Incontinence
Patient Care and Treatment

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this continuing education course, you will have increased your understanding of incontinence assessment and treatment. Specific learning objectives to address potential knowledge gaps include:

• Discuss the impact of incontinence on individuals.
• Identify the different types of incontinence.
• Describe the process of conducting a urinary incontinence assessment.
• Summarize treatment options for urinary incontinence.
• Discuss assessment, diagnosis, and interventions for bowel incontinence.

INTRODUCTION

Incontinence can be a silent and debilitating condition. It can affect individuals in all age groups and walks of life. The classic picture may be of elderly patients in nursing facilities struggling with frequent episodes of bowel and bladder incontinence and wearing diapers. However, this does not tell the full story. Many individuals who are pursuing careers, participating in family activities, and involved in their communities struggle with incontinence on a daily basis. It is estimated that incontinence affects about 33 million people in the United States (NAFC, 2019b).

The definition of urinary incontinence is the inability to control the time and place of voiding, resulting in the involuntary loss of urine. Approximately 43% of people living in the community and close to 70% of those residing in nursing care facilities experience some form of urinary incontinence (WOCN, 2016).

The definition of bowel incontinence, also known as fecal incontinence or accidental bowel leakage, is loss of normal control of the bowel. Bowel incontinence is associated with diminished awareness of rectal fullness and diminished ability to control the urge to defecate or pass gas until an appropriate time and place is available.

Data show that between 0.5% and 1% of individuals in the community under the age of 65 experience bowel incontinence, while 3% to 8% of those over the age of 65 are affected. The frequency of bowel incontinence in nursing homes is estimated to affect 47% to 50% of residents. However, it is believed that the data available on the prevalence of bowel incontinence do not capture the extent of the problem due to underreporting (WOCN, 2016).

The complications associated with urinary and bowel incontinence can seriously impact the physical and emotional well-being of those affected with either or both of these conditions. In a survey of community-dwelling individuals with urinary incontinence, 80% stated they have to deal with incontinence on a daily basis or three to five times per week, and 90% of individuals in the survey expressed feelings of loneliness, isolation, hopelessness, and depression (NAFC, 2019b).

Results from quality of life surveys show that bowel incontinence has a negative impact on nearly every part of an individual’s life, including friendships, marriage, sexuality, employment prospects, and the capacity to take part in exercise. Bowel incontinence has been found to be a consistent factor in elderly placement in care facilities. Bowel incontinence is also a leading cause of falls in the elderly population (WOCN, 2016). In another survey, respondents ranked bowel incontinence and urinary incontinence as the 4th and 8th most stigmatizing health conditions respectively out of a list of 30 choices (Simon Foundation, 2019b).

Patients’ bladder and bowel health, particularly incontinence, are often neglected by healthcare professionals. Studies indicate that for female patients it takes approximately six years from the onset of the symptoms of incontinence until they are diagnosed (NAFC, 2018c). Unless the clinician asks about bowel and bladder health, especially problems with incontinence, the patient is often too embarrassed to bring it up. Older patients who are otherwise healthy may also consider incontinence an expected outcome of aging.

TYPES OF URINARY INCONTINENCE

In simplest terms, urinary continence means to stay dry and that there is no leakage of urine regardless of the activity the person is engaged in. Continence means that even with a full bladder and a “need” to go, the person can take the necessary steps to void without rushing and without urine leakage.

The normal pattern for urination is 6 to 8 times per 24 hours. Those under the age of 65 years can expect to void perhaps once during the night. For those over 65 years, the pattern is one to two voids during the night. When the bladder starts filling, the first signal to void usually occurs when there is 150–200 cc of urine present; at this stage the detrusor muscle of the bladder begins to stretch. It is possible to ignore this first signal to void if the time and place are not convenient. When the bladder capacity reaches 400–600 cc of urine, it is time to void (Haag, 2019).

It is important for clinicians to remember that urinary incontinence is not a disease itself; it is a symptom of some other malfunctioning in the human body. Early diagnosis is essential to determine whether there is an underlying serious medical condition causing urinary incontinence. Some of those conditions include multiple sclerosis (MS), Parkinson’s disease, and tumor. Approximately 80% of individuals with MS develop some form of urinary incontinence (WOCN, 2016).

Urinary incontinence can be divided into several different types, with different underlying factors associated with each type.

Acute or Transient Urinary Incontinence

Acute or transient urinary incontinence occurs in individuals with no previous history of urinary incontinence. It usually comes on suddenly and lasts less than six months (WOCN, 2016). This type of urinary incontinence is caused by reversible factors such as:

• Urinary tract infection
• Medications
• Stool impaction
• Atrophic urethritis and vaginitis
  (WOCN, 2016)

URINARY TRACT INFECTION (UTI)

Urinary tract infections are a major cause of transient incontinence. They can occur in any age group and gender, but they are more common in females. Evidence shows that by the age of 35 years, 50% of women have experienced at least one UTI. Urinary tract infections can develop in the kidneys, bladder, or urethra, and the most common causative organism is E. coli (NAFC, 2019c). The offending organism causes inflammation of the bladder wall and urethra.

The symptoms of a UTI include:

• Urgency to void
• Increased frequency of urination
• Pain with urination
• Cloudy-colored urine, often with a malodor
• Fever
  (NAFC, 2019c)

A change in mental status, such as sudden confusion in elderly patients, along with a new onset of urinary incontinence is a primary symptom of a UTI (WOCN, 2016).

Diagnosis of a UTI can be made by a urine culture and is treated by antibiotic therapy. Patients are advised to stay well hydrated, and female patients are advised against using any female hygiene products that could irritate the urethra (NAFC, 2019c).

MEDICATIONS

Medications can frequently result in urinary incontinence. The medications most commonly associated with urinary incontinence are diuretics. Diuretics can be responsible for the rapid production of large amounts of urine, which can result in incontinent episodes, especially in patients with compromised mobility. This can be of particular concern for older adults.

Other categories of medications that can cause urinary incontinence include:

• Alpha-blockers used to treat high blood pressure can cause the muscles surrounding the bladder neck to relax, resulting in urine leakage.
• Antipsychotics, antihistamines, and tricyclic antidepressants can lead to urinary retention and overflow incontinence (involuntary leakage of a small amount of urine from an over-distended bladder).
• Calcium–channel blockers used for the treatment of high blood pressure can cause urinary retention and overflow incontinence.

Since each patient will have an individualized response to medications, it is important for clinicians to be aware of the patient’s medications and to discuss the possibility of urinary incontinence. If incontinence does occur, the healthcare provider may be able to make medication adjustments (Simon Foundation, 2019d).

STOOL IMPACTION

Constipation can result in urinary incontinence. The bladder and rectum are in close proximity in the restricted space in the bony pelvis, and fecal impaction causes the bowel to become distended, leading to obstruction of the bladder neck. Obstruction of the bladder neck can make it difficult for the patient to urinate, causing a build-up of urine in the bladder that results in overflow incontinence. There is also a possibility that straining during bowel movements, which is common with chronic constipation, may result in weakening of the pelvic floor muscles. Clinicians should always inquire about bowel health in conjunction with bladder health, especially when there is an issue with urinary incontinence (WOCN, 2016).

ATROPHIC URETHRITIS

In women, urinary continence is in part dependent on coaptation of the walls of the urethra (when the urethral walls collapse together). The urethra in females is about 4 cm in length and made up of four layers, which supports urethral closure or coaptation. Diminished estrogen supplies, especially in older females, leads to dryness and thinning of the urethral tissue (atrophic urethritis), lessening coaptation and causing urinary leakage. Treatment with estrogen vaginal suppositories or creams can help to counteract this problem (WOCN, 2016).

