolapse and must be correctly positioned.
Bladder retraining programmes can help improve an overactive bladder by helping the bladder become more compliant to holding urine. Bladder retraining takes time and determination but can be very successful. Keep a diary or record of how often you pass urine for at least three days (use a chart). Gradually increase the time between visits to the toilet. For example, if you normally go to the toilet every hour, try to hold on a little bit longer e.g. 1 hour fifteen minutes.This slowly increases bladder compliance. As it becomes more used to holding more urine, the problems of an overactive bladder and urgency are reduced. Some people find retraining easy and can do it quickly. Others find it harder and it can take longer. Often it gets easier to overcome the urge to pass water. Never rush to the toilet mid-urge; relax in sitting or standing position and wait a minute until the urge disappears before walking calmly to the toilet or resuming one’s activities. It is important to drink enough but not excessive fluid for the bladder retraining to work (approximately 1.5-2 litres per day). Antimuscarinic drugs can be prescribed by a GP to help reduce the urge to go when you are doing bladder retraining.
It is important to drink sufficient fluid each day. Try to drink six to eight cups or glasses of fluid each day. It is best to avoid drinking too much caffeine, fizzy drinks or alcohol. Drink plain water, fruit juice or herbal tea and decaffeinated coffee, tea and drinks.
People who are overweight may find that adopting a healthy eating plan could help them lose weight and reduce their continence problem. Dietary advice may be available from your health professional or local health centre.
There are a variety of medications available for bladder conditions. Your GP, continence adviser or consultant will discuss which medication is appropriate for you.
Some medications which are being taken for other conditions can increase/precipitate incontinence episodes.
Emotional/mental health issues
At present helping patients cope with the emotional side of incontinence is largely managed by voluntary and charitable organisations (see Box 1 below).
|Box 1: Sources of further information for patients and carers|
Bladder Pain Syndrome Association (BPSA)
3 Bath Place, Rivington Street, London EC2A 3JR Tel: 0808 800 1234
Offers a free cancer information and support service staffed by qualified and experienced cancer nurses.
|Chartered Society of Physiotherapy
14 Bedford Row, London WC1R 4ED Tel: 020 7306 6666
307 Hatton Square, 16 Baldwins Gardens, London EC1N 7RJ Tel: 0845 345 0165 (helpline Mon-Fri, 9.30am-1pm)Tel: 020 7404 6875 (office)
Email: email@example.com Website:www.continence-foundation.org.uk
|Cystitis and Overactive Bladder Foundation
76 High Street, Stony, Stafford, Buckinghamshire MK11 1AH Tel: 01908 569169
Email: firstname.lastname@example.org Website:www.cobfoundation.org Provides information, leaflets and support to people with all forms of cystitis and overactive bladders.
|Adapted from SIGN 79. Management of urinary incontinence in primary care. Edinburgh: Scottish Intercollegiate Guidelines Network, 2004.|
Containment products can be obtained via prescription from your GP or a community nurse.
Catheters – a catheter is a hollow tube normally inserted into the bladder to drain urine.
- A urethral catheter is inserted into the bladder via the urethra and left in place with either a valve to allow drainage or connected to a drainage bag
- A suprapubic catheter is one that is inserted into the bladder just above the pubic bone
- An intermittent catheter is inserted into the bladder via the urethra and is generally used by the patient or a carer up to six times each day.
There are many different types of catheters available and patients should be encouraged to try different types to find out which is the most suitable.
Drainage bags – there are a variety of different types of drainage bags available for drainage of urine when using an indwelling catheter. They are attached to the end of the catheter tube and can be secured on to the leg, abdomen or, in some cases, a catheter bag holder.
Catheter valves – these are used to enable the catheter to be emptied directly into the toilet or suitable container eliminating the need for a drainage bag. There are a variety of valves available from your GP or community nurse.
Sheaths – a sheath fits over the penis and urine passes through a tube into a bag that is usually strapped to the leg or a urine bag holder. There are a variety of sheaths available and it is important that the correct size of sheath is used. Your health professional can advise on finding the most suitable product.
Pads – there are many types of pads on the market although most Health Boards limit the type that can be provided within their area. It is important to have the correct pad for your needs. These products are usually allocated free of charge.
Accessories – bag straps are available to secure the drainage bag to your leg. There are also sleeve type holders for the drainage bag that you put on your leg to keep the bag in place. These are available on prescription.
Overnight stands for catheter bags come in either plastic (excellent for using away from home) or metal and are useful in ensuring good overnight drainage. They are not available on prescription but can be ordered from a district nurse.
Washable bed and chair protection, including mattress covers, can be purchased. You can obtain information about products by contacting support organisations such as PromoCon or Incontact (see Box 1above).
Reproduced from SIGN 79. Management of urinary incontinence in primary care. Edinburgh: Scottish Intercollegiate Guidelines Network, 2004.