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Bladder and Bowel Learning Resource

This updated resource aims to support RCN members to promote continence and manage incontinence for people with bladder and bowel problems.

An introduction from Ali Wileman, Forum Chair

Introduction

From an early age, most people have the ability to control their bladder and bowel. This is known as continence.

Continence is the ability to pass urine or faeces voluntarily in a socially acceptable place.

A person needs to be able to:

  • recognise the need to void
  • identify the correct place to void
  • reach the toilet
  • hold on until the toilet is reached
  • pass urine or faeces once there.

Incontinence is the unwanted and involuntary leakage of urine or stool or wind.

Many people will be affected by incontinence at some point in their life.

It is estimated that 14 million men, women, young people and children of all ages are living with bladder problems and 6.5 million adults in the UK suffer with some form of bowel problem (NHS England, 2018).

Given the sensitive nature of the condition, many people wait a long time before discussing the issue with a health care professional.

It is estimated that fewer than 40% of people with urinary incontinence seek help for their condition from a GP or nurse. This figure is even higher for those with faecal incontinence. These conditions can have a huge impact on all areas of an individual's life, from self-esteem and wellbeing to quality of life. Yet these conditions can be managed, treated and sometimes cured with the right support and advice.

References
NHS England (2018) Excellence in Continence Care
NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management NG123

This is the second edition of the resource that has been developed by the Royal College of Nursing (RCN) and the RCN Bladder and Bowel Forum.

It aims to support RCN members to promote continence and manage incontinence for people with bladder and bowel problems.

This resource is for registered nurses, nursing students and nursing support workers (which includes assistant practitioners, nursing associates, health care assistants, nursing assistants and health care support workers) working in any health and social care setting or specialism. 

Our goal is to give you a greater understanding of your role in assessing and supporting people with incontinence.

Conditions affecting the bladder and bowel often go unreported and therefore undiagnosed. As these conditions can be managed, treated and sometimes cured, this resource has been created to help give you a better understanding of continence, what conditions can affect continence and what you can do to assess and support individuals with continence issues. 

Since the first edition, the Nursing and Midwifery Council (NMC) launched its ‘Future nurse: Standards of proficiency for registered nurses’ in 2018, which included bladder and bowel health in nurse training.

Further resources

NMC (2018) Standards of proficiency for registered nursing associates

After reading this resource you should be able to: 

  • explain how a healthy bladder and bowel works 
  • outline the different types of bladder and bowel problems, assessments, treatments and management solutions available 
  • recognise the red flags 
  • list the barriers to continence 
  • demonstrate the confidence to have open and non-judgemental discussions about bladder and bowel problems with an individual, their family and carers 
  • understand the needs of someone with incontinence and the impact the condition can have on them 
  • help the individual with bladder and bowel problems to manage their condition and support their quality of life and maintain their dignity and privacy.

How the bladder and bowel works

The urinary tract is the body's drainage system for removing urine, which is made up of waste and fluid.

Micturition

The bladder is a muscular sac, located in the pelvis. The bladder is connected to the kidneys by two tubes called ureters. Each day the kidneys filter about 170 litres of blood, from which they produce about 2 litres of urine, which flows down the ureters to the bladder.

Micturition part one

The flow of urine in both men and women is controlled by the internal and external urethal spincter. Control of the internal spincter is involuntary, control of the external spincter is voluntary.

micturition part two

Urine flows down the ureters and collects in the bladder. As the bladder dills it expands, and as the surface starts to stretch. Receptors in the surface send a signal to the brain to indicate that the bladder is filling, and as it approaches its maximum capacity this generates a feeling of discomfort.

Eventually the need to urinate becomes urgent and the brain sends a signal to the sphincter muscles to relax and urine is released from the bladder. The bladder empties and process is repeated.

micturition part three

 

Kidneys 

The kidneys are two bean-shaped organs that filter waste products, chemicals and unneeded fluid from the blood and produce urine. Located just below the ribcage on either side of the spine, they filter about 170 litres of blood a day, which produces 1.5 to 2 litres of urine. 

Ureters

Ureters are thin tubes of muscle that carry urine from each of the kidneys to the bladder. 

Bladder 

Located in the pelvis between the pelvic bones, the bladder is a hollow, muscular, balloon-shaped organ that expands as it fills with urine. Sitting in the bladder, the trigone is a triangle shaped smooth muscle that contains the ureteric and internal urethral orifices.

A bladder can hold around 400-600mL of urine.

The bladder empties five to eight times a day.

How often an individual needs to urinate depends on how quickly the kidneys produce the urine that fills the bladder. 

As the bladder fills to capacity, the stretch receptors within the trigone sends signals to the brain telling the individual that they need to pass urine. The bladder is emptied through the urethra, which is located at the bottom of the bladder.

Three sets of muscles work together to keep urine in the bladder:

  1. muscles of the urethra 
  2. bladder neck, composed of the second set of muscles called the internal sphincter 
  3. pelvic floor muscles, also known as the external sphincter, surround and support the urethra. 

When it's time to urinate, the brain signals the muscular bladder wall (detrusor) to tighten, which squeezes urine out of the bladder. The sphincters then relax allowing urine to exit the bladder. 

The digestive system 

Digestive system part one

Food moves down the oesophagus from the mouth and into the stomach, which it mixes with the digestive juices and enzymes. After a period of time the food passes into the duodenum where most of the chemical digestion takes places. Muscles push the semi digested food into the small intestine for further mixing.

Digestive system part two

The walls of the small intestine have blood vessels where nutrients are absorbed into the blood stream. The food is pushed through the small intestine into the large intestine, where any remaining nutrients are absorbed along with any excess water. As this happens the food is turned into a solid and formed into a stool which is expelled from the body during a bowel movement.

Digestive system part two

Peristalsis is the process by which food moves through the intestines. This is done by muscles located in the walls contracting in waves and pushing the food along. Here, a partially formed stool can be seen moving along the top section of the large intestine.

Food is moved through the different sections of the digestive tract by a process called peristalsis, which is a series of wave-like muscle contractions. It usually takes between 24 and 72 hours for food to move through the digestive system. The sections are separated by bands of muscles, known as sphincters, which are valves that control the movement of food from one area of the digestive tract to another. It's important that the food stays in each of the sections long enough for the gut to absorb fluid and nutrients before expelling it as waste. 

The small intestine (small bowel) 

The small bowel is about six to eight meters long and two centimeters wide and is comprised of three parts: 

  1. duodenum 
  2. jejunum 
  3. ileum. 

Food passes from the stomach through each of these three parts. The purpose of the small intestine is to absorb nutrients and much of the fluid from foods. As food moves from the small intestine to the colon it has a porridge-like consistency. 

The colon (large intestine) 

The colon, or large intestine (also known as the large bowel), starts at the final portion of the small intestine and ends at the rectum. The colon is about two meters long and six to seven centimeters wide. It is made up of the caecum, ascending, transverse, descending and sigmoid colon. 

The colon is host to a countless number of micro-organisms that support the processing and elimination of waste. It can take between 12 and 48 hours for food to make its way through the colon. 

The rectum and anus 

Once food has passed through the bowel the waste moves to the rectum which stretches, triggering a message to the brain to say that the rectum is full and needs to be emptied. The pelvic floor muscles ensure that the anus remains closed until the person is ready to open their bowels. The nerves can usually tell the brain whether it’s wind or stool that is filling the rectum. 

Bowel and bladder movements 

For the bowel to function properly it needs: 

  • the nerves of the rectum and anus to be sending the correct messages to the brain so that it can sense when stool or wind arrives in the rectum and can transmit messages to the muscles to hold it in 
  • the internal and external anal sphincters to be working 
  • stools which are not too soft or too hard. 

Normal bowel function 

The frequency and consistency of bowel movements will vary from person to person. Frequency averages between three times a day to three times a week, with the stool being soft and easy to pass. 

Stool consistency is usually measured using the Bristol Stool Chart and ideally should be between three and four. 

Bristol stool chart
Lewis SJ, Heaton KW (1997) Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology 32: 920–4

A good position on the toilet is when knees are higher than hips (unless recent hip surgery), leaning slightly forward and with the elbows on knees, relax and breath easily and do not strain. 