Urge Urinary Incontinence

Urge urinary incontinence is the most frequently occurring type of urinary incontinence and the result of an overactive detrusor muscle (a smooth muscle that forms part of the bladder wall). When the detrusor muscle contracts, the bladder empties.

Urge incontinence is caused by an abnormal sensitivity and contractibility of the bladder wall, but the exact mechanism is not known. Possible causes include changes in the levels of neurotransmitters, with heightened stimulation of sensory fibers indicating early bladder fullness. In adults over 65, the bladder is more susceptible to untimely contractions. The amount of urine lost can vary from small to considerable (Haag, 2019; WOCN, 2016).

The most significant finding in urge incontinence is an overpowering urge to void together with the involuntary loss of urine. Urge incontinence is sometimes referred to as the “key-in-lock” syndrome, in which the bladder may begin to contract when the individual knows they will soon be able to reach the toilet and they will be overcome by a sudden urge to void (Haag, 2019). Triggers for urge incontinence also include the sound of running water or making a position change (WOCN, 2016).

Other symptoms of urge incontinence are needing to void frequently and voiding during the night (nocturia). Nighttime voiding is particularly problematic for older adults, causing disruption in sleep and increasing the risk for falls.

Urge urinary incontinence can be found in women of any age group but is more common in older women. Statistically, about 9% of women under the age of 45 have problems with urge incontinence, while in women over the age of 75, the rate increases to 31% (Stoppler, 2017). Urge incontinence is the most common type of urinary incontinence in the male population, with 40% to 80% of men with incontinence estimated to have urge incontinence (Simon Foundation, 2019c).

Stress Urinary Incontinence

With stress urinary incontinence, the patient typically complains of involuntary urine leakage with exertion (e.g., sneezing, coughing, laughing, running, or lifting). This type of incontinence is also known as activity-associated incontinence.

Stress incontinence is primarily caused by the inability of the sphincter muscle to sustain closure when the patient is performing activities that increase abdominal and bladder pressure, referred to as sphincter insufficiency. This, in turn, leads to a partially open urethra, which allows urine to escape (WOCN, 2016; Shah, 2019).

Weak pelvic floor muscles are a secondary contributor to stress urinary incontinence. In particular, the levator ani muscle (which lends support to the bladder from below) in females is susceptible to damage during childbirth, with around 5% to 10% of females with a first-time vaginal delivery found to have some degree of laceration of this muscle. The greatest risk of levator ani damage is among those who undergo forceps-assisted deliveries (Schuiling & Likis, 2017).

Stress urinary incontinence can have a debilitating impact on women’s lives and activities. Women with stress urinary incontinence are acutely aware that their control over urination has been greatly diminished, and a simple act such as walking across a room could result in urine leakage.

Stress urinary incontinence is less common in males, affecting less than10% of men with urinary incontinence. Men most often experience stress urinary incontinence after surgery for prostate cancer or for an enlarged prostate.

Mixed Urinary Incontinence

Patients with mixed urinary incontinence have symptoms of both stress incontinence and urge incontinence. It combines bladder muscle dysfunction resulting in bladder over-activity with sphincter dysfunction resulting in urine leakage associated with urgency (WOCN, 2016). Usually, the symptoms of one type of incontinence (stress or urge) are more severe than the other.

Mixed urinary incontinence is a common problem, and the majority of women with incontinence have mixed incontinence. It is usually more prevalent among older women. Mixed urinary incontinence is also found in men who have had their prostate gland removed or undergone surgery for an enlarged prostate. As with women, mixed urinary incontinence occurs in older men (Underwood, 2017).

Functional Incontinence

In most instances of functional incontinence, the bladder, urethra, and sphincter mechanism is functioning correctly, and the incontinence results from problems outside the urinary tract. These external problems impede the person’s ability to respond appropriately to the need to void. The most frequent types of impairments resulting in functional incontinence are:

• Impaired mobility
• Impaired cognitive function
  (WOCN, 2016)

Impaired mobility can pose several difficulties for individuals, including an inability to reach the restroom in time to void and a hampered ability to prepare for voiding. In some cases, the person may be dependent on others for assistance with toileting, and if assistance is not readily available, incontinence may occur.

Impaired cognition can have several causes, such as advanced dementia. In cases of cognitive impairment, the person does not recognize the urge to void or is unable to recall the stages of voiding (WOCN, 2016).

Medications can also lead to functional incontinence, for example, a person with some degree of impaired mobility who also takes a diuretic medication to treat hypertension or congestive heart failure. The diuretic medication will increase the volume of urine, and the urgency to void along with the extra time needed to reach the restroom may result in episodes of incontinence (Underwood, 2017).

Neurogenic Bladder

Neurogenic bladder is caused by a lack of neuron regulation of the lower urinary tract mechanism. The most common finding in neurogenic bladder is a lesion located between the sacral cord and the brain. These lesions occur most frequently in persons with spinal cord injury and conditions such as multiple sclerosis (WOCN, 2016).

Patients with neurogenic bladder have no sensory awareness of bladder filling. They are unable to instigate voiding and have lost control over the urinary sphincter. This inability to maintain continence is due to a loss of communication between the cerebral cortex, the brain stem, the bladder, and the sphincter muscle. Since the patient has lost voluntary control over voiding, bladder emptying happens due to reflex arc responding to bladder filling.

Patients with neurogenic bladder are at risk for developing a severe problem called detrusor sphincter dysynergia, which is characterized by failure of the sphincter to relax in response to contraction of the detrusor muscle (WOCN, 2016).

Peyronie’s Disease

The name of this condition is somewhat misleading, since it is not an actual disease but a condition that results from injury or damage to the penile tissue. The consequence of this injury is the development of an irregular twist or curvature of the penis (NAFC, 2018b). Peyronie’s disease is caused by a problem with wound healing, leading to an accumulation of collagen tissue on the shaft of the penis. This can occur after a single traumatic event or due to frequent minute injuries during sexual intercourse. Other causes include:

• Vigorous sport activities
• Autoimmune conditions, such as scleroderma
• Diabetes
• Heredity
  (NIDDK, 2020)

Scar tissue builds up on the surface of the penis and leads to a change in the shape of the penis over a period of time. The condition usually stabilizes after a period of 3–12 months (Mayo Clinic, 2020b). This gradual change distinguishes Peyonie’s disease from a hereditary curvature of the penis, which remains constant.

Apart from urinary incontinence, the other symptoms of Peryonie’s disease include:

• Firm lumps on the shaft of the penis
• Shortening of the penis
• Erectile dysfunction
• Pain with or without an erection
  (NAFC, 2018b)

Peyronie’s disease has been estimated to affect about 1 in every 100 men in this country but based on investigation of those who describe having symptoms of Peyronie’s disease, a more accurate prevalence has been predicted as 1 in 10 men. It can occur in men of all ages, but it is not a common condition in men in their 20s and 30s, with the rates increasing with age (NIDDK, 2020).

Incontinence in Children

Urine leakage is the most frequently occurring urine symptom in children and teenagers. Problems with urinary incontinence can result in emotional and mental health issues that may be revealed as behavioral disorders in children. Teenagers who had problems with urinary incontinence during their childhood can develop pervasive concerns about continence and bladder control (Shah, 2019).

Children usually become continent between the ages of 2–4 years, although it is highly individualized. Research has demonstrated an incidence of urinary incontinence in children who are 7-1/2 years old as 7.8%, with the possible consideration that urinary incontinence could have a genetic link.

