Incontinence: Investigation and Management
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Take a thorough history and perform a complete physical examination for patients with incontinence. Perform additional investigations as indicated by initial findings. | Level of Evidence Not Assessed |
| Address Patient-centered Concerns | ||
|---|---|---|
| 2 | Consider the potentially serious adverse effects that even mild urinary incontinence has on a patient’s quality of life. | Level of Evidence Not Assessed |
| 3 | Provide information and advice on treatment options available in both primary and secondary care. | Level of Evidence Not Assessed |
| 4 | Use a validated quality of life and incontinence severity questionnaire. | Level of Evidence Not Assessed |
| Provide Local Care | ||
|---|---|---|
| 5 | Develop and implement a treatment plan based on the type and cause of incontinence. | Level of Evidence Not Assessed |
| 6 | Recommend containment products and reassess their suitability. Consider absorbent products as: - a coping strategy pending definitive treatment - an adjunct to other ongoing therapy - long term management of urinary incontinence only after other treatment options have been explored | Level of Evidence Not Assessed |
| 7 | Inspect genital-perineal area daily to identify signs of contact dermatitis and skin erosions. | Level of Evidence Not Assessed |
| 8 | Develop individualized skin care plans for patients with incontinence and intact or irritated skin, based on regularly cleansing, moisturizing and protecting the perineal skin. | Level of Evidence Not Assessed |
| 9 | Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing appropriate skin and barrier creams. | Level of Evidence Not Assessed |
| 10 | Treat infected skin or other skin complications appropriately. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 11 | Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information. | Level of Evidence Not Assessed |
Background
Investigation of urinary and fecal incontinence may identify reversible or treatable conditions. Specific management strategies for patients with incontinence are determined by the type and cause of the problem.Urinary incontinence is divided into urge, stress, overflow, functional, and mixed incontinence. Diagnosis entails a complete history, including a detailed voiding history, a physical examination, including a directed neurologic examination, plus selected investigations. Basic investigation includes urinalysis and culture, blood urea nitrogen, and creatinine. Additional investigations that may be required include urinary tract imaging, cytology, cystoscopy and urodynamics.
The initial management approach is to address potentially reversible factors, such as provision of assistance with toileting for immobile patients; identification and management of depression; treatment of urinary tract infection or fecal impaction; and altering medications or dosage schedules that may worsen incontinence, such as evening diuretic doses. Management strategies can be grouped into the following categories:
• Behavioural treatment: Urge and stress incontinence may respond to behavioural treatment, such as bladder training, pelvic floor muscle exercises, and biofeedback. These approaches may be helpful in the geriatric nursing home population.
• Medical therapy includes anticholinergic agents for urge incontinence; topical and systemic estrogen in women with atrophic vaginitis and urethritis; and alpha-blocker therapy for benign prostatic hypertrophy.
• Surgical treatment, such as bladder neck suspension and sling procedures, may be effective for stress incontinence in female patients. Artificial urinary sphincters may correct post-prostatectomy incontinence or neurologic sphincter deficiency.
• Newer treatments: Sacral nerve root stimulation or injection of bulking agents around the sphincter may be attempted in patients who do not respond to medical therapy.
Fecal incontinence is complex and multifactorial. A complete history, physical examination, and functional and anatomic assessment of the anorectum, anal sphincters and pelvic floor are necessary for diagnosis and determination of appropriate treatment. For selected patients, anorectal manometry, anal endosonography, and pudendal nerve latency may be useful investigations.
Management strategies include the following:
• Bowel training programs, including ensuring adequate fluid and fibre intake, using stool softeners appropriately, and providing regular toileting, can manage chronic constipation and prevent fecal impaction and incontinence.
• Biofeedback may help with incontinence associated with neurologic disorders.
• Surgery may be appropriate for patients with pelvic floor, anal canal, or anal sphincter damage.
• Newer treatments: Nerve stimulation or injection of bulking agents in the sphincter may be useful for incontinence that does not respond to other treatments.
• Colostomy may be an option for severe fecal incontinence that is not responsive to other interventions.
References
| Essential Publications |
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