Correct seating position 

See: RCN (2019) Management of Lower Bowel Dysfunction, including Digital Rectal Examination and Digital Removal of Faeces

Bladder and bowel problems

Double incontinence is when both bowel and bladder control problems are experienced.

Incontinence is a common problem, with urinary incontinence being more common than faecal. There are a number of different types of urinary incontinence, which are described below. 

The main types of bladder problems are: 

  • urgency urinary incontinence - an involuntary leakage of urinary accompanied or followed by the feeling of urgent need to void
  • stress urinary incontinence - an involuntary leakage of urine on exertion, such as coughing, sneezing or exercising
  • mixed urinary incontinence - both urgency and stress symptoms 
  • nocturnal enuresis - involuntary loss of urine during sleep 
  • leakage following passing urine and continuous urinary leakage - these are symptomatic forms of incontinence 
  • overactive bladder - (may not be incontinent) characterised by the storage symptoms of urgency, usually with frequency and nocturia (waking to pass urine) 
  • neurogenic bladder dysfunction - urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination. 

Stress incontinence 

Stress incontinence is the involuntary loss of a small amount of urine when pressure increases in the abdomen, for example when coughing or sneezing. It is a problem that predominantly affects women. 

What causes stress incontinence?

Weakness may be caused by a variety of factors, including: 

  • surgery - particularly in men following prostate surgery 
  • pregnancy and childbirth 
  • obesity 
  • menopause 
  • chronic cough 
  • chronic constipation.

What can be done? 

Pelvic floor exercises, vaginal weights, surgery, oestrogen, washables pants or disposable containment product as a last resort. 

Passive incontinence 

When a person feels no urge to open their bladder or bowels. They are unaware that the bladder or rectum is full and ready to be emptied and cannot consciously control their bladder or bowel movements, therefore urine or stools can pass without their knowledge. 

Additional causes of incontinence in men

  • Prostatitis - an inflammation of the prostate gland
  • Prostate cancer - this is treatable when identified early.
Enlarged prostate  

The prostate is approximately the size of a walnut and surrounds the urethra just below the bladder. Its main function is to secrete prostate fluid, one of the components of semen. The muscles of the prostate gland also help propel this fluid into the urethra during ejaculation.

Men can suffer from prostatitis, an inflammation of the prostate gland.

Symptoms can include:

  • pain in pelvis, genitals, lower back and buttocks
  • frequency of urination
  • pain when urinating
  • difficulty urinating and “stop-start” peeing
  • pain when ejaculating
  • tiredness, aching joints, chills and fever.

It is important to consult a responsible clinician if these symptoms are experienced.

Benign Prostatic Hyperplasia (BPH)

The prostate gland often enlarges as men get older and, in some cases, it can become problematic. As the prostate enlarges it may cause narrowing of the urethra. The bladder then needs to contract harder to squeeze urine out. This can cause the bladder to weaken and lose the ability to empty completely, causing overflow incontinence.

BPH can be managed with lifestyle changes, medication and sometimes surgery.

Symptoms:

  • the need to urinate more frequently, often at night
  • difficulty starting to pass urine
  • weak flow
  • feeling the bladder has not emptied
  • taking a long time to urinate.

Normally a General Practitioner will take a full history of symptoms and perform an examination. They will request a prostate specific antigen (PSA) blood test and carry out a digital rectal examination.

Other factors affecting both men and women

Functional incontinence is where a person is usually aware of the need to urinate, but for one or more physical or psychological reasons they are unable to get to the toilet.

People with dementia may be aware of the need to go to the toilet but may not be able to express this need. There could be a noticeable change in behaviour, such as agitation or restlessness. They may have forgotten where the toilet is or be in unfamiliar surroundings.

Physical problems such as poor eyesight, mobility or dexterity can all lead to difficulty accessing the toilet. Fear of falling, depression and anxiety can also be factors, as well as environmental factors, such as poor lighting, low chairs, stairs or steps and unusual surroundings. Inadequate toilet facilities or a person's fear of using them can also contribute to someone being incontinent.

Outflow obstruction

This is where the bladder neck is restricted. It is more common in men because as they age the prostate gland naturally enlarges, restricting the urethra and making it harder to pass urine. It may also enlarge as a result of cancer.

Other causes of outflow obstruction include urethral strictures and chronic constipation.

Symptoms of outflow obstruction include:

  • passing small, frequent amounts of urine
  • hesitancy in starting to pass urine
  • poor urine flow
  • post micturition (post urination) dribble.

Detrusor underactivity

This is where the bladder muscle is underactive and does not contract properly to effectively pass urine and empty. The bladder will stretch and potentially retain large volumes of urine.

It is caused by damage to the nerves supplying the bladder or to the lower spinal cord. It is usually experienced by people with a spinal injury and neurological conditions, such as multiple sclerosis and diabetic neuropathy.

Symptoms of detrusor hypoactivity include:

  • a lack of bladder sensation
  • an ability to go long periods of time without passing urine
  • overflow incontinence - if the bladder is overfull and can’t fully empty.

In both types of voiding difficulties people may experience frequent urinary tract infections.

Surgery

  • having surgery on the lower abdomen can cause the bladder to tilt leading to incontinence or damage to the sphincter.

Pregnancy and childbirth

  • it is common for women to experience incontinence during pregnancy and following childbirth.

Excess weight

  • excess weight causes pressure on the bladder and makes incontinence worse.

Stress incontinence

Go to 'Types of incontinence' for more information

Overactive bladder (Urgency) 

A person with overactive bladder may not have incontinence but have symptoms that significantly affect their quality of life. 

Symptoms of overactive bladder include: 

  • frequency - needing to pass urine frequently 
  • urgency - an urgent need to pass urine; at times the person may not reach the toilet in time and be incontinent 
  • nocturia - waking during the night to use the toilet. 

What causes an overactive bladder?

  • increase in age
  • diuretics, anxiety
  • post menopause
  • faecal impaction
  • diabetes
  • irritation to the bladder i.e. stones
  • urinary tract infection (UTI)
  • fluids and some medications.

What can be done? 

  • limit caffeine, alcohol and carbonated drinks, bladder retraining, antimuscarinics. 

Nocturnal Polyuria

Nocturnal Polyuria is when you produce too much urine overnight. It is defined as passing more than one third of your 24-hour urine output at night.

Causes? 

  • heart failure
  • medication
  • sleep apnoea
  • drinking too much before bedtime.  

What can be done? 

  • adjusting diet and fluid intake
  • elevation of swollen legs during the day
  • increase exercise
  • diuretic
  • nasal or tablet antidiuretic hormone.

Urinary Tract Infections (UTI’s) 

Ruling out a urinary tract infection is a key part of a continence assessment. A urinary tract infection can cause urinary frequency and urgency which can lead to incontinence. If the urinary tract infection is diagnosed and treated, the incontinence symptoms may resolve. Smelly or cloudy urine alone, are not signs of a urinary tract infection, but may indicate the patient is dehydrated.  

UTI's can affect different parts of your urinary tract. They are divided into three types: 

  • lower urinary tract infection (LUTI)
  • upper urinary tract infection (UUTI)
  • Catheter Acquired Urinary Tract Infection (CAUTI).  

Each is diagnosed by a clinical assessment including baseline patient observations.   

We will look at each type of infection and then at risks associated with misdiagnosing UTI’s by using urinalysis sticks inappropriately, linked to recent learning about ‘Asymptomatic Bacteriuria’.  

Lower Urinary Tract Infections (LUTI's) 

LUTI’s affect your bladder (cystitis) and or your urethra (urethritis.)

Symptoms of a lower urinary tract infection include:

  • needing to pass urine urgently or more frequently than usual 
  • pain or a burning sensation when passing urine 
  • blood in your urine 
  • pain in lower abdomen 
  • feeling tired and unwell 
  • new onset or worsening incontinence 
  • increased voiding at night.

Spotting symptoms

UTI symptoms may be difficult to spot in people with dementia.

Patients can seek advice from NHS 111.

The NHS will advise a patient to seek non-urgent advice from their GP if: 

  • they are a man with symptoms of a UTI 
  • they are pregnant and have symptoms of a UTI 
  • a child has symptoms of a UTI 
  • they are caring for someone elderly who may have a UTI 
  • they have not had a UTI before 
  • they have blood in their urine 
  • their symptoms do not improve within a few days 
  • their symptoms come back after treatment 
  • if a patient has symptoms of a sexually transmitted infection (STI), they can also get treatment from a sexual health clinic.