Urinary incontinence or enuresis has two types. Primary enuresis in children occurs when the child never gains continence. Secondary enuresis refers to the onset of urinary incontinence in children who have achieved continence for at least 6 months. For most children, problems with bladder control resolves as they get older. Parents and caregivers, although frustrated with the problem, can be educated that incontinence in children is not due to laziness, heedlessness on the part of the child, or problems with toilet training. The majority of children who experience incontinence are emotionally and physically normal (NIDDK, 2017).

Conditions that can lead to incontinence in children include:

• Urinary tract infection
• Vesicouretal reflux (VUR) retrograde flow of urine from the bladder to the kidneys
• Constipation
• Diabetes
• Structural malformation of the urinary tract, such as narrowing of the urethra
• Arousal disorder (unable to respond to physical signals that urination is needed)
• Sexual abuse

Depending on the symptoms and severity of the problem, a child may be referred to a pediatric urologist. Treatment options include:

• Bedwetting alarm
• Nighttime waking and toileting by parents
• Bladder therapy
• Psychotherapy
• Medications such as desmopressin (DDAVP, Nocdurna)
  (WOCN, 2016; NAFC, 2018a)

Incontinence in Adults During Sleep

Bedwetting is an atypical condition related to urinary continence, and it occurs in both children and adults. Adult bedwetting, also known as sleep enuresis, can happen for many reasons, including depression and anxiety. Approximately 1% to 2% of adults have problems with bedwetting. There are several factors that can be related to sleep enuresis, including:

• Heredity. There is a strong possibility of a genetic component in the development of sleep enuresis. An individual is at greater risk if one or both parents experienced bedwetting as children.
• Imbalance in the production of antidiuretic hormone (ADH). This hormone, released by the pituitary gland, decreases the amount of urine produced in the kidneys. Usually there is an increase in ADH production at night to maintain continence. If there is a decrease in the amount of ADH produced or the kidneys do not respond appropriately to the hormone, there is an increased production of urine that can result in sleep enuresis.
• Small bladder capacity. Individuals with decreased bladder capacity (which can be caused by bladder obstruction, pressure on the bladder caused by an enlarged prostate gland in males, and inflammation) are at greater risk for sleep enuresis. This is not due to a decrease in the actual size of the bladder but to a decrease in the functional capacity of the bladder.
• Overactive detrusor muscle. Studies have found that overactive detrusor muscle occurs in 70% to 80% of people with sleep enuresis (NAFC, 2019a).
• Urinary tract infection. UTI can increase the risk of bedwetting in some individuals.
• Medications. The side effects from certain medications can increase the risk of sleep enuresis. These medications include sleep medications, hypnotics, and medications used to treat psychiatric conditions, such as thioridazine and clozapine.
• Underlying health conditions. Examples include pelvic organ prolapse in females, prostate enlargement in males due to either benign or malignant causes, bladder cancer, diabetes, and sleep apnea.

Treatment for adult bedwetting focuses on determining the underlying cause and requires a thorough assessment of the patient by the clinician. Behavioral interventions can include decreasing fluid intake in the evenings, using bedwetting alarms, and using absorbent products (NAFC, 2019a).

ASSESSMENT OF THE PATIENT WITH URINARY INCONTINENCE

Problems with urinary incontinence can be acutely embarrassing for individuals. Therefore, the clinician must adopt a holistic approach to the assessment of a patient with urinary incontinence and be cognizant of its impact on all aspects of the patient’s life.

Initial Assessment

During the initial assessment, patients are asked about:

• Onset and duration of symptoms
• Precipitating factors
• Approximate number of incontinent episodes in a 24-hour period
• Amount of urine leakage
• Fluid intake, including types of fluids, and time of day when most fluids are consumed
• Any self-imposed fluid restrictions due to incontinence
• Episodes of bowel incontinence, including onset and duration, precipitating factors, and frequency

Obtaining a complete medication profile is vital, not only of prescription medications, but also over-the-counter medications, including herbal and vitamin supplements.

The clinician obtains a full and detailed health history, beginning with existing conditions that may lead to incontinence.

One of the goals of the initial patient assessment is to determine whether urinary incontinence may be related to an underlying condition that requires further evaluation and treatment. In such instances, the patient is referred to specialty practitioners. Symptoms that indicate the need for further evaluation include:

• History of frequent or persistent urinary tract infections
• Gross or microscopic hematuria
• Uterine prolapse
• Signs of neurological conditions
• Presence of a mass in the bladder or urethral or pelvic areas
  (Abrams et al., 2017)

Major Systems Assessment

RESPIRATORY ASSESSMENT

Acute or chronic coughing causes an increase in intra-abdominal pressure that may result in stress urinary incontinence or exacerbate the symptoms in those who already have some degree of incontinence. The clinician asks about cigarette smoking, which is a factor in persistent coughing. Nicotine has also been shown to cause bladder irritation in some individuals, which adds to the risk of urinary frequency and urgency (WOCN, 2016).

CARDIOVASCULAR ASSESSMENT

Certain cardiac conditions, such as heart failure and cardiac arrhythmias, can place patients at greater risk for nocturia, difficulty getting to the toilet in time before urine leakage, and a greater risk for falls. Clinicians must consider that diuretics used in the treatment of heart failure may contribute to urinary incontinence (WOCN, 2016).

ENDOCRINE ASSESSMENT

Diabetes is a risk factor for urinary incontinence. Peripheral autonomic neuropathy can cause problems with bladder storage, and poorly controlled diabetes can lead to polyuria (the production of abnormally large amounts of urine), which can increase the risk for urge urinary incontinence. Polyuria can also potentially increase the risk for functional incontinence and make existing functional incontinence worse (WOCN, 2016).

Neurological Assessment

A neurologic assessment is critical for a patient with urinary incontinence. Urination is regulated by spinal cord reflex centers, the micturition center in the pons, and cortical and subcortical areas in the brain. The sacral spinal cord segments 2–4 (S2–4) play a pivotal role in the voiding process, providing for relaxation of the internal and external sphincters and facilitating the flow of urine (Lehman, 2015).

Several neurologic conditions can affect voiding. Stroke and Parkinson’s disease are associated with urinary incontinence, in particular urge urinary incontinence. Multiple sclerosis and spinal cord injury are associated with neurogenic bladder and impaired bladder contraction (Abrams et al., 2017).

Genitourinary Assessment

VOIDING SYMPTOMS

Voiding symptoms associated with urinary incontinence in all genders include:

• Hesitancy: a delay in starting urination
• Slow urine stream: the person’s observation of diminished urine flow compared to their longstanding pattern
• Intermittent stream: flow of urine during voiding that stops and starts and reoccurs frequently
• Straining to void: increase in muscle contraction required to begin micturition
• Spraying of urine: described by the individual as urine spraying out rather than streaming
• Dribbling: a prolonged trickle of urine at the end stage of voiding
• Sensation of incomplete bladder emptying: the sensation of the bladder not being empty after completion of voiding
• Need to instantly urinate again: needing to void a second time immediately after voiding the first time
• Postvoiding leakage: uncontrolled leakage of more urine as soon as urination is complete
• Dysuria: discomfort or pain with urination
  (Abrams et al., 2017)

MALE ANATOMY

Since urinary incontinence is less common among those with a male anatomy, it is an area that may be overlooked by clinicians during assessment of such patients. Physical assessment includes abdominal palpation for a distended bladder as well as examination of the external genitalia. The location of the urethral meatus is determined, along with the ease of retraction of the foreskin and any indication of congenital deformity (Abrams et al., 2017).

