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Managing incontinence in primary care

Deborah Rigby
MSc RGN FEATC
Continence Advisor
St Martin's Hospital
Bath

It is estimated that one in six people over 40 are incontinent "several times a month", and that most will not seek help.(1) One in three women and one in 10 men in the UK at some time during their lives have a continence problem.(2) Incontinence has long been considered a taboo subject and is known to cause distress, embarrassment and reduction in self-esteem. Containment is no longer the first-line treatment - patients should be given access to an assessment, with a management plan addressing the cause. It is said that 80% of incontinence is treatable,(3) and there is a range of treatments that can help.

The cost of incontinence
The Continence Foundation estimates the NHS expenditure on absorbent products to be in excess of £120m annually.(4) The RCN estimates that the cost of incontinence could rise to at least £2b by the year 2020 without adjustment for inflation.(5) This is also without taking into account appropriate use of hospital beds, impaired quality of life, an ageing population and the hidden cost of informal care. The containment of incontinence can improve home care, and there are a number of products available. Giving advice on the right product not only improves care but can offer financial savings.
Constipation accounts for three million GP consultations each year; it is suggested that 10% of the UK population take laxatives regularly.(6) The cost to the NHS has been estimated at £47m, but this accounts only for the 11 million prescriptions written in 1998 by GPs.(7)

Evidence-based care
Continence promotion and management has been well researched and provides a sound rationale for evidence-based practice;(8) however, much of this research is not known about or used in clinical practice. Current practice is based on an assessment-led service using agreed care pathways to aid the assessment process. Care pathways can provide a framework for good practice, and depending on the outcome of the initial assessment, further management options can then be decided. Current continence assessment may be done in primary or secondary care with a multidisciplinary approach.
The following initial assessment guidance is offered to primary care practitioners:

  • Test urine; if positive to nitrates send MSU (midstream specimen of urine); if urinary tract infection, repeat after treatment.
  • Review current medication and recent changes that may influence continence.
  • Ask the patient to keep a diary of voiding frequency and fluid intake.
  • Discuss fluid type and suggest avoidance of caffeine drinks.
  • Discuss bowel habits; exclude constipation (see Figure 1).
  • If the patient has mobility, dexterity or environmental problems, record the action taken.
  • Record the current method of containment of incontinence (if there is one).

[[NIP02_fig1_79]]

Ask patients to complete the symptom profile (Table 1) and commence the appropriate management option (Table 2).

[[NIP02_table1_80]]

[[NIP02_table2_80]]

The future
Incontinence needs to be discussed in general practice because the treatment options can be relatively simple and cost-effective. Care pathways and integrated working offer an opportunity for collaborative working.
There are significant ongoing training needs in primary, secondary and tertiary care in order to deliver appropriate continence advice and treatment. Distance learning packages offer an alternative form of update on care and management and need to be further developed in this field.
In promoting continence we can reduce incontinence and thereby improve quality of life for patients, their families and their carers.

References

  1. Perry S, et al. An epidemiological study to establish the prevalence of urinary symptoms and felt need in the community: the Leicester MRC Incontinence Study. J Public Health Med 2000;22(3):427-34.
  2. Brocklehurst J. Urinary incontinence in the community - analysis of a Mori poll. BMJ 1993;396:832-4.
  3. O'Brien J, et al. Urinary incontinence: prevalence, need for treatment and effectiveness of intervention by nurses. BMJ 1991;303:1380-412.
  4. Pollock D. Towards a service of the highest quality.London: The Continence Foundation; 1998.
  5. Roy S. The cost of incontinence. London: Royal College of Nursing; 1997.
  6. Moayyeddi P. The patient with constipation. Nursing Update 1998; 24 June:1302-6.
  7. Petticrew M. Treatment of constipation in older people. Nursing Times 1997;93(48):55-6.
  8. Agency for Health Care Policy and Research. Urinary incontinence in adults: acute and chronic management. Maryland: US Department of Health and Human Services; 1996.
  9. Bayliss V, et al. Br J Nurs 2000;9:590-6.

Resources
Association for Continence Advice
W:www.aca.uk.com

The Continence Foundation
307 Hatton Square
16 Baldwin Gardens
London EC1N 7RL
T:020 7404 6875
E:continence.foundation@dial.pipex.com

ERIC
34 Old School House
Brittania Road
Kingswood
Bristol BS15 2DB
T:0117 960 3060
E:enuresis@compuserve.com

Further reading
Department of Health. Good practice in continence services. London: Department of Health; 2000.

Department of Health. Essence of care. London: Department of Health; 2001.

Roe B, Wilson K, Doll H, Brooks P. An evaluation of health interventions by primary health care teams and continence advisory services on patient outcomes related to incontinence. Oxford: Health Service Research Unit; 1996.

Royal College of Physicians. Incontinence causes, management, and provision of services. London: Royal College of Physicians; 1995.