This site is intended for health professionals only

Urinary incontinence: facts for practice nurses

Jane Lucy
RGN NDNCert DiPHEd Nursing Studies (Lond) NP FEATC
Clinical Nurse Specialist
Continence Services
Eastbourne and County Healthcare NHS Trust

Urinary incontinence is defined as "loss of urine that is objectively demonstrable and a social or hygienic problem".(1) It is estimated that in an average Primary Care Group/Trust (PCG/T) practice of 102,700 population, 5,600 people will have urinary incontinence.(2)
Incontinence is a condition with many causes and ­associated factors. The effects of urinary incontinence can impact on many aspects of a person's life and have very serious implications on their health and general well­being.(3) Incontinence is associated with and impacts on other health areas. Smoking and high body mass index are implicated as risk factors in urinary stress ­incontinence.(4,5) Incontinence in the elderly is also ­associated with falls, particularly at night.(6)
Women are more vulnerable to developing ­­­incontinence, with strong associations with childbirth,(7) and some association with postmenopause hypo-oestrogenism and gynaecological surgery.(8,9) As men become older they begin to experience difficulties, often associated with prostate enlargement and/or malignancy and prostate surgery. Radical ­prostatectomy is ­particularly associated with urinary ­incontinence and impotence.(10) 
It has been shown that both sexes are reluctant to seek help for their problem, whether from embarrassment or fear. Incontinence is one of the last taboo subjects to be mentioned in polite society.(11) People with incontinence frequently adopt unhealthy strategies to help themselves cope with their problem. They may restrict their intake of fluids, which can lead to dehydration and constipation, or develop an overfrequent voiding pattern that reduces the functional bladder capacity. Both of these strategies will exacerbate the problem. They may avoid exercise and social activities, which is detrimental to their physical and mental health. Urinary leakage can occur during sexual intercourse so women may avoid this, which may put relationships at risk.(12)
It is estimated that 70-80% of "suitable cases" of incontinence can be improved or cured in the primary healthcare setting.(13) Regrettably the majority of ­continence care in the community is reactive and relies on the provision of incontinence pads and other ­expensive forms of management. This may be because the person with incontinence does not always receive an assessment of their problem to elicit the cause and identify possible treatment options.(14) This is the basic standard for continence care as stated in the Department of Health Good Practice Guidelines.(15) The main responsibility for providing continence care is within the PCG/Ts. Multiprofessional collaboration is ideally placed in developing an integrated continence care strategy.(16) The guidance also requires the PCG/Ts not only to assess and provide firstline treatment, but also to identify those in their area who have ­incontinence or who are at risk of developing it.(15)
Urinary incontinence is normally classified into types to simplify treatment protocols, although the complexity of the subject means that there are often other ­influencing factors. Urinary tract infection, constipation and the action of some medications can cause bladder dysfunction. Environmental factors and functional disability such as immobility will affect the individual's ability to cope with bladder function.(17) Table 1 shows the main types of incontinence likely to be encountered by the practice nurse.

[[NIP01_table1_61]]

Health promotion with the aim of achieving positive health gain for the local population is a key element underpinning the practice nurse role. Practice nurses are in a unique position to identify and advise people who may be vulnerable to developing or who already have an incontinence problem. Clinical situations such as family planning, cervical cytology, clinics for asthma, diabetes, leg ulcers, hypertension, well-people's clinics and so on all provide an opportunity to sensitively enquire whether there are any problems with bladder control. It not ­advisable to use the word incontinence as this is very often associated with complete lack of control and sometimes has very negative connotations.
Practice nurses' work very often means a rapid throughput of patients in order to meet ever-increasing demands. It may not be practical for the practice nurse to carry out the indepth assessment that is required, and the patient will need to be directed to a member of the team who can undertake this procedure. However, there are certain interventions that are comparatively simple but may prevent incontinence occurring, or that can lead to an improvement in the symptoms. Table 2 shows several interventions that can be undertaken by the practice nurse with the appropriate training.

[[NIP01_table2_63]]

The primary care team is where the continence care needs of the population can be identified and, in the majority of cases, be met through the use of the diverse skills within the team. Continence care is now receiving government recognition. Following the Department of Health Guidelines, the "Essence for Care" resource pack for benchmarking has been recently launched.(18) In addition, Incontact is undertaking a public consultation to find out the views of people with continence problems, the first step on the road to producing a "Manifesto for Continence", which will be launched later this year.(19)
These are challenging times for nurses in primary care. An efficient and effective high-quality continence service must be a priority within each PCT. The practice nurse can have a very significant role in this area of care. Continence care is a fascinating healthcare specialty that offers considerable ­opportunities for further learning, professional development and job satisfaction.