FEMALE ANATOMY

The medical history and physical assessment of patients with female anatomy address a number of genitourinary issues:

• Pregnancy and the type and circumstances of delivery can significantly increase a woman’s risk for incontinence. During pregnancy the increased pressure of the enlarging uterus on the bladder can lead to episodes of transient incontinence.
• Pelvic surgeries and pelvic pain can be related to problems with pelvic muscle support.
• Vaginitis can lead to the development of urge incontinence, so the clinician must inquire about symptoms such as pruritis, vaginal discharge, and malodor.
• Endometriosis (the growth of uterine lining tissue outside of the uterus) can result in urge urinary incontinence.
• Pelvic organ prolapse, which the patient may experience as a sensation of a vaginal “bulge,” increases the risk for urinary incontinence.
  (WOCN, 2016)

During the physical examination, the clinician pays close attention to the abdominal region. The presence of scars may indicate past surgeries. Abdominal palpitation can help to detect bladder fullness or retention. Any vaginal pain is recorded, as well as any atrophic changes to the vulva. In postmenopausal patients, findings related to incontinence may include vaginal dryness, pain, itching, or irritation, and vaginal atrophy related to estrogen depletion (Abrams et al., 2017; WOCN, 2016).

Pelvic Floor Muscle Strength Assessment

An examination may be indicated to determine pelvic floor muscle strength. A vaginal examination of the female anatomy or a rectal examination of the male anatomy is a critical part of a continence assessment to determine pelvic floor muscle strength. These exams are carried out by professionals, including RNs, APRNs, OTs, and PTs, who have the appropriate training and qualifications.

The clinician begins by explaining to the patient the reason for the examination and how it will be performed, including obtaining verbal and/or written consent per facility policy. It is vital that the clinician preserves the patient’s dignity and comfort at all times while performing these procedures.

VAGINAL EXAMINATION

Prior to carrying out a digital assessment of pelvic floor muscle strength, it is advisable for the clinician to evaluate for the existence of intravaginal pain. The clinician does this by gently palpating the vaginal walls with a gloved index finger beginning at the 6 o’clock location at the level of the hymnal remnants (a stretch of tissue in the vagina where the hymen used to be) and gradually moving the gloved index finger to the 9, 12 , 3 o’clock locations, and back to the 6 o’clock location at the same level to complete the full assessment. Moving the gloved index finger a little deeper into the vaginal vault each time, the clinician performs several more rounds of the above assessment to determine if the patient will be able to tolerate a full digital examination of the pelvic muscle floor strength (Berghmans et al., 2020).

The clinician then carefully inserts one or two gloved fingers into the vagina and inquires if the patient is aware of the fingers in the vaginal vault. The patient is asked to contract the vaginal muscles around the clinician’s finger as if trying to prevent urinating or passing gas. This effort permits the clinician to assess the patient’s capacity to:

• Identify and isolate the pelvic floor muscles
• Contract the pelvic floor muscles
• Relax the pelvic floor muscles
  (WOCN, 2016)

The pelvic floor muscle strength evaluation is graded using the Modified Oxford Scale (see table).

MODIFIED OXFORD SCALE

Patient Capacity	Grade	Description
Absent	0	No palpable muscle contraction noted
Slight trace	1/5	A slight, quick contraction with insubstantial compression of the clinician’s finger
Feeble	2/5	Feeble contraction with faint pressure felt on the clinician’s finger; may or may not result in lifting of clinician’s finger; sustained >1 second but <3 seconds
Moderate	3/5	Moderate contraction and compression noted on the clinician’s finger; may or may not result in lifting of the clinician’s finger; sustained for a minimum of 4–6 seconds and can be replicated 3 times
Steady	4/5	A solid contraction with effective compression of the clinician’s finger and lifting of the clinician’s finger near the pelvic bone; sustained for a minimum of 7–9 seconds and can be replicated 4–5 times
Robust	5/5	Distinct strong contraction and compression of the clinician’s finger along with posterior lifting of the clinician’s finger; sustained for a minimum of 10 seconds and can be replicated 4–5 times

While performing the pelvic muscle strength assessment, the clinician maintains eye contact with the patient as much as possible and is aware of the patient’s nonverbal communication that may indicate discomfort or pain with the procedure, such as the patient holding their breath or guarding. The clinician also assesses for any irregularities such as anterior or posterior vaginal wall defects or uterine prolapse.

The clinician keeps in mind that the above measurement of pelvic floor muscle strength performed with the patient in a semisupine position may not be an accurate indication of pelvic muscle functionality during normal daily activities. Based on the results of the above assessment, the clinician discusses an individualized treatment plan with the patient (see “Pelvic Floor Exercises” later in this course) (Berghmans et al., 2020).

RECTAL EXAMINATION

A digital rectal examination is used to assess pelvic muscle strength in males and in females who cannot endure a vaginal examination. The Oxford scale listed above is also used to determine pelvic muscle tone with rectal examinations.

The clinician inserts a gloved finger into the patient’s rectum, and then the patient is instructed to contract their rectal muscles around the clinician’s finger (WOCN, 2016). For both male and female patients, a rectal exam also allows the clinician to assess for rectal impaction. Rectal examination for male patients is a means for assessing the prostate gland; an enlarged prostate gland can be palpated through the rectum wall.

Evaluation of perineal reaction to different stimuli is important in assessing neurological involvement. The clinician assesses the patient’s response to light touch, and their ability to distinguish between sharp and dull stimuli are noted. Saddle anesthesia (diminished or loss of sensation to the buttocks, perineum, and inner aspects of the thighs) is found in the presence of a spinal cord lesion that affects S2–4 (Abrams et al., 2017; WOCN, 2016).

Skin Assessment

Maintaining skin integrity can be challenging for patients with urinary incontinence (and for their caretakers, among patients who need assistance). Incontinence-associated dermatitis (IAD), also called perineal dermatitis, can be caused by urine and stool coming in sustained contact with the skin surface. It is found on the perineal area, buttocks, and upper thighs.

Both urine and stool are caustic to the skin and lead to maceration and breakdown of the acid mantle that protects the skin integrity. The most common presentation of IAD is reddened skin. In people with darker skin, IAD may present as areas of hypo- or hyperpigmentation. When left untreated, it can progress to a partial-thickness skin injury. A serious concern for patients with IAD is their greater risk for developing pressure injury.

Another important concern for patients with incontinence is malodor of their skin and clothing. This is another factor that leads to isolation and decreased participation in activities (Baranoski & Ayello, 2016; Wound Care Resource, 2015).

Functional Assessment

Patients who have limitations in functional ability, such as difficulties with ambulation and sitting balance, are at high risk for functional incontinence. A functional assessment of the patient includes a comprehensive review of the patient’s ability to maintain independence in activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

A functional assessment can be performed by a physical therapist or occupational therapist. The clinician first assesses for balance. Is the patient able to maintain a safe sitting position without losing their balance? Are they safe when standing independently and ambulating? If assistance is needed for any of these activities, how much assistance is required? Range of motion, transfer ability, ambulation, coordination and proprioception will also be evaluated (Lehman, 2015).

A home evaluation is particularly valuable because it provides insight into environmental issues that can lead to or increase the risk for incontinence, e.g., poor lighting, inadequate toileting facilities, and placement of furniture or rugs that hinder quick access to bathrooms.

Several musculoskeletal conditions can impede a patient’s ability to maintain continence, including osteo- and rheumatoid arthritis and back problems, to name a few. These conditions affect ambulation and the person’s ability to reach a bathroom as well as dexterity and the ability to manipulate clothing to successfully achieve toileting. Chronic pain and fatigue can also impair motivation to attain continence. Other mobility impediments include braces, splints, and immobilizers (Lehman, 2015).