Upper Urinary Tract Infections (UUTI’s) 

UUTIs affect your kidneys leading to Pyelonephritis. Patients with an upper urinary tract infection are normally unwell. The common symptoms are listed below. It important to learn that these patients may not mention their bladder at all, but often feel nauseous, or are being sick, have a very high temperature and muscles aches.  

Symptoms of an upper urinary tract infection may include the same symptoms as LUTI and will include one or more of the following:

  • pain in your sides or lower back  
  • a very high temperature or you feel hot and shivery 
  • feel nauseous or are vomiting 
  • diarrhoea in older people
  • changes in behaviour such as severe confusion or agitation.

These symptoms suggest a kidney infection, which can be serious if it's not treated. Urgent assessment should be sought for these patients e.g. by ringing 111.   

Asymptomatic bacteriuria

Bacteriuria is not a disease. The human body needs bacteria known as normal flora, as a key part of the body’s defences against infection and because of their influence on nutrition.

Bacteriuria can be described as the presence of bacteria in urine when seen under a microscope. We all have some level of bacteria in our urine at all times. 

Asymptomatic bacteriuria can be described as the presence of bacteria in urine, when seen under a microscope in a urine sample taken from a patient without any typical symptoms of lower or upper urinary tract infections. This means there is bacteria in the urine, but the patient has no signs or symptoms of a urinary tract infection and therefore does not need any treatment with anti-biotics.  

Symptomatic bacteriuria is the presence of a significant amount of bacteriuria in urine when counted under a microscope, from a patient showing more than one of the signs and symptoms of a lower or upper urinary tract infection.  

Bacteriuria in the urine is uncommon in people under 65 years but increases in those over 65 years.  Bacteriuria is more common in some populations of institutionalised women, for example those living in residential or nursing homes and in people with long term indwelling urinary catheters. 

Urinalysis detects the presence of bacteria in the urine by detecting Leucocytes which are white blood cells produced by the body to fight bacteria and Nitrates which are enzymes produced by bacteria.

In the past, health care professionals have used urinalysis and results from urine samples sent for microscopy to diagnose UTI’s. If they found leucocytes and nitrates in patient groups, we now know to have asymptomatic bacteriuria as a normal process, antibiotics would be prescribed for the patient, even though they did not have any signs or symptoms of a urinary tract infection.

The National Institute for Health and care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) now recommended that urinalysis is NOT used to diagnose a urinary tract infection in these groups of patients. Instead a diagnosis must be made purely on a clinical assessment of signs and symptoms.  

Urinalysis is still useful as part of a holistic assessment for UTI in adults under the age of 65.  

Urinary tract infection (UTI) is the second most common clinical reason for anti-biotics to be prescribed in the UK. The overuse of antibiotics can lead to patient’s having unwanted side effects such as diarrhoea, loss of appetite, thrush infections and could lead to them contracting Clostridium Difficile Infection (CDI) or methicillin resistant Staphylococcus aureus (MRSA) infection. The overuse of antibiotics is also leading to bacteria becoming resistant to them, reducing the number of effective treatments we have.  

Further resource: Scottish Intercollegiate Guidelines Network (2012) Management of suspected bacterial urinary tract infection in adults. A national clinical guideline

Catheter Acquired Urinary Tract Infection (CAUTI)  

100% of patients with an indwelling catheter have bacteriuria therefore urinalysis should never be used to diagnose a CAUTI for a patient with an indwelling catheter or if they use intermittent catheters. These patients should be diagnosed by a holistic assessment including baseline observations, based on their clinical signs and symptoms. The catheter provides a focus for bacterial biofilm formation and most catheterised patients have at least 2 types of bacterial colonisation. Urinary tract infection is the most common hospital acquired infection in the UK, accounting for 23% of all infections and the majority of these are associated with catheters for 8% of hospital acquired bacteraemia (SIGN 2012).

The longer a patient has a catheter in situ the chance of getting a CAUTI increases.  

Always ask:

Does the patient need a catheter? If the answer is NO, ensure plans are made to do a trial without a catheter. 

Diagnosis of a CAUTI must always involve assessing for clinical signs and symptoms compatible with a CAUTI. 

Dip stick testing of urine must NOT be used to diagnose a CAUTI, because:

  • patients with a urinary catheter may have non-visible haematuria due to ongoing trauma of the catheter 
  • patients with a urinary catheter are likely to have bacterial colonisation of their urine due to the presence of the catheter which would show as leucocytes and nitrates on a urinalysis stick.

Symptoms of a CAUTI include:

  • renal angle tenderness or suprapubic pain
  • chills/rigors
  • new costovertebral tenderness
  • new onset delirium
  • malaise, or lethargy with no other identified cause
  • acute haematuria
  • pelvic discomfort.

In those whose catheters have been removed or who are using intermittent catheters:

  • dysuria
  • urgent or frequent urination
  • supra-pubic pain or tenderness.

In patients with spinal cord injury:

  • increased spasticity
  • autonomic dysreflexia
  • fever greater than 37.9°C or 1.5°C above baseline on two occasions during 12 hours.  

If a patient is diagnosed with a CAUTI, a clinical assessment should be made to see if the catheter can be removed. If this is not possible, if the catheter has been in place for more than seven days, ensure the catheter is changed before or as soon as is practicable after antibiotics have been are commenced. Evidence shows this gives the body the best chance of fighting the infection as bacteria will have built up on the old catheter.

Further resource: NICE guidance and information on treatment of a CAUTI: NICE (2018) Urinary tract infection (catheter-associated): antimicrobial prescribing

Urosepsis

What is sepsis? 

Sepsis is a life-threatening reaction to an infection. It happens when your immune system overreacts to an infection and starts to damage your body's own tissues and organs. You cannot catch sepsis from another person. Sepsis is sometimes called septicaemia or blood poisoning. If not treated immediately, sepsis can result in organ failure and death. Yet with early diagnosis, it can be treated with antibiotics. 

Urosepsis is defined as sepsis whose source is the urogenital tract. It is most often related to an upper urinary tract infection. 

Sepsis can initially look like flu, gastroenteritis or a chest infection. There is no one sign, and symptoms present differently between adults and children. 

Further resource: Sepsis Trust

How to spot sepsis in an adult

If a person you are caring for looks or feels unwell, doing an early warning score such as the National Early Warning Score (NEWS) can help you to recognise sepsis, raise the alarm quickly to a senior colleague or health care professional and prioritise care so they can be treated within the hour.

Seek medical help urgently if you (or another adult) develop any of these signs:

  • Slurred speech or confusion 
  • Extreme shivering or muscle pain 
  • Passing no urine (in a day) 
  • Severe breathlessness 
  • It feels like you’re going to die 
  • Skin mottled or discoloured.

Call 999 and just ask: could it be sepsis? 

This RCN resource on Sepsis contains guidance on how to assess adults for sepsis and what to do if you think a patient could have sepsis.

Urinalysis 

Urinalysis is a key part of any Continence Assessment. New onset incontinence could be linked to an undiagnosed urinary tract infection. Urinalysis gives us further information to help us assess our patient’s holistically and diagnose and treat type or types of urinary incontinence, and contributing factors such as undiagnosed diabetes, or haematuria suggesting a possible underlying bladder cancer.  

Urinalysis as a diagnostic tool for urinary tract infections, should only be used for adults in their own homes, under the age of 65, as the chances of asymptomatic bacteriuria are lower, meaning urinalysis becomes a more useful diagnostic tool.  

To Dip or Not to Dip training presentation

Watch this 15-minute presentation aimed at staff working in residential and nursing care home settings. This is recommended for any health care professionals as the general principles apply to all health care settings. It is a useful summary explaining further the signs and symptoms of a urinary tract infection and the need to ensure patients are diagnosed and treated based on clinical signs and symptoms, reducing the unnecessary prescription of antibiotics.  

Further resources

Royal College of Physicians. National Early Warning Score (NEWS) 2
NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management
NICE (2018) Urinary tract infection (catheter-associated): antimicrobial prescribing
NICE. Guidelines about COVID-19
NICE (2018) Urinary tract infection (lower): antimicrobial prescribing
NICE (2018) Urinary tract infection (recurrent): antimicrobial prescribing
NICE. Urinary tract infections overview
The UK Sepsis Trust. About sepsis
SIGN (2012) Management of suspected bacterial urinary tract infection in adults (2012)

Some medications can disrupt the normal process of storing and passing urine or increase the amount of urine produced. However, medication should not be stopped without consulting a GP or consultant.

