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Assessment is the key to incontinence treatment

Jane Mules
RGN
Continence Helpline Nurse Manager
The Continence Foundation
London
E:janemules@hotmail.com

Urinary incontinence is a common problem, affecting around six million people in the UK.(1) The Department of Health's recently published guidelines on incontinence recommend that identifying those with incontinence, offering appropriate assessment and delivering firstline treatment should take place in a primary care setting.(2) The guidelines also recommend that even simple treatments should not be carried out without an initial assessment. 
The GP's surgery is often the first place where those with incontinence go for help, and the practice nurse is ideally placed to spread the positive message that much can be done to treat this condition. A thorough assessment is the key to successful management of incontinence, and this takes time and a relaxed environment.

Types of incontinence
The common causes of incontinence are listed in Table 1. Other causes of bladder problems include nocturnal enuresis (bed wetting), nocturia (getting up at least twice overnight) and fistulas. Fistulas lead to symptoms of continuous leakage and may be related to previous surgery or tumours. This type of incontinence needs to be reviewed by a medical specialist.

[[NIP05_table1_48]]

Assessment of incontinence
Accurate assessment is vital for a successful outcome,(3) as it is not possible to resolve the problem until the cause is known. A basic assessment can be carried out by any registered nurse. It needs to be multifaceted and should include a urological history, a medical history, a physical examination and tests. Table 2 gives details of the areas to cover during assessment. A checklist is useful to ensure that all areas are covered.

[[NIP05_table2_50]]

The idea of assessment is to build up a picture of the symptoms, possible causes and the patient's feelings and attitudes towards the problem, which are crucial to the development of a patient-focused treatment plan. Urological history gives the signs and symptoms of the incontinence, while past medical history gives clues as to the underlying causes and any exacerbating factors. Physical examination can provide an idea of the patient's general health and reveal associated factors such as vaginitis and skin soreness due to leaking. Vaginal and/or rectal examination may be appropriate depending on the patient's symptoms and the practitioner's expertise. There is no point, for example, in doing a vaginal examination to assess pelvic floor muscle strength without training. 
Urinalysis is the most important test. It is simple and inexpensive but can provide a wealth of information. A frequency and volume chart provides useful information about bladder capacity, frequency and the number of incontinence episodes.
During an assessment there are a number of things to look out for. These include worrying symptoms and transient incontinence, the first area that should be investigated (see Table 3 for causes). Transient incontinence is usually of recent onset and has a readily identifiable cause. For example, someone with a urinary tract infection may describe recent onset of leakage associated with burning and pain and possibly irritative symptoms. Urinalysis will show leukocytes and nitrites. Treatment of the infection will often resolve the problem (although some incontinence has more than one cause, hence the need for thorough assessment). Identifying and treating transient and reversible causes is an important first step as treatments are usually straightforward. Referral may then be necessary for treatment of the underlying problem.

[[NIP05_table3_50]]
 
Worrying symptoms, such as pelvic pain, haematuria, recurrent urinary tract infection and a change in bowel habit lasting more than a couple of weeks, may be due to an underlying and undiagnosed medical condition, and needs to be referred. Third-degree prolapses and fistulas also need to be immediately referred, as conservative treatment will not be effective. Those who do not wish to try conservative treatments should be referred, as they will not be motivated to succeed with self-help strategies. 
For those with ongoing incontinence who are motivated to help themselves there are a variety of treatment options, including toileting programmes, pelvic floor exercises and diet and fluid changes. With the right treatment options the message is positive - most incontinence can be cured.

[[NIP05_pp_50]]

References

  1. SIFO Research and Consulting AB. Data Available from Pharmacia and Upjohn; 1998.
  2. Department of Health. Good Practices in Continence Services. London: Department of Health; 2000.
  3. Norton C. Nursing for Continence. Buckinghamshire: Beaconsfield Publishers; 1996.

Resources
The Continence Foundation
307 Hatton Square
London EC1N 7RJ
Provides literature and advice on any bladder or bowel problem
Helpline:0845 345 0165
W:www.continence-foundation.org.uk.
Incontact
United House North Road
London N7 9DP
Support group for those with incontinence
W:www.incontact.org
Promocon
Redbank house
4 St Chad's Street
Cheetham Manchester M8 8QA
Gives information on products
W:www.disabledliving. co.uk/promo1.html
ERIC (Enuresis Resource and Information Centre)
34 Old School House
Britannia Road
Kingswood
Bristol BS15 2DB
Helpline provides advice on bed wetting and soiling in children
T:0117 960 3060
W:www.eric.org.uk