The clinician also inquires about the patient’s living situation and occupations, such as:

• Do they live in the community or a care facility?
• If in the community, with family or others?
• Are they still in the workforce?
• What are their activities and hobbies?
• Do they require assistance from others to perform activities of daily living, such as toileting?
• Is their bathroom easily accessible?
• Does the patient use a bedside commode or urinal at night?
  (WOCN, 2016)

Cognitive/Mental Status Assessment

Cognitive conditions can impact an individual’s ability to maintain continence. For instance, depression and dementia may lessen the motivation for toileting. Persons with cognitive decline may not recognize the need for toileting or they may not remember the location of the toilet or how to prepare for toileting (WOCN, 2016). The Mini-Mental State Exam (MMSE) is a short, structured test that can be used as an initial assessment of a patient’s cognitive status (Rosenzweig, 2020).

• Delirium (an abrupt change in mental function resulting in confusion and decreased awareness of the environment) is associated with an acute onset of urinary incontinence. Delirium is reversible and can be caused by dehydration and/or a urinary tract infection, especially in those over 65 years.
• Dementia is a progressive condition and results in worsening episodes of incontinence. Those with advanced dementia may not be able to make known their need for toileting, may respond to toileting help with distress, and may be unable to respond to toileting cues from caretakers (WOCN, 2016).
• Depression is a frequently occurring and underdiagnosed condition in older patients and in those with cognitive loss. It may lessen the motivation for toileting and heighten the risk for urinary incontinence. Conversely, many persons with urinary incontinence are too embarrassed to seek professional help and may instead withdraw from society as a means of dealing with their condition, which may increase the risk for depression (WOCN, 2016).

Laboratory and Diagnostic Studies

Laboratory and diagnostic studies play a critical role in diagnosing urinary incontinence. Some of the more common tests performed are discussed below.

URINALYSIS

For all patients with urinary incontinence, a urinalysis is ordered to assess for the presence of urinary tract infection and hematuria. Results from a urinalysis may require a follow-up urine culture and sensitivity testing.

POSTVOIDING RESIDUAL

Measurement of postvoiding residual determines the amount of urine in the bladder after the patient voids. There are two methods of measuring postvoiding residual:

• A catheter is inserted into the bladder (using sterile technique) immediately after the patient has voided to drain and measure the amount of any residual urine left in the bladder.
• A noninvasive ultrasonic examination of the patient’s abdomen measures the amount of urine remaining in the bladder. Ultrasound has proven to be as accurate as catheterization at measuring postvoiding residual and is the preferred method (Abrams et al., 2017).

Postvoiding residuals greater than 250 cc of urine are regarded as abnormally high and increase the risk for renal damage (WOCN, 2016).

BLOOD TESTS

Blood tests include a prostate-specific antigen test (PSA) for men. This test checks the amount of PSA present in the blood, with a result of ≥4 nanograms/ml considered abnormal and requiring further investigation. Elevated levels can indicate an enlarged prostate, prostatitis, or prostate cancer.

Other blood tests to assess the status of renal and endocrine functioning include:

• Blood urea nitrogen (BUN)
• Serum creatinine
• Complete blood count (CBC)
• Estimated glomerular filtration rate (which maybe done as part of a blood chemistry panel)
• Fasting blood sugar
• Hemoglobin A1C
  (Abrams et al., 2017; WOCN, 2016)

PAD TEST

A pad test is a noninvasive method used to measure the amount of urine lost in each incontinent episode and to determine the severity of urine incontinence. Pad tests can be done at home by having the patient wear pads continuously for 24–48 hours. The pad is weighed before and after an episode of incontinence. A one-hour pad test can be done in the clinical setting by inserting a predetermined amount of saline into the patient’s bladder before they are asked to perform a series of exercises. A pad test, however, will not distinguish between the different types of incontinence (Abrams et al., 2017).

BLADDER DIARY

The patient (or their caretaker) may be requested to keep a 24-hour record of:

• Fluid intake
• Frequency and amount of voiding
• Number of incontinent episodes
• Activities the patient was engaged in when an episode of incontinence occurred
• Any patient-reported sensation of urgency, discomfort, or pain

URODYNAMIC TESTING

Urodynamic testing is used to gain a clear picture of how well the lower urinary tract is functioning, the bladder’s urine storage capabilities, and how well the bladder can empty. Types of urodynamic testing include:

• Uroflowmetry. This is a noninvasive test that can be used for male and female patients. It measures the flow rate of urine and the patient’s ability to empty the bladder. The patient is asked to arrive for the test with a full bladder. The patient is provided with privacy and asked to void into a commode fitted with a flow meter funnel. The flow of urine is continuously measured and the findings displayed on a graph. A normal uroflowmetry test produces a bell-shaped curve (Abrams et al., 2017; WOCN, 2016).
• Filling cystometry. This test measures the pressure within the bladder to determine its storage capacity and intra-activity abdominal pressures. It is an invasive test and requires the placement of two pressure-sensitive catheters, one in the patient’s bladder and the other in the rectum, which gauge the abdominal pressure range. The bladder is then filled with normal saline via the catheter placed in the bladder. Pressure is monitored while the bladder is being filled and before the patient is allowed to void. The abdominal pressure readings are subtracted from the bladder pressure readings, and the resulting value indicates the pressure wielded by the bladder (Abrams et al., 2017; WOCN, 2016).
• Electromyography (EMG). Electrode patches are placed in the groin area to monitor the functioning of the pelvic muscles during the different stages of voiding, with the electrical output from the pelvic floor muscles displayed graphically. During the bladder-filling phase, a slight increase in electrical activity should be noted, which is referred to as the guarding reflex. During voiding, the pelvic floor muscles will normally relax, indicated by minimal or no EMG activity, while abnormal pelvic floor functioning is characterized by an increase in EMG activity during voiding (WOCN, 2016).

TREATING INCONTINENCE

A multidisciplinary team of healthcare professionals is involved in the diagnosis and treatment of incontinence. They include:

• Urologists
• Urogynecologists, who are specially trained in the care of women with pelvic floor disorders
• Primary care providers such as physicians and nurse practitioners
• Nurses, including those with specialized training and certification in incontinence care. In conjunction with other disciplines, nurses are involved in patient assessment, addressing behavioral and lifestyle changes, and interventions such as bladder training.
• Physical therapists are proficient in the evaluation and treatment of urinary and fecal incontinence and may also specialize in interventions for pelvic floor disorders, including instruction in pelvic floor exercises, manual manipulation, and other treatment modalities (such as electrostimulation, biofeedback, and/or vaginal dilators or weighted vaginal cones).
• Occupational therapists are involved in training to increase the awareness of pelvic floor muscle activity and developing lifestyle interventions (i.e., ADL, IADL, home assessment) to cope with urinary incontinence.
  (APTA, 2018; AUGS, 2017; Wallace et al., 2019; WOCN, 2016)

During the assessment process and before interventions are put in place, it is important for each clinician to establish the patient’s perception of the severity of the problem and its impact on their life. Treatment should be guided by the limitations incontinence places on the patient and the degree of intervention preferable to them (Stoppler, 2017).

Treatment generally begins with noninvasive interventions that reduce incontinence and enhance coping skills.

Lifestyle Interventions

Lifestyle and behavioral interventions are the first line of treatment for urinary incontinence and may include smoking cessation and weight loss. Obesity increases pressure on the bladder and pelvic floor muscles and increases the risk of developing stress urinary incontinence. It has been shown that for every five-unit increase in body mass index (BMI) females increase their likelihood of developing urinary incontinence by as much as 70% (WOCN, 2016; Cunningham & Valasek, 2019; Schuiling, 2017).

Patients are also instructed to avoid dehydration. Decreased fluid intake can cause concentrated urine, which can irritate the bladder. It can also lead to the formation of kidney stones and increase the risk of urinary tract infections and constipation. Adults ages 65 and over are particularly susceptible to the effects of dehydration. Older patients are educated not to wait to feel thirsty before drinking fluids and that dark-colored urine can be a sign of dehydration.