These are a few examples:

  • diuretics (water tablets) such as thiazides and furosemide increase urine production
  • opioids such as morphine can interfere with bladder contraction and cause or exacerbate constipation
  • Angiotensin Converting Enzyme (ACE) inhibitors such as Ramipril and Captopril are usually used to treat high blood pressure. However, they can cause a cough and worsen stress incontinence
  • antidepressants such as citalopram are used to treat mood disorders and can interfere with bladder contraction and make constipation worse
  • sedatives such as diazepam and lorazepam can slow the reflexes, affecting the ability to recognise the signal that the bladder is full
  • Hormone Replacement Therapy (HRT) – the lower urinary tract is sensitive to the effects of oestrogen and during the menopause levels naturally decline. There is conflicting advice and evidence about whether or not HRT affects bladder control
  • alcohol and caffeine are diuretics that can increase urine production. Caffeine can cause irritation of the bladder lining
  • nicotine is thought to irritate the detrusor muscle and trigger urge incontinence. Smoking can also cause a cough, which can lead to urine leakage
  • ketamine is a drug used medically in anaesthesia and as a pain killer but has been used as a recreational drug due to its hallucinogenic and euphoric properties. In large and repeated doses, it has been found to cause shrinkage and fibrotic changes to the bladder. It can cause frequency, bleeding and pain on passing urine. 

Further resources

ICS (2017) Evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence 2017
NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management NG123
NICE (2015) Lower urinary tract symptoms in men: management

Bowel incontinence

It is estimated that one in 10 people will be affected by bowel incontinence at some point in their life, although it is more common in women and older people. 

Constipation 

Straining during bowel movements can weaken the pelvic floor muscles or a full bowel can press against the bladder causing the urgent need to urinate or having to pass urine more frequently. 

Constipation can be treated by: 

  • drinking more water
  • eating foods rich in fibre 
  • doing regular exercise 
  • practising pelvic floor exercises 
  • not ignoring the urge to pass stools 
  • checking the side effects of medications
  • iron supplements, calcium supplements and opioids such as morphine can cause constipation
  • discussing any concerns with a health care professional and not stopping medication without seeking advice first. 

Further resources

RCN Gastroenterology subject guides
RCN (2019) Management of Lower Bowel Dysfunction, including Digital Rectal Examination and Digital Removal of Faeces for more information on bowels and the digestive system.

Urge incontinence

When a person feels the urge to pass faeces but has to rush to make it on time. 

Flatus (wind) incontinence

When a person feels the rectum filling, but their body's nerves cannot tell whether it is wind or a stool. 

Passive incontinence

When a person feels no urge to open their bowels. They are unaware that the rectum is full and ready to be emptied and cannot consciously control their bowel movements; therefore, stools can pass without their knowledge. 

Anal and rectal incontinence

The inability to control the muscles of the rectal canal and anal sphincter. If the nerves are damaged in the rectum control problems and leakage can occur. 

Overflow incontinence

The leakage of watery faeces caused by a blockage of hard faeces. This can be mistaken for diarrhoea. 

Further resource: RCN (2019) Management of Lower Bowel Dysfunction, including Digital Rectal Examination and Digital Removal of Faeces

Opioids

Opioids such as morphine can interfere with bladder contraction and cause or exacerbate constipation. 

Antidepressants

Antidepressants such as citalopram are used to treat mood disorders and can interfere with bladder contraction and make constipation worse.

Assessment

Incontinence can be a sensitive subject for many people. Often it is associated with shame and guilt. But the more that is understood about the condition, for instance knowing that incontinence is a common problem that is not restricted to older people, the more confident you will feel discussing the issue and supporting the individual. 

Breaking down barriers 

To support people with incontinence effectively, you need to improve your knowledge. With the right information and advice, you can provide people with support and guidance tailored to their needs.

Beginning the conversation 

When raising the topic of incontinence with a patient for the first time, you should aim to achieve three things: 

  1. Identify whether there is a continence issue 
  2. Does the individual or their carers perceive it to be a problem? 
  3. Encourage the individual to discuss their anxieties and what support they need. 

The following tips might help: 

Are you the right person to talk to? 

Consider whether the person needs to be referred to someone with more specialist knowledge. 

How will they respond?

It may be uncomfortable for the person to discuss their incontinence with you, so their response may be one of embarrassment and frustration, even anger. If you can anticipate what their reaction will be, then it can help you to work more effectively with them. 

When is the right time? 

Knowing when to raise the subject is important; it is best done when the individual is calm and can focus on what is being said. Be aware of cues that might indicate that the person wants to discuss something with you. This might be something like "I'm slightly worried about going out and don't take my water pills." 

What tone should I use?

You should use an empathic, matter-of-fact tone of voice. If you feel uncomfortable, don't let this show as it can make the person uncomfortable too. 

Living with incontinence can be challenging. People with the condition may feel uncomfortable discussing it with others and may be embarrassed to admit they have a problem, which can result in them not getting the support and advice that could improve their quality of life. 

The nature of the condition means that the person lives with the fear of having “accidents”, particularly in public, which can lead to feelings of shame and embarrassment resulting in social isolation. 

“My wife would be horrified if she knew she had been incontinent. She has always been so immaculate and proud of her appearance”- Husband whose wife has dementia

"The staff are always so busy, and I feel like a nuisance when I press the buzzer. I don’t want to have an accident. That would make more work for them”– 95-year-old inpatient  

'Over time incontinence leads to a curtailment of daily activities e.g. going out, shopping etc. which decreases self-esteem' (Cartwright R, Srikrishna S, Cardozo L, Robinson D. Validity and reliability of the patient’s perception of intensity of urgency scale in overactive bladder. BJU International. 2010)

Support 

Many health care professionals lack the time and understanding to support people with incontinence effectively, which can lead to individuals being given inappropriate advice. Informal carers can feel overwhelmed and stressed and the daily management of incontinence can feel like a constant cycle of changing and washing. However, by introducing a continence strategy the individual, health care professional and informal carers can gain more control, as well as reduce the workload and enhance the quality of care provided.  

Ability to communicate 

Many people find it difficult to communicate the need to go to the toilet. They may: 

  • be unable to express need for the toilet verbally due to aphasia or dysphasia 
  • lack the language skills to describe need, for example, they may speak no English or have limited vocabulary 
  • may use Makaton or other sign language to express need, requiring other people to understand 
  • may not be able to read, recognise or see signs to toilet facilities 
  • have speech which may be difficult for others to understand if slurred or words are confused.

These may be exacerbated if the person is stressed because of the difficulty in making others understand. 

The assessment process should be able to identify how a person communicates. Body language is a useful tool for identifying the need in a person with learning or cognitive difficulties. Carers or relatives may easily spot when an individual wants to go to the toilet just by the change in their body language. 

Some people communicate using low tech aids, such as communication books, signs, picture symbols or augmentative and alternative communication aids (electronic talkers).  

However, by simply taking the time to understand how each individual communicates, (they may have unique signs) you can start to recognise when they want to go to the toilet.  

Anxiety 

Many people with incontinence feel anxious about going to the toilet and this can cause them unnecessary stress. They may feel: 

  • embarrassed at time and frequency when at work 
  • pressure as some employers have strict monitoring of toilet breaks 
  • fear and stress about availability and accessibility of toilet facilities 
  • worried about being disturbed or overheard 
  • scared others may notice them having frequent toilet breaks 
  • fear of having accidents. 

Attitudes 

If a member of staff has a negative attitude it is distressing for the person who is incontinent and can prevent them from discussing their problem in an open and supportive way. No one enjoys handling other people’s urine and faeces, but as a nurse the member of staff has a responsibility not to allow personal feelings to get in the way of providing dignified and compassionate care. 

"This is the fourth time I've cleaned you up today. You should really sort yourself out" 

Comments like this are unacceptable and unprofessional and should be addressed under a disciplinary discussion. 

