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Practice-based commissioning for continence problems

Judith Wardle
PhD
Director
Continence
Foundation

Practice-based commissioning is the concern not just of GPs but of the entire community-based team. The Health Reform states: "Practices will be discussing and shaping services with health professionals across primary and secondary care, social
services and parts of local government."(1)
One of the areas that is in danger of being neglected is the assessment and treatment of continence problems, because people are so reluctant to admit even to themselves that they have a continence problem, often because they are overwhelmed by their own embarrassment and the stigma attached to the condition. Nurses working in primary care are particularly well placed to be able to pick up hidden continence problems, give the practice evidence-based advice and refer to a continence specialist. Nursing experiences should influence practice-based commissioning, especially where there is unmet need. If nurses are to recognise continence problems, they should know what to expect in this area: the types of incontinence, the likely prevalence of the problems, and the extent to which many continence problems can be lessened or overcome by "conservative" treatments.

Definition
Continence problems may affect bladder or bowels. People may have continence problems that do not actually involve being incontinent of either urine or faeces, so it is important not to restrict thinking on this subject to the idea of incontinence. The major types of bladder problem are stress incontinence and overactive bladder (OAB) syndrome - some people have a mixture of both.

Stress incontinence
Stress incontinence occurs when a person leaks urine when "stress" (ie, pressure) is put on the pelvic floor muscles during activities, such as lifting, laughing or coughing. Its commonest cause in women is pregnancy. In many women the pregnancy itself, with the weight of the baby and amniotic fluid added to the natural process of muscles relaxing to accommodate the pregnancy, results in a weakening of the pelvic floor muscles. Some women's muscles fail to recover from this. Other women suffer a perineal tear during delivery, which weakens the area. Later in life, the pelvic floor may be weakened by the loss of oestrogen postmenopause. In men, stress incontinence most commonly occurs after an operation for removal of the prostate.(2)

Overactive bladder syndrome
OAB is complex. The most widely known symptom is urge incontinence: having to rush to the toilet as soon as the warning of the need to pass urine, but often leaking before getting there. In most cases, the cause is unknown and may happen at any age, but it can also occur as a result of neurological and spinal diseases and trauma to the brain or spine. However, there is also "urgency", which is the same need to rush to the toilet, but without actually leaking. The other parts of the syndrome are frequency (needing to pass urine more than the average five or six times a day, on a regular basis) and nocturia (needing to get up at night - once or twice a night is normal, especially in older people, but more than that is a problem).

Bedwetting
Bedwetting can occur in adults as well as children - some people have a lifelong problem. Research is ongoing to try to understand the causes, but it does run in some families and can be made worse by anxiety.(3) Sometimes incontinence is an overflow from retention and can be a serious problem. This can occur if there is obstruction in the urethra, particularly common in men with enlarged prostates, but also if the bladder itself has ceased to contract normally. Also, some children may be born with malformation of parts of the urinary system.

Bowel problems
Bowel problems may be congenital. Others can be caused by obstetric trauma - a major tear in the perineum or the anal sphincter - and, as with the bladder, by neurological or spinal cord injury and diseases. There are also diseases specific to the bowel, such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS) and Crohn's disease.

Prevalence
Reported prevalence of continence problems has undergone a rapid increase in the last six to seven years. However, this may well be because researchers today are better at asking questions about the problems. Asking specific questions such as "Do you have to rush to the toilet?" and "Do you sometimes leak when you cough?" is much more likely to receive an honest answer than "Are you incontinent?" The emphasis for all healthcare professionals should be "continence".
The prevalence of bladder problems in women is 16.8% for stress incontinence and 6.7% for urge incontinence. Milsom has identified that for every person with urge incontinence there are another two who have urgency without actual incontinence. That gives 21.2% with OAB, and a total of 37.9% of women with bladder problems.(4,5) There is less data on bladder problems in men, but a Medical Research Council study covering the whole of Leicestershire found 28.4% of men over 40 years with problems.(6) Figures on bowel problems are even less reliable, ranging from 1.4% in the general population to 15% in the over-85s.(7,8) The figure given for all continence problems in children is 8%.(9)
Not all people with continence problems admit they need help, but the more people have active lifestyles the more continence problems are likely to have an effect.(3) Nurses, and some physiotherapists, are best placed to offer first-line treatment, practical advice and support. Conservative treatments that are known to be effective include:

  • Pelvic floor muscle exercises - provided these are carried out correctly. Seventy percent of women can be cured or improved to their own satisfaction levels.(10)
  • Bladder training - gradually learning how to hold on longer between urination.
  • lAdvice on increasing fluid intake, but also avoiding drinks that may irritate the bladder, such as drinks containing caffeine, carbonated drinks and beer.
  • Losing weight.
  • Avoiding/managing smoker's cough.

What can primary care nurses do?
Sensitivity is required to approach the topic so that the appropriate action to address continence problems can be determined. Patient questionnaires are available that identify the types of incontinence. Advice on lifestyle changes and bladder training charts are available when trying to overcome OAB symptoms. When a patient has started on a course of pelvic floor exercises, nurses can help to motivate them to continue - many people give up too soon. In organisational terms, nurses should be able to refer patients directly to their local continence service instead of via the GP.

Continence and practice-based commissioning
From December 2006, commissioning guidance is available for treatment in primary care. Nurses should:

  • Inform the practice about the number of people who have continence issues and who need treating; many patients will not have told their doctor.
  • Identify people who should receive treatment, instead of having their condition managed by an incontinence pad. Pelvic floor muscle exercises and bladder training can be taught to many older people.
  • Identify whole groups of people who are at risk but may be overlooked: young mothers, people with learning disabilities, people with mental health problems, ethnic minorities.

It is important to work with continence nurse specialists and physiotherapists to ensure more treatment takes place in primary care. This concurs with the White Paper (January 2006), it costs less than a referral to secondary care, and treatment in the community (as outlined above) works for most people. Nurses should inform commissioners of the consequences where the continence service is being cut because of budget deficits. Nurses should also be aware of their PBC groups and be sure to attend or get views included in any decision-making. These views will be informed by a professional stance, but also by the advocacy role we hold for our patients. Seeking out and supporting continence awareness in routine consultations puts nursing in a highly influential position to determine where NHS resources should be best placed.

References

  1. DH. Health reform in England: update and commissioning framework. London: DH; 2006.
  2. 3rd International Consultation on Incontinence. Plymouth: Health Publications Ltd; 2005. p. 275-6, 284.
  3. 3rd International Consultation on Incontinence. Plymouth: Health Publications Ltd; 2005. p. 262.
  4. Hunskaar S, Lose G, Sykes D, Voss S. Prevalence of urinary incontinence in women in four european
    countries. BJU Int 2004;93:324-30.
  5. Milsom I, Abrams P, Cardozo L, et al. How widespread are the symptoms of overactive bladder and how are they managed? BJU Int 2001;87:760-6.
  6. Perry S, et al. An epidemiological study to establish the prevalence of urinary symptoms and felt need in the community. J Public Health Med 2000;22:427-34.
  7. Perry S, et al. Prevalence of faecal incontinence in adults aged 40 years or more living in the community. Gut 2002;50:480-4.
  8. Royal College of Physicians. Incontinence: causes,
    management and provision of services. London: RCP; 1997.
  9. Information from ERIC (Education  & Resources for Improving Childhood Continence), the national charity for children with continence problems.
  10. Toozs-Hobson P, Cardozo L. Urinary incontinence in women. London: Dorling Kindersley; 1999.


Resources

Continence Foundation
Materials available include:

  • Patient leaflets and factsheets
  • Books for patients and professionals
  • Tools for nurses(diagrams of the male/female pelvic organs and a diagnostic wheel for urinary incontinence)
  • Continence Review. A journal for all healthcare professionals, with general articles and abstracts from research journals
  • "Friends of the Foundation". Members give financial support and keep up with activities

Helpline: 020 7404 6875 Helpline staffed by
continence nurse
specialists: 0845 345 0165 (mornings only)
W: www.continence-
foundation.org.uk

Primary Care Contracting
W: www.pcc.nhs.uk