The timing of fluid intake is discussed with the patient, with the recommendation to limit fluid intake in the later part of the day (Simon Foundation, 2019a).

Other lifestyle interventions that maybe beneficial in treating incontinence include:

• Reducing coffee intake
• Limiting intake of alcohol and carbonated beverages
• Preventing constipation

Bladder Retraining

For urge and stress incontinence, a bladder-retraining program can be initiated during the daytime hours.

To begin, the patient is asked to maintain a voiding diary to establish their voiding pattern. Then, the patient is asked to void 15 minutes prior to their usual voiding time in order to avert the urge sensation to void. For example, if the voiding diary shows that the patient voids every 90–95 minutes, the retraining program will start with voiding every 60 minutes. If the urge to void arises before the 60-minute interval, the patient is encouraged to postpone voiding if possible until the scheduled time, or at a minimum to wait for five minutes beyond the initial urge to void. At intervals that are comfortable for the patient, perhaps weekly, a goal is set to extend the voiding time by another 15–30 minutes until a 3- to 4-hour time period is achieved between each void (Schuiling, 2017).

Urinary Incontinence Products

Some patients may need to or choose to use incontinence products, including:

• Patients for whom incontinence can be completely reversed
• Patients who have to cope with incontinence for a period of time, e.g., those waiting to achieve the benefits of pelvic floor muscle training
• Patients who choose incontinence management over other interventions

For all of these people, incontinence products are an essential intervention in maintaining their personal and social activities (WOCN, 2016).

Absorbent products can include panty liners, pads, and specially designed underwear. Patients with female anatomy are advised to use incontinence pads rather than feminine hygiene pads for moderate to heavy leakage. Incontinence products are created with the surface area nearest to the urethral orifice, which is superior to the vagina. These products are highly absorbent, with a decrease in skin irritation, when compared to less absorbent products (UCF, 2019).

For patients with male anatomy, a drip shield can be used for mild episodes of incontinence, while a drip guard is useful for more excessive leakage. The shields have a waterproof backing. They are placed over the head of the penis and can be secured in place by wearing relatively snug-fitting underwear (Underwood, 2017).

When deciding on the optimal product(s) to use, the clinician, patient, and caregiver take into consideration the following factors:

• Severity of the incontinence problem
• Anatomy of the patient
• Physical build, height, and weight of the patient
• Mental capacity
• Mobility level
• Problems with dexterity
• Eyesight
• Lifestyle, including home and work environments
• Level of independence or assistance needed
• Available storage
• Personal preferences and priorities, such as need for discreetness
  (Abrams et al., 2017)

Treating Incontinence-Associated Dermatitis

The primary approach to the treatment of IAD includes:

• Reversing the cause(s) of incontinence or reducing the incidence of incontinence
• Avoiding cleansing the perineal area with soap; substituting cleansing products that prevent overdrying or irritation of the skin
• When bathing, using warm, not hot, water and refraining from vigorous rubbing or scrubbing of the skin
• After cleansing and drying, applying a barrier cream such as zinc oxide or dimethicone

If an absorptive product is used for incontinence containment, it should wick urine (and stool, if applicable) away from the skin (WOCN, 2016).

Psychological and Emotional Interventions

Psychological and emotional interventions aim to enhance the patient’s ability to cope with urinary symptoms. Many people with urinary incontinence feel alone and are unable to talk to family or friends about their problem. Being able to talk to a clinician about constant fear of uncontrolled urinary leakage and the feelings of embarrassment and depression is an important step in developing coping mechanisms (Underwood, 2017; Shah, 2019).

Incontinence Devices

Pessaries provide a low-risk treatment choice for many women and are used frequently. These devices are fitted into the vagina and provide support to pelvic organs that have moved downward. They also supply compression to the urethra to decrease the risk of urinary incontinence. Whether the patient is sexually active will influence the type of pessary used. Most women find pessaries comfortable.

Pessaries are fitted by the clinician and usually require follow-up appointments every 3–6 months to ensure the patient is appropriately self-managing pessary use. During the follow-up visit, the clinician exams the vaginal vault for any signs of mechanical erosion or other lesions. The clinician also inspects the pessary for any signs of damage (WOCN, 2016).

Pessaries are not suitable in all cases, such as for women who have scarring of the vagina, vaginal dryness, or a restricted or shortened vagina. Women with weakened pelvic muscles may have difficulty keeping a pessary in place, but strengthening of pelvic floor muscles may alleviate this problem (AUGS, 2016).

Men with urinary incontinence can use clamps as an alternative to pads and collection devices. A clamp prevents incontinence by exerting pressure on the penis. It is placed around the base of the penis and secured just to the point where it will prevent urine leakage. Clamps are recommended for men who are diagnosed with stress incontinence only.

The use of clamps requires careful assessment by the clinician. The clinician must ensure that the patient has no cognitive deficits and that they have the manual dexterity to apply and remove the clamp safely. Patients are educated to use clamps with caution since they can impede blood flow, resulting in ischemic damage to the penis. Patients are also reminded to be alert for signs of skin damage to the penile surface caused by the clamp. Clamps have been found to be most successful in situations that require short-term usage, such as when a patient has to attend a meeting or is engaged in recreational activities (WOCN, 2016).

Pelvic Floor Exercises

In 1950, Dr. Arnold Kegel developed pelvic floor exercises known as Kegel’s exercises (Haag, 2019). More generally referred to as pelvic floor muscle training (PFMT), this is the first-line treatment for women with urinary incontinence. It has been found that PFMT provides benefits regardless of the type of incontinence present. Although there is abundant evidence that PFMT is a safe and effective treatment, many candidates who could benefit from PFMT have only a scant understanding and insight into this treatment choice.

Positive results reported by women include decreased episodes of incontinence and an improved quality of life (Dumoulin et al., 2018). Research has been shown that strengthening the muscles of the pelvic floor can diminish the incidence of urinary incontinence by up to 90% (Mayo Clinic, 2017).

PFMT has not been as well studied in men as it has been in women, but it is still considered a primary recommendation for men with urinary incontinence after radical prostatectomy (WOCN, 2016). Continence may be regained sooner if PFMT instruction is introduced in the preoperative or immediate postoperative period to male patients undergoing radical prostatectomy surgery (Abrams et al., 2017).

Instruction in pelvic floor muscle training is provided by physical therapists who have obtained specialized PFMT training. Important first steps include patient education about the utility of PFMT, exploring patients’ treatment expectations, and realistic goal setting. Patients are advised that PFMT requires a time commitment and that positive results may only be noticeable after several treatment sessions (Wallace et al., 2019).

How does PFMT work? During a strong contraction, the levator ani muscles are moved upward and forward, facilitating compression of the urethra and adding to urethral closing pressure. Strengthened pelvic floor muscles give support to the bladder neck and the proximal urethra. Maintaining the urethra in its normal position during pursuits that heighten intra-abdominal pressure decreases the likelihood of urine leakage.

In conjunction with the patient, the clinician creates an individualized program of exercises. A key factor to success is the patient’s level of motivation and their willingness to adhere to the exercise maintenance program (Abrams et al., 2017).

The clinician first teaches the patient how to identify the pelvic floor muscles by instructing them to “draw in” or contract the muscles around the vagina and/or anal sphincter, as if they are trying to stop urination or defecation. The contraction of these muscles is maintained for about 10 seconds, followed by a period of relaxation for a minimum of 10 seconds. A typical training schedule is to perform 3–4 rounds of pelvic muscle exercises each day and to include 10–15 repetitions in each round. The clinician teaches the patient to perform the exercises while sitting, standing, and lying supine. The patient is counseled not to use the abdominal or buttock muscles while doing pelvic floor muscle exercises. For some patients this takes time and conscious effort to master (WOCN, 2016).