Dignity 

Dignity logo 

"Dignity is concerned with how people feel, think and behave in relation to the worth or value of themselves and others. To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals" 

Dignified care should be person-centred and not just focused on tasks and processes. An important element of care is to be aware of and sensitive to the features of a person’s life, including their values, feelings and beliefs. Being in need of support, both physically and emotionally, can make anyone vulnerable. 

You may find the following resources useful:

RCN - 'How would you feel?' video

Dignity, Privacy and Confidentiality 

6C's

The daily management of incontinence can be stressful for individuals with the condition, so any advice and support you can offer them will be invaluable. 

"My goal is to get to the bathroom on my own and to be able to wipe my own bottom”  - (38-year-old stroke patient) 

It is important to remember the 6Cs of nursing when managing individuals with incontinence: 

  • be compassionate. Incontinence can be a sensitive issue for patients to discuss and uncomfortable to deal with on a day to-day basis 
  • manage a patient’s continence needs competently 
  • communicate effectively to enable the person to get their needs and wants met 
  • be courageous. Overcome your own issues and concerns about supporting a person with incontinence 
  • make a commitment  to manage and support the person the best way you can using all your knowledge and skills
  • meet the care challenges of incontinence head on. 

By keeping the 6Cs at the forefront of management of individuals with incontinence, you may find that the experience becomes positive and meaningful where the patient feels valued and is given the tools to manage and cope with their incontinence. 

Assessment tools

There are different types and causes of incontinence. A continence assessment helps to determine what the problem is and what treatment is required. It includes details of the individual’s signs and symptoms and a physical examination may be indicated. 

Further resource: RCN (2020) Genital examination in women

Quality of life questionnaires

There are questionnaires that can help to measure quality of life, developed by the International Consultation on Incontinence Questionnaire (ICIQ) group. These tools are specifically related to incontinence and enable people to report their own perspective of their situation.

Further resource: ICIQ - UI short form

Symptom profiles to help diagnose the bladder problem.

Pathways

Care Pathways support health care professional and patient to take a stepped approach after diagnosis, which is evidenced based.

Further resource: Urinary continence assessment, treatment and management - using the Colley Model

The consent of the individual to an examination must be gained; however, if there is any doubt about the individual’s capacity the intervention should only be undertaken in the person's best interest. It is important to identify why the person is seeking advice at this time.  

Points to consider include: 

  • how often the person goes to the toilet to urinate and defecate and whether this is a change to their normal routine 
  • current or previous medical history (including pregnancy and urine infections) 
  • possibility of physical or sexual abuse, including Female Genital Mutilation - FGM 
  • a rough estimate of the amount of urine passed 
  • visual description of the faeces (normally based on Bristol Stool Chart) 
  • if there is leakage, whether it is urine or faeces 
  • information about diet and fluid intake 
  • any medications being taken (both prescribed and over the counter) 
  • lifestyle factors, including recreational drugs, alcohol, smoking and weight 
  • ability – for example, whether the person can feed, dress and bathe on their own.
  • mobility – physical or environmental factors 
  • capacity – does the person recognise the need to go to the toilet or do they forget where the toilet is?

Bladder diary

Having a 3-day bladder diary with information about the type of drink and the amount in 24 hours can be used to support part of the assessment.

Examples of bladder diary and bowel charts:

Bladder diary

Bowel chart

  • do you know the size of the cup/mug is drunk?
  • what is type of drink? Is it caffeinated? Or caffeine free as caffeine can irritate the bladder as can fizzy drinks.
  • an output of urine, to highlight voiding issue, such as overactive bladder, retention of urine.  

Hydration

Promoting the importance of hydration is key to improving bladder and bowel symptoms. Human beings are made up of 75-80% water. Studies suggest most healthy people should try to drink six to eight glasses of water each day. Water is the best fluid for optimum bladder health, however some people need to drink less water because of certain health conditions such as kidney failure, heart disease and being underweight (Abrams Fluid Intake Matrix guide, 1996).

Tools like the Fluid Intake Matrix can help to support the volume of fluids that a person should be having in 24 hours.

Fluid Intake Matrix

A guide to the volume of fluid required per body weight for 24 hours. Not to be followed if medical condition contra-indicates i.e chronic renal failure.

Fluid intake matrix

This matrix is to be used as a guideline and broadly it is suggested that patients fall within a margin of error +/-10%. The guideline applies to body frame and gross obesity should not be taken as a guide for increasing fluid.

Activity levels should not be taken into account.

Reference: Abrams & Klevmar 'Frequency Volume Charts - an indispensable part of lower urinary tract assessment' 1996 Scandinavian Journal of Neurology 179. 47 - 53

Dehydration occurs when the body expels more fluids than it is taking in, dehydration can lead to urinary tract infections which can become severe enough to warrant antibiotics. Longer term dehydration can cause kidney stones and kidney infections. Concentrated urine consists of more solutes which are dissolved particles like sugars which should be expelled as waste, these particles can irritate the bladder causing frequency, urgency and overactive bladder. Added ingredients in fizzy drinks and energy drinks and caffeine in tea and coffee can exacerbate certain bladder symptoms. Acidic foods and drinks, such as lemons, limes, oranges and grapefruit’s, tomatoes and tomato products are also reported to aggravate bladder symptoms.

Dehydration is one of the most common causes of infrequent bowel function and chronic constipation, which results in hard stools which are difficult to pass. Besides water, vegetable juices, clear soups and herbal teas are all good quality sources of fluids. There is evidence suggesting increased water consumption enhances the effects of a high-fibre diet on stool frequency and reduces laxative consumption in adult patients with functional constipation.

Are you drinking enough?

Making sure you are drinking enough fluids can help your recovery and keep you fit and healthy, preventing dehydration.

You should aim to drink at least 1.6 to 2 litres (approx. three to four pints) of fluid per day to stay hydrated. This is the same as around eight glasses or mugs of fluid.

Signs of dehydration can include: a dry mouth or lips, thirst, tiredness, headache, dry and loose skin, and dark coloured or strong smelling urine. 

Use the urine colour chart below to check if you may be dehydrated. If you are concerned please speak to a nurse.

Are you drinking enough?

There is a growing body of evidence linking fluid balance with bladder and bowel dysfunction and we now have online hydration toolkits available to support staff in achieving optimum hydration. It can be challenging for some to drink sufficient fluids to achieve optimum hydration and these tool kits have a wealth of resources and guides to support you in clinical practice.

More information related to hydration can be accessed here: 

RCN. Hydration essentials.
NICE (2018) Reducing incidence of Urinary Tract Infections by promoting hydration in care homes.
NICE (2018) Seven glasses a day, keep UTIs at bay.

Red Flags

National Institute for Health and Care Excellence (NICE) guidelines suggest that a referral should be made for urgent or specialist investigation if an individual has any of the following ‘red flag’ symptoms see NICE guidance:

Bladder

  • haematuria (blood in the urine) 
  • recurrent urinary tract infections (3 or more in last 6 months) 
  • loin pain (pain in the lower back) 
  • recurrent catheter blockages 
  • hydro nephrosis or kidney stones on imaging 
  • biochemical evidence of renal deterioration.  

Bowel 

  • rectal bleeding 
  • mucous present on defaecation 
  • altered bowel habit (frequency or consistency) 
  • unexplained weight loss. 

Recent travel to other countries (particularly developing countries) should be identified. 

Any possible safeguarding issues should be identified and managed according to local protocols.

Further resources:

NICE. Suspected cancer recognition and referral: site or type of cancer
NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management NG123
NICE (2015) Lower urinary tract symptoms in men: management CG97

Urinalysis

Bladder 

Testing Urine, as part of a continence assessment in line with NICE Guidance.

Urinalysis for a Continence Assessment

Urinalysis for a continence assessment

Urinalysis for a continence assessment pt2

Reference: Produced by Southern Health NHS Foundation Trust with permission to use

Bristol Stool Chart 

People have different bowel habits and most who regularly “go” three times a week and pass good stools (not too hard or soft) are considered to have normal bowels. 

To help health care professionals determine what is “normal”, a visual guide was developed to identify the type of stool passed. The Bristol Stool Chart is an assessment tool designed to classify human faeces into seven categories. 

Bristol stool chart

Lewis SJ, Heaton KW (1997) Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology 32: 920–4

What each type means?

  • Type 1-2 indicate constipation
  • Type 3-4 are ideal stools 
  • Type 5-7 may indicate diarrhoea and a need to empty the bowels urgently 

Treatment

Treatment for bowel incontinence depends on underlying cause and the pattern of the symptoms. 