[[NIP01_pp_63]]

References

  1. Anderson JT, Abrahams P, Blaivas JG, Stanton SL. ICS: The ­standardisation of terminology of lower urinary tract function. Scand J Urol Nephrol 1998;114 (Suppl.):5-19.
  2. The Continence Foundation. Incontinence - a challenge and an ­opportunity for Primary Care. London: The Continence Foundation; 2000.
  3. Moore K, Fader M. Promoting ­continence in the community. Br J Community Nurs 1999;4(1):36-43.
  4. Bump R, McClish DK. Cigarette smoking and urinary incontinence in women. Am J Obstet Gynecol 1992;167:1213-8.
  5. Burgio KL, Matthews KA, Engel B. Prevalence, incidence and correlates of urinary incontinence in healthy, middle-aged women. J Urol 1991;146:1255-9.
  6. Brown J. Urinary Incontinence: does it increase risk for falls and fractures? J Am Geriatr Soc 2000;48(7):721-5.
  7. Allen RE, Hosker GL, Smith AR, Warrell DW. Pelvic floor damage and childbirth: a neurophysical study. Br J Obstet Gynaecol 1990;97:770-9.
  8. Fantl JA, Cardozo L, McClish D.  Oestrogen therapy in the management of urinary incontinence: meta-analysis. Obstet Gynecol 1994;83(11):12-18.
  9. Parys BT, Haylen BT, Hutton JL, Parsons KF. The effects of simple hysterectomy on vesico-urethral ­function. Br J Urol 1989;64:594-9.
  10. Maxfield J, Dennison K, Forristal H. Prostatic problems. In: Laker C, editor. Urological nursing. London: Scutari Press; 1994.
  11. Haslam J. Managing stress ­incontinence. J Comm Nurs 1997;11(2):16-20.
  12. Ashworth PD, Hagan MT. The meaning of incontinence: a qualitative study of non-geriatric sufferers. J Adv Nurs 1993;18(9):1415-23.
  13. Royal College of Physicians. Incontinence:?causes, management and provision of services. London:?Royal College of Physicians; 1995.
  14. Audit Commission. First assessment: a review of district nursing services in England and Wales. London: Audit Commission; 1999.
  15. Department of Health. Good ­practice in continence services. London: Department of Health; 2000.
  16. The Continence Foundation. Making the case for investment in an ­integrated continence service. London: The Continence Foundation; 2000.
  17. Colley W. Charting new waters. Nurs Times 1996; 92:56-68.
  18. Department of Health. Essence of care - patient-focussed benchmarking for health care practitioners. London: Department of Health; 2001.
  19. Incontact. Manifesto for ­continence. Incontact Magazine London: Incontact; Spring 2001.
  20. Laycock J. Pelvic floor re-education for the promotion of continence. In: Schlusser B, Laycock J, Norton P, Stanton S, editors. Clinical nursing ­practice: the promotion and management of continence. Herts: Prentice Hall International Ltd; 1994.
  21. Bump R, Hurt WG , Fantl JA, Wyman JF. Assessment of Kagel pelvic muscle exercise after brief verbal instruction. Am J Obstet Gynecol 1991;165(2):322-9.
  22. Moore KN, Dorey GF. Conservative treatment of urinary incontinence in men: a review of the literature. Physiotherapy 1999;85:77-87.
  23. Hill S. Urinary symptoms: how to make a differential diagnosis in the primary care setting. In: Piercy V, editor. Nursing Dialogue No 29. Kettering: Barrie Raven Associates; 1998.
  24. NPF. Drugs for urinary frequency, enuresis and incontinence. In: Nurse Prescribers Formulary (1999-2001) London: BMJ Books; 2001.
  25. Addison R. A guide to bladder ultrasound. Nurs Times 2000;96(40):14-15.

Resources
The Continence Foundation
307 Hatton Square 16 Balwin Gardens
London EC1 7RJ
T:020 7404 6875
W:www.continence-foundation.org.uk
Association for Continence Advice
102a Astra House Arklow Road New Cross,
London SE14 6EB
T:020 8692 4680
W:www.aca.uk.com
Incontact
United House
North Road London N7 9DP
T:020 7700 7035
W:www.incontact.org

Further reading
Getcliffe K,Dolman M.
Promoting continence - a ­clinical research resource.
London:Balliére Tindall; 1997.
Button D,Roe B,Webb C,Colin-Thorne D,Gardner L.
Continence-promotion and management.
London:Whurr Publishers Ltd; 1998