Pharmacology

Several different classes of medications are used to treat urinary incontinence. These include:

• Anticholinergics (also known as antimuscarinics) reduce bladder contractions, increase bladder capacity, and decrease the urgency to void. Medications in this category include fesoterodine (Toviaz) and solifenacin (VESIcare).
• Beta-3 agonists, such as mirabegron (Myrbetriq), have been shown to reduce the number of incontinent episodes per day (Bragg et al., 2014).
• Anti-depressants. Impramine (Tofranil) is a tricyclic antidepressant sometimes used to treat bed wetting in children 6 years of age and up. Duloxetine (Cymbalta) is a serotonin/norepinephrine reuptake inhibitor approved in Europe for the treatment of stress urinary incontinence, but it is not approved by the Federal Drug Administration (FDA) for incontinence treatment in the United States.
• Topical estrogen. Estrogen receptors are found in the vagina and also in the tissues of the bladder and urethra. It is thought that estrogen deficiency contributes to the development of urinary incontinence (Abrams et al., 2017; WOCN, 2016).

Surgical Interventions

The most commonly used surgical interventions are described below:

• Sling procedures are used for urethral support and to exert external urethral compression. The most frequently performed sling procedure involves the placement of a synthetic mesh to form a suburethral sling. The midurethral sling procedure is currently regarded as the “gold standard” for the treatment of stress urinary incontinence in women. Sling procedures are also regarded as an effective choice for male patients coping with incontinence after prostatectomy surgery, in particular those with slight to moderate leakage.
• Artificial urinary sphincter. For male patients this procedure has been found to give the best long-term success in dealing with urinary incontinence after radical prostatectomy surgery. It is regarded as the primary surgical intervention for these patients.
• Urethral bulking agents. The injection of bulking agents is used to cushion the urethral mucosa, thereby increasing urethral coaptation (closing) and reestablishing continence. Collagen and synthetic agents are used as bulking materials. The body will eventually absorb collagen, and so collagen bulking agents usually require repeat injections every 6 to 18 months. Synthetic materials require less-frequent repeat treatments.
  (WOCN, 2016; Abram et al., 2017; Shah, 2019)

BOWEL INCONTINENCE

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK, 2019) defines bowel incontinence as “the inability to hold a bowel movement until reaching the bathroom.” Fecal incontinence can occur at any age, but it is more common in older adults (WOCN, 2016). It is estimated that bowel incontinence affects 1 in 5 adults ages 65 years and up who live in the community and residential care settings and affects half of those living in long-term care facilities (Abrams et al., 2017).

Types of Fecal Incontinence

Fecal incontinence can be divided into several different types.

URGE FECAL INCONTINENCE

Urge fecal incontinence occurs when the individual experiences an immediate urge to defecate and is unable to reach the restroom in time. Causes of urge fecal incontinence include colorectal motility disorders, reduced rectal capacity, and malfunctioning of the external anal sphincter. The primary function of the external sphincter is to maintain continence when there is stool or flatus in the rectum (Abrams et al., 2017; WOCN, 2016).

PASSIVE FECAL INCONTINENCE

Passive fecal incontinence refers to stool or gas that is passed and the individual is not aware that it has happened. This occurs when anal closure is not intact and there is a lack of sensation. It can be caused by rectal prolapse, injury, or trauma, sometimes sustained during childbirth. Passive incontinence ranges from slight soiling of undergarments to complete evacuation of bowel contents. It is frequently found in persons with cognitive impairments such as dementia (Abrams et al., 2017; WOCN, 2016).

PARTIAL FECAL INCONTINENCE

Partial fecal incontinence occurs when there is a small amount of fecal leakage resulting in soiling of underwear. This can be a continuous problem, or it can occur from time to time in persons who are normally continent. It can be caused by malfunctioning of the internal anal sphincter, which is responsible for preventing leakage of small amounts of stool and gas, or it can be caused by diminished sensory ability that impedes detection of stool in the rectal vault (WOCN, 2016).

FUNCTIONAL BOWEL INCONTINENCE

Functional incontinence is associated with physical limitations, mobility issues, and structural impediments such as inaccessibility of toileting facilities (Abrams et al., 2017).

OVERFLOW INCONTINENCE

Overflow incontinence occurs as a result of stool impaction, where there is leaking of soft feces from around hard, impacted stool. This is not always easy to diagnose, and it is a frequent problem among frail elderly residents in long-term care facilities (Abrams et al., 2017).

Patient Assessment

INTERVIEW

During the interview with the patient, the clinician develops an inclusive assessment of the problem with bowel incontinence. This includes such factors as:

• Onset of the problem and its severity
• Whether the patient still has some controlled bowel movements
• Stool consistency during both continent and incontinent episodes of bowel evacuation
• Whether the patient experiences episodes of constipation or diarrhea
• Whether the patient is aware of when there is gas or stool in the rectal vault
• Whether the patient can distinguish between gas and stool
• How long the patient can maintain continence when they have the urge to defecate

The interview also includes detailed questions about the patient’s food and fluid intake as well as a complete review of their medication profile. The clinician pays specific attention to the patient’s use or misuse of laxatives and any large intake of caffeine products, alcohol, and food items that contain sorbitol (an artificial sweetener), which can result in loose stools that are more difficult to contain (WOCN, 2016; Abrams et al., 2017). Alarm signals include worsening bowel symptoms, weight loss, and blood loss, and require immediate further assessment.

The above problem-focused history helps the clinician to determine the type of bowel incontinence the patient is experiencing: urge fecal incontinence, passive fecal incontinence, or minor leakage of bowel contents.

Beyond this, the holistic assessment will determine pre-existing conditions that could result in bowel incontinence. Some of the major conditions that may give rise to bowel incontinence include:

• Diabetes. Diabetes has been found to be a risk factor for bowel incontinence. Metformin, an oral medication used in the treatment of diabetes, has been found to be an independent factor in the development of bowel incontinence in individuals with diabetes (Abrams et al., 2017).
• Obesity. Obesity is a significant risk factor for bowel incontinence. Research has found that the rate varies widely, from 16% to 68%, with increase in BMI correlated to increased risk of bowel incontinence (WOCN, 2016).
• Radiation treatment. It has been found that there is a high incidence of bowel incontinence after the use of pelvic floor radiation for prostate cancer, gynecological cancers, and rectal and anal cancers (Abrams et al., 2017).
• Irregular bowel elimination. Diarrhea and fecal impaction are leading causes of bowel incontinence, especially in older adults.
• Dementia. The incidence of bowel incontinence is higher in patients with dementia than those of similar age without this condition.
• Depression. Depression is a risk factor; this may be related to the side effects of anti-depression medication.
• Irritable bowel syndrome. Irritable bowel syndrome is a risk factor for bowel incontinence.
• Spinal cord injury. Patients with spinal cord injury frequently have issues with bowel incontinence.