Trying the least intrusive treatments first, such as dietary changes and exercise programmes, is often recommended. Medication and surgery are usually only considered if other treatments haven't worked. 

Treatment that can help with bowel incontinence includes: 

Dietary changes 

Bowel incontinence associated with diarrhoea or constipation can often be controlled by making changes to the diet. 

Diarrhoea 

NICE provides the following dietary advice to people with diarrhoea associated with bowel incontinence:

  • limit fibre intake from wholegrain breads, bran, cereals, nuts and seeds (except golden linseeds) 
  • avoid skin, pips and pith from fruit and vegetables
  • limit fresh and dried fruit to three portions a day and fruit juice to one small glass a day (make up the recommended ‘five a day’ with vegetables) 
  • reduce consumption of fizzy drinks and drinks containing caffeine 
  • avoid foods high in fat, such as chips, fast foods and burgers. 

Constipation 

A high-fibre diet is usually recommended for most people with constipation-associated bowel incontinence. A GP can confirm whether a high-fibre diet is suitable. Fibre can soften stools, making them easier to pass. Foods that are high in fibre include: 

  • fruit and vegetables
  • beans
  • wholegrain rice
  • whole-wheat pasta
  • wholemeal bread
  • seeds, nuts and oats
  • fluids can help to soften stools and make them easier to pass. 

Pelvic floor muscle training 

Pelvic floor muscle training is a type of exercise programme used to treat cases of bowel incontinence caused by weakness in the pelvic floor muscles. 

Bowel retraining 

Bowel retraining is used to treat people with reduced sensation in their rectum as a result of nerve damage, or for those who have recurring episodes of constipation. 

There are three goals in bowel retraining: 

  • to improve stool consistency 
  • to establish a regular time to empty the bowels 
  • to find ways of stimulating the bowels to empty themselves.

Living with incontinence: Tips you can recommend 

  • women should sit on the toilet rather than hover as it will enable them to empty their bladders properly 
  • sit comfortably with knees just above hip level, with arms on knees to open bowels. 
  • eat a well-balanced diet 
  • never go to the toilet ‘just in case’ because the bladder will get used to holding smaller volumes, thus developing frequency and urgency. 
  • feel relaxed, unhurried and safe when using a toilet 
  • stop smoking 
  • carry a spare set of clothes for continence issues 
  • drink gradually throughout the day, large volumes in the evening could lead to nocturnal frequency 
  • practice pelvic floor exercises 
  • cut down on caffeine - has a diuretic effect 
  • stay hydrated - people often cut down on water and other fluids to reduce the risk of accidents, but by drinking less urine becomes more concentrated, which is more irritating for the bladder and increases urinary incontinence 
  • a Radar key will allow access to all disabled public toilets and can be obtained from the local authority or online. 
  • lose weight - extra weight may increase pressure in the abdomen and worsen urinary incontinence. 

Barriers to maintaining continence

It is estimated that more than three million people in the UK are affected by incontinence which has no anatomical cause. The person may be rendered incontinent because of physical, psychological, emotional, cognitive or environmental factors. Some of these are listed below. 

Learning/cognitive disability 

Learning disability or cognitive impairment needs to be taken into consideration when carrying out a continence assessment. Bowel and bladder control may take longer to develop in individuals with learning disabilities. Specialist continence support for these people can result in them becoming continent. 

Language barrier

We must make sure, wherever practical, that arrangements are made to meet patients’ language and communication needs.

Mobility 

If a person has the ability to know when they need to go to the toilet, but are unable to do so independently, they may experience continence issues. 

For some people, accessing the toilet can be so challenging that using a pad or requesting a catheter is easier than trying to remain continent. If the person is a wheelchair user and needs support to go to the toilet, it can be particularly challenging as help is not always available in a timely manner. 

A full assessment may identify toileting aids and equipment (such as urinals, handrails, commodes and removable clothing) that can support an individual to remain independent and, in some cases, major adaptations such as hoists, downstairs toilet or stairlift may be appropriate.

Environmental factors 

When people are out and about in the community, toilets can often become an issue. The location and accessibility of toilets can be a barrier to continence, and with councils closing more public toilets it makes getting to a toilet even more difficult. 

In general people do not like to be heard on the toilet or may be embarrassed when using public toilets. Often these facilities are not clean and can be unpleasant to visit. If a person does not have a choice in where they go to the toilet, it may become preferable to be incontinent than use an unsuitable bathroom or toilet. 

People with Autistic Spectrum Disorders (ASD) may only be able to use a toilet in the home environment or use certain toilets when they are in an unfamiliar place, so this will need to be planned before going outside of the home. 

Flooring in bathroom areas need careful consideration as certain colours or shiny floors can make the floor look wet and cause problems for people with visual impairments. 

Care homes and hospitals often locate toilets away from main areas and they may be poorly marked or signposted. If an individual cannot locate the toilet or it is too far away, involuntary incontinence may occur. 

Often signage on toilet doors can be confusing, especially for people with dementia. Complicated or modern icons might be used, which some people may find difficult to recognise as the place where they can go to the toilet. 

Other examples of where the environment can make it difficult for people to go to the toilet: 

  • poor maintenance of public toilet facilities – wet, dirty floors 
  • many accessible facilities need a Radar key to gain access, which can be obtained from the local council 
  • poor consideration of space needed by wheelchair users or people with young children in pushchairs 
  • doors are often heavy and open outwards, requiring assistance from another person to gain access 
  • no hoists or changing plinths in the majority of accessible facilities 
  • person has to transfer to the toilet by standing or using transfer aids  
  • a limited number of cubicles in men’s toilets and lots crammed into ladies toilets, making it hard to gain privacy if they have diarrhoea or offensive smelling stools or flatulence. 

Assessing an individual for the correct equipment to manage and maintain their continence is imperative. It will require input from a specialist continence professional who may be a nurse or an occupational therapist. 

There is a wide variety of equipment on the market and finding the most appropriate for the individual is vital. The types of equipment may range from raised toilet seats to highly specialised toilets that may include the facility to wash the person. 

Simple things that can help support people with incontinence include: 

  • toilet paper is always available 
  • the bathroom area is clean 
  • toilet doors are able to close 
  • sufficient space and access needs to be provided to allow for staff, wheelchairs and other aids.

Clothing 

Clothing can be a barrier to managing incontinence. If a person has poor manual dexterity, they can find it difficult to undo or pull-down garments. There are a number of companies which manufacture clothing that is easy to remove, pull down, etc. For example, skirts with velcro sides, trousers/pants with drop down fronts. These garments look functional and unfashionable or just unappealing and people should seek advice about where they might find clothing that meets their needs and looks nice. As an alternative, it may be possible to alter existing clothing to make dressing and living with incontinence more manageable. 

Equipment and devices 

A number of products are available to help with the management of incontinence. These include: 

  • handheld urinals (urine collection bottles) 
  • a catheter, a thin tube that is inserted into the bladder to drain urine. It may be used intermittently or on a long-term basis 
  • devices that are placed into the vagina or urethra to prevent urine leakage, for example during exercise 
  • urinary sheath 
  • absorbent products, such as incontinence pants or pads.

Urinary catheters

Following your clinical assessment and collaborative decision making on the need for a urinary catheter consideration then needs to be given on make (potentially guided by local formulary), size (sex, urethral/ suprapubic and clinical assessment) and type:

Indwelling (Short term) – used for 28 days or less

Indwelling (Long term) – used for up to 12 weeks

Intermittent - inserted several times a day, for just long enough to drain the bladder, and then removed

A Suprapubic (SP) Catheter is initially surgically inserted through the skin to the bladder, it is important to check that the catheter is licenced to be used for a SP Catheter.

Further resources

RCN (2019) Catheter care: guidance for health care professionals 
NHS England. Urinary catheter tools  
NHS (2020)Types of urinary catheters 

Toilet Aides

Bed pans

Bed pans are a portable receptacle for bed bound patients. They are often made from a plastic which can be washed at high temperatures or recycled or moulded pulp that can be disposed of after use.  

Positives: low cost, can be reusable and easy to clean. 

Negatives: User may find it uncomfortable to use while lying down. User may need assistance to get bed pan in position.  