Bowel incontinence can have a detrimental effect on the individual’s quality of life and is an acutely embarrassing problem. Psychological findings associated with bowel incontinence include:

• Diminished self-esteem and confidence
• Unwillingness to discuss bowel incontinence with others, including clinicians
• Heightened risk for anxiety and depression
• Demoralization by negative feelings of embarrassment, fear, and shame
• Dependence on caretakers and loneliness

PHYSICAL EXAMINATION

The physical examination of the patient includes the following components:

• Digital rectal exam, which allows the clinician to assess rectal filling, resting anal tone, the patient’s ability to generate a voluntary contraction, and overall anal sensitivity
• Examination of perineal skin surfaces for signs of incontinence-induced skin damage such as redness, rash, and excoriation
• Assessment of the perineal area for signs of obstetrical injury in female patients or scars from previous surgery
• Abdominal palpitation to assess for pain, tenderness, and possible abdominal masses

DIAGNOSTIC TESTING

Diagnostic testing for bowel incontinence includes:

• Stool tests for ova and parasites and stool culture for various infectious organisms such as salmonella, E. coli, and C. difficile
• Anoscopy and proctoscopy to assess for hemorrhoids and anorectal masses
• Endo-anal ultrasound (EAUS) (regarded as the “gold standard”) to determine the presence of anal sphincter injury
• Anorectal manometry to evaluate pressures in the anal canal and distal rectum; primarily used to gauge the functionality of the internal and external anal sphincters
• Defecography to identify functional difficulties with rectal emptying, which can occur in the presence of rectal prolapse or posterior vaginal prolapse (rectocele)
  (WOCN, 2016; Abrams et al., 2017)

Management and Treatment Interventions

Managing bowel incontinence requires a holistic, multidisciplinary team approach, with interchanging and overlapping roles between nursing, physical therapy, and occupational therapy. The overall goal of management interventions is either the complete elimination of bowel incontinence or, where this is not achievable, a decrease in the frequency or severity of bowel incontinence.

The first step in deciding on a management program is a discussion between the patient, family, caregivers, and clinicians regarding the treatment options available and which will best fit the patient’s unique circumstances.

Conservative management of bowel incontinence is the primary intervention for patients without anal sphincter damage or defects. Patients who have sphincter defects are recommended to have a surgical evaluation (Abrams et al., 2017).

BOWEL RETRAINING

First-line interventions include establishing a regular bowel habit. The clinician educates the patient and family about peristaltic contractions of the colon, which are most active in the morning after wakening and after eating. These contractions aid with bowel evacuation and should not be ignored. After breakfast is considered the optimum time to schedule toileting. The clinician emphasizes the importance of establishing a regular time for toileting and maintaining that routine, even if at first the patient does not feel a need for defecation. Following a consistent schedule will assist in training the bowel to empty.

DIETARY CHANGES

Dietary adjustments are frequently necessary in reducing the rate of bowel incontinence. Successful dietary approaches include:

• Scheduling meals to meet individual needs for travel, work, and recreational activities
• Decreasing food intake and avoiding large meals
• Maintaining a food diary to identify foods that may worsen episodes of incontinence and then eliminating those foods from the diet
• Adding yogurt, high-fiber foods, and/or a fiber supplement to the diet
• Increasing water intake to 2 to 3 liters daily

PHARMOCOLOGIC TREATMENT

The medication loperamide (Imodium) is a first-line treatment used to treat bowel incontinence associated with loose stools. Patients taking loperamide are warned not to drink tonic water, which can interact with loperamide and result in serious heart problems (Drugs.com, 2019; Abrams et al., 2017).

BOWEL THERAPY TREATMENTS

When the pressure of the stool in the rectum is more than the pressure in the pelvic floor, then the individual will achieve a bowel movement. Therefore, the pelvic floor must be able to contract so that the individual can maintain bowel continence, and the pelvic floor muscles must be able to relax to facilitate defecation. For individuals who are unable to relax the pelvic floor muscles, this leads to straining and incomplete emptying of stool (Buonoma, 2019).

Therapeutic treatments that can be used for bowel incontinence include:

• Pelvic floor muscle training (PFMT). The procedure for teaching and performing PFMT exercises is basically the same as for patients with urinary incontinence (see “Pelvic Floor Exercises” earlier in this course). The primary goal of physiotherapeutic muscle training in the treatment of bowel incontinence is to enhance the strength, tension, endurance, and coordination of the anal sphincter and the pelvic floor muscles. The clinician develops an individualized exercise pattern for each patient based on their baseline pelvic muscle strength and endurance.
• Biofeedback is regarded as the primary treatment for mild to moderate incontinence. Biofeedback enhances sensory awareness, increases pelvic muscle strength and ability, and augments coordination between abdominal and pelvic floor muscles. Since one of the main obstacles to pelvic floor strengthening is the inability of patients to correctly identify and isolate pelvic floor muscle contractions, biofeedback is used to assist the patient to identify the pelvic floor muscle and anal sphincter contractions without the concurrent contraction of other muscles.
• Devices used to provide biofeedback include anorectal manometry and surface or endoanal EMG. The goal for using these devices is to provide the patient with knowledge about their muscle activity or a variation in the anal canal pressures. Biofeedback done in conjunction with PFMT has proven to be successful in the treatment of bowel incontinence not responsive to lifestyle changes. Biofeedback is helpful to more than 75% of those with pelvic floor dysfunction.
• Perineal massage has been found to be therapeutic in the prevention of fecal incontinence when it is performed in late stages of pregnancy. Antenatal perineal massage results in relaxation, enhances the blood flow within the perineum, and allows the pelvic floor muscles to become more flexible. Research indicates that pelvic floor massage has no adverse side effects and is well tolerated by women. The recommended treatment is 10 minutes of massage each day beginning at the 34th week of pregnancy until delivery.
• Electrical stimulation of the anal mucosa and/or tibial nerve may be used to improve anal sphincter functionality.
  (Abrams et al., 2017; Cleveland Clinic, 2020; Mazur-Bialy, 2020; WOCN, 2016)

FECAL CONTAINMENT

Various products are used for fecal containment. These include pads and briefs. Other devices used are:

• Anal plug. This is a small, cup-shaped device that is placed in the rectum. An attached string is used to remove the device.
• Anal pouch. This is an external collection device with a wafer that sticks to the perianal skin. The pouch is equipped with a resealable port that allows it to be drained. Pouches can be difficult to apply and difficult to maintain adherence.

SKIN CARE

Bowel incontinence places the patient at risk for skin damage. Stool is more irritating to the skin than urine, and a combination of urine and fecal incontinence increases the risk for skin breakdown. A skincare protocol is individualized for each patient, depending on the severity and frequency of bowel incontinence. Moisture barrier products are used, especially when there is frequent and excessive bowel incontinence. Zinc oxide may be used, or a combination of zinc oxide and petrolatum, which allows for easier application, and removal, than zinc oxide on its own.

SURGICAL TREATMENTS

When bowel incontinence cannot be successfully managed using conservative treatments, a surgical evaluation should be considered. Several different surgical interventions used to treat bowel incontinence. (It is beyond the scope of this course to discuss them in detail.) Surgical interventions include:

• Sphincteroplasty: A procedure to repair a damaged or weakened anal sphincter
• Sphincter replacement: A procedure to replace a damaged sphincter with an artificial sphincter, which is an inflatable cuff implanted around the anal canal
• Dynamic graciloplasty: Relocating the gracilis or gluteus maximus muscles by wrapping them around the anal sphincter to restore muscle tone
• Sacral nerve stimulation: Implanting electrodes to treat internal sphincter and external sphincter muscle damage
  (Mayo Clinic, 2020a; Abrams et al., 2017; WOCN, 2016)

CONCLUSION

Bladder and bowel incontinence are frequently a hidden and unspoken problem. Due to shame and embarrassment, many people are hesitant to discuss these issues with healthcare providers. Incontinence results in both physical and emotional problems that diminish the quality of life for individuals in all age groups. Older adults often consider incontinence as a consequence of aging and one they must learn to live with. It is up to clinicians to be proactive in inquiring about problems with incontinence with sensitivity and not to assume that there is no problem if the patient does not bring it up on their own.