Bed pan 

Commodes

Commodes are a chair with concealed toilet bowls. Commodes are available with the following features designed to make them comfortable, convenient and stable, such as adjustable height, removable arms, splayed legs and footrests. 

Positives: Discreet, can be placed near the bed for easy access at night, some are suitable to be used as shower chairs or can be wheeled over a normal toilet. 

Negatives: The commode and pale require regular and thorough cleaning and disinfection to prevent cross infection.

Commode 

Free-standing toilet frame

A free-standing toilet frame is made from a steel frame that locates around the toilet to offer toileting support. A Sani chair is similar but with a toilet seat attached.

Positives: flexible can be altered to be the correct height for the patient. No need for building alterations.

Negatives: not secured to the wall or floor – could tip or cause entrapment. 

 Free standing toilet frame

Floor / wall mounted toilet supports

Floor / wall mounted toilet supports are useful where space is limited as they can be folded up out of the way when not required. They are particularly appropriate for users who may be transferring to and from a wheelchair.

Floor/wall mounted toilet support 

Raised toilet seat

The raised toilet seat can be fitted over the existing toilet seat and is secured in place to the toilet bowl with two clamps at the rear, available with or without lid. 

Positives: Easy to fit, available in different heights depending on patient.

Negatives: risk of falls if not fitted correctly.

Raised toilet seat 

RADAR keys

RADAR keys: The Royal Association for Disability and Rehabilitation, which is now Disability Rights UK, worked in partnership with Nicholls & Clarke, the inventors of the RADAR lock and together they created the National Key Scheme (NKS). The first RADAR locks were fitted in 1981 to help keep accessible toilets free and clean for disabled people.  

Positives: Easily available from most local authorities who will sell or give a RADAR key. 

Negatives: If you are travelling to Europe, the RADAR key will not work so you will need to buy a Euro key 

RADAR key 

Bottom wipers

Bottom Wipers are designed to help those who may have limited dexterity or other mobility issues with their personal toilet hygiene, it is a discreet and effective, it is a bathroom aid that can help maintain personal hygiene when reaching becomes difficult. 

Positives: promotes independence reducing cost of carers. Maintains skin integrity by preventing body fluids to damage the skin. 

Negatives: Unable to see if bottom is clean and condition of skin. 

bottom wiper 2

Foot stools

Foot stool are to assist in achieving the 'right' angle when going to the toilet.  When squatting, the puborectalis muscle loosens creating a straight passageway into the rectum.   

Positives: easy and discreet storage when not in use. 

Negatives: risk of falls if person forgets that their feet are raised off the floor.

Foot stool

Body suit

Body suit is made in the UK from 100% cotton, which provides the user with exceptional comfort. Cotton bodysuits are the ideal solution to provide extra security for keeping incontinence pads in place whilst also helping to prevent tapes from coming unstuck. The bodysuit features 3 metal steel snaps at the crotch to allow for easy access and fitting. For maximum hygiene, the cotton bodysuit can be either machine or hand washed up to 40 degrees Celsius 

Positives: added security for those worried that incontinence pads may become dislodged or at risk of choking from Superabsorbent Polymer in pads.  

Negatives: Risk assessment may be required if used in patients’ best interest. 

Body suit

Male Continence devices 

Male devices are a range of products that men can use as alternatives to absorbent pads. They are divided into two main categories according to their function:  

Some are designed to contain bladder leakage this includes sheaths and body-worn urinals.

Some are designed to prevent bladder leakage – such as the penile compression device or clamp.

Portable urinals for men

These are designed specifically to fit the male anatomy and to be convenient to the user.  

Positives: Male urinals can be put into position by or for the patient as and when required. Some have an option to add a drainage bag.

Negatives: Urinals can be heavy to manage when full and a patient’s hand control is poor, they may need assistance to empty the urinal. Risk of spillage if the patient.

Portable urinal

Sheath

Is very similar to a contraceptive condom. It fits over the penis and collects urine as it leaves the body. You may also hear them called Condom catheters and will be connected to a leg drainage bag or a night drainage bag.

Positives: Sheaths are supplied in a range of lengths and sizes. Ensure a size that provides a secure fit without being too tight. If the man has a shortened penis (this is common after some treatments for prostate cancer) there are sheaths available in shorter sizes with the adhesive band nearer the tip of the sheath and extra thin sheaths. 

Negatives: They don’t work well if the man has a short or retracted penis and in which case products designed specifically for this purpose may work better.  

Sheath 2 

Devices for penile retraction

Pubic pressure urinal

This is a reusable product made out of latex, it consists of a ring which is held in place with straps or underwear in the same way as body-worn urinals but the ring is held firmly in place against the pubis and applies pressure to help the penis to protrude.  

Positives: Pubic-pressure devices are effective in men with a retracted penis. They are available as single devices or integrated in underwear  

Negatives: they require specialist assessment for the correct size and fit, as when the fitting is incorrect, these devices can cause tissue damage. 

Male external continence device

This is an innovative external continence device which enables men to manage their own urine output with confidence. It offers an effective longer lasting alternative to sheaths and pads and can be used for up to 48 hours. 

Positives: Good for men with a retracted or shorter penis. Longer wear time than standard sheaths up to 72 hours.

Negatives: When first using the device the device, the body will need to get used to the hydrocolloid in the adhesive. This phase normally takes 24-72 hours after the first application depending on the condition of the skin (this is not always visible). During this period the device the device, may need to be replaced more often, whilst the hydrocolloid absorbs any excess moisture. 

Penile pouches / Male urinary pouch external collection device

These are small urine collection bags with an adhesive ring that is stuck onto the pubic bone around the penis. The hole can be cut to size to fit different penis widths. 

The pouch collects urine and there is a tap at the bottom to allow the user to empty it into a toilet or urinal.

Positives: They are usually disposable and can be worn for 24-48 hours. 

Negatives: it may be necessary to shave or trim the pubic hair in order to ensure that the adhesive can hold the pouch in place properly. It is likely that they work better in a standing position rather than seated. 

Male urinary pouch

Female continence devices

Portable urinals for women

These are designed specifically to fit the female anatomy and to be convenient to the user.  

Positives: Most female urinals have a flat narrow end which can be easily put into position underneath the patient. This can be particularly useful if the lady is not very flexible and has difficulty moving her legs apart. 

Negatives: Urinals can be heavy to manage when full and a patient’s hand control is poor, they may need assistance to empty the urinal. Risk of spillage if the patient has to lie down.

Female urinal

Funnel

A funnel is designed for women to use out of bed. It is recommended that the woman sits on the edge of a chair/bed or stands and holds the funnel in place.  

Positive: The funnel is moulded from a soft plastic, which comfortably seals with the skin and helps minimise leakage. 

Negatives: must be used with a drainage bag, leg bag or bottle bag.

Female funnel

Female hydrophilic urine director

Allows a woman to pass urine while standing or in a wheelchair.

Hydrophilic urine detector

Female urinary pouch

The latex-free female urinary pouch provides an effective way to manage urine output for non-ambulatory patients.  

Positives: The female urinary pouch is a cut-to-fit, vinyl, self-adhering pouch, can be worn for up to 1 week. Attaches to a leg bag or 2L night bag.

Negatives. Do not use this product if the perineal skin is compromised, or if the patient sits in a chair, or is ambulatory.

Female urinary pouch

Specialist care

Incontinence can usually be treated, and if it is not treatable then it can be managed. The treatment will depend on the type of incontinence, how severe it is and what is causing it. Sometimes it will require a combination of treatments. If the patient requires specialist care, refer to your local NHS services.

Initial treatments will focus on approaches that don't involve medication or surgery.

These include:

  • Lifestyle changes - such as reducing caffeine intake (including green tea), stopping smoking and losing weight.
  • Pelvic floor muscle training - this technique strengthens the pelvic floor muscles and is an effective treatment for stress incontinence, especially if the muscle has been damaged.  
  • Bladder training - bladder training involves learning techniques to increase the length of time between feeling the need to urinate and passing urine. The course usually lasts for at least six weeks and can be combined with the Kegel exercises. Some individuals may find that timed toileting is helpful, particularly people with a learning disability or cognitive impairment.

Medication can be used to ease and treat symptoms of urinary incontinence. However, all drugs should be used with caution, particularly in older people.

Oxybutynin, Tolterodine, Solifenacin 

Oxybutynin, Tolterodine, Solifenacin are anticholinergics which block signals that trigger abnormal bladder contractions associated with overactive bladder. 

Mirabegron

Mirabegron relaxes the bladder muscle and increases the amount of urine the bladder muscle can hold. 

Duloxetine 

Duloxetine is sometimes used for stress incontinence in place of surgery. 

Desmopressin 

Desmopressin reduces urine production at night. 

 

A number of surgical procedures can be undertaken if other treatments are unsuccessful. 

NICE has produced patient decision aids and user guides.

Further resource: NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management.

Tape procedure 

A vaginal tape procedure is an operation to help women with stress incontinence. A 1cm synthetic tape is inserted through an incision in the vagina and threaded behind the urethra (the tube that allows urine to pass outside the body). The middle part of the tape supports the urethra, thereby preventing leakage. The tape stays in place permanently.

See the latest report in relation to Tape complications from Baroness Cumberledge: First Do No Harm The report of the Independent Medicines and Medical Devices Safety (2020). Review 

Colposuspension 

Colposuspension involves making an incision in the lower abdomen, lifting up the neck of the bladder and stitching it in this lifted position. It can help prevent involuntary leaks in women with stress incontinence. See:

Further resource: NHS Surgery and procedures - Urinary incontinence.

There are two types of colposuspension: 

  • an open colposuspension – where surgery is carried out through a large incision
  • a laparoscopic (‘keyhole’) colposuspension – where surgery is carried out through one or more small incisions using special, small surgical instruments. 

Sling procedures

Sling procedures involve making an incision in the lower abdomen and vagina so a sling can be placed around the neck of the bladder to support it and prevent accidental urine leaks. 

The sling can be made of: 

  • a synthetic material
  • tissue taken from another part of the body (an autologous sling)
  • tissue donated from another person (an allograft sling)
  • tissue taken from an animal (a xenograft sling), such as cow or pig tissue.  

Urethral bulking agents

A urethral bulking agent is a substance that can be injected into the walls of the urethra in women with stress incontinence. This increases the size of the urethral walls and allows the urethra to stay closed with more force. 

Artificial urinary sphincter 

The urinary sphincter is a ring of muscle that stays closed to prevent urine flowing from the bladder into the urethra. An artificial urinary sphincter is a device fitted to relieve urinary incontinence. It replaces the damaged sphincter to restore control of the flow of urine. 

It tends to be used more often as a treatment for men with stress incontinence and is only rarely used in women. 

An artificial sphincter consists of three parts: 

  • a circular cuff that is placed around the urethra – this can be filled with fluid when necessary to compress the urethra and prevent urine passing through it 
  • a small pump placed in the scrotum (when used in men) that contains the mechanism for controlling the flow of fluid to and from the cuff 
  • a small fluid-filled reservoir in the abdomen – the fluid passes between this reservoir and the cuff as the device is activated and de-activated. 

Botulinum toxin A injections 

Botulinum toxin A (Botox) can be injected into the sides of the bladder to treat urge incontinence and overactive bladder syndrome (OAB). This medication can sometimes help relieve these problems by relaxing the bladder. The effect can last for several months and the injections can be repeated if they help. 

Sacral nerve stimulation 

The sacral nerves are located at the bottom of the back. They carry signals from the brain to some of the muscles used when urinating, such as the detrusor muscle that surrounds the bladder. 

During the operation, a medical device is inserted under the skin near one of the sacral nerves, usually in one of the buttocks. An electrical current is sent from the device to the sacral nerve. It should improve the way signals are sent between the brain and the detrusor muscles, and so reduce the urge to urinate and restore the normal function of the bladder. 

Posterior tibial nerve stimulation 

The posterior tibial nerve runs down the leg to the ankle. It contains nerve fibres that start from the same place as nerves that run to the bladder and pelvic floor. It is thought that stimulating the tibial nerve will affect these other nerves and help control bladder problems, such as urge incontinence. 

The treatment targets the tibial nerve in the ankle and modifies the nerve impulses sent to the bladder, which contribute to the development of urgency. A fine needle is inserted into the tibial nerve just above the ankle and an electrode is placed on the foot. A mild electric current is passed through the needle to stimulate the tibial nerve. 

Augmentation cystoplasty 

This procedure involves making the bladder bigger by adding a piece of tissue from the intestine into the bladder wall. The aim is to increase bladder capacity and reduce the effect of the contractions of the bladder. 

After the procedure, a catheter may be put in place. The difficulties passing urine can also mean that people who have augmentation cystoplasty can experience recurrent urinary tract infections. 

Urinary diversion 

A urinary diversion is a procedure to release urine from the body when urination is not possible because the urinary system is damaged or not working. Any problem in the bladder that blocks the flow of urine and causes it to accumulate in the ureters (the tubes that lead from the kidneys to your bladder) may result in the need for a urinary diversion. 

A urinary diversion may mean a urostomy, which requires a pouch to be worn outside the body, or a continent diversion, which involves the creation of a pouch or bladder inside the body, usually using part of the digestive tract. 

NICE has produced patient decision aids and user guides.

Further resource: NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management.

Biofeedback 

Biofeedback is a bowel retraining exercise that involves placing a small electric probe into the anus. The sensor relays detailed information about the movement and pressure of the muscles in the rectum to an attached computer. 

The individual is asked to perform a series of exercises designed to improve bowel function. The sensor checks that the exercises are being performed in the right way. 

Anal plugs 

Anal plugs are one way to prevent involuntary soiling. An anal plug is made of foam and designed to be inserted into the anus. 

If the plug comes into contact with moisture from the bowel, it expands and prevents leakage or soiling. Anal plugs can be worn for up to 12 hours, after which time they are removed using an attached string. 

Disposable body pads 

Disposable body pads are contoured pads that soak up liquid stools and protect the skin. They can be used in cases of mild bowel incontinence. 

Single-use silicone inserts

Single-use silicone inserts, which form a seal around the rectum until the next bowel movement, are also being investigated as a treatment option for moderate to severe bowel incontinence. 

Medication can be used to help treat soft or loose stools or constipation associated with bowel incontinence. 

Loperamide

Loperamide is a medicine widely used to treat diarrhoea. It works by slowing down the movement of stools through the digestive system, allowing more water to be absorbed from the stools. 

Laxatives

Laxatives are used to treat constipation. They loosen stools and increase bowel movement. Bulk-forming laxatives are usually recommended as they help the stools to retain fluid. This means they’re less likely to dry out, which can lead to faecal impaction.

Suppositories and enemas 

Suppositories and enemas are used when other treatments are deemed ineffective. Suppositories are small and bullet-shaped and are used to deliver medication to soften hard faeces blocking the rectum. Enemas work in a similar way but the medication is delivered through a small tube inserted into the rectum. 

Rectal irrigation 

Rectal irrigation is used when bowel incontinence is caused by faecal impaction and other treatments have failed to remove the impacted stool from the rectum. The procedure involves placing a small tube in the anus and injecting a medicine in fluid form to wash out the rectum.  

If current local formulary devices are not suitable for the patient, you may consider contacting your local bladder and bowel service through your local NHS trust. Some items may be available to purchase.

Body-Worn Urinal (BWU)

Is a general term used to describe a wide range of male devices which are mainly reusable (although they can have a disposable part such as a leg bag) that are designed to collect urine as it leaves the body. They offer an alternative to a disposable sheath system and are secured in place using either straps, specially designed underwear or occasionally adhesive. 

Positives: They are good for men who would like an alternative to a sheath or would like to try a reusable product. As many BWU are reusable, men who have to pay for their products may find one a cost-effective option for at least some of the time. It is durable, made of high-quality materials and easy to keep clean. If handled maintained properly, the system can last for months.

Negatives: They do not work well for men with a retracted or shortened penis, if this is the case try products specially designed for this purpose.

Body worn urinal 

Male urine collection system brief

These are a unique and innovative male urinary continence management system and has been designed to provide men with comfort and independence.

Positives: soft cotton pants, reusable.

Negatives: measurement maybe required.

[2 briefs images]

Cotton boxer brief

The cotton boxer-briefs discreet and secure hold a plastic ergonomic curved receptacle inside a front pocket that channels urine into a 500ml reusable collection bag. No tubes or straps are required - just attach the bag directly to the receptacle through the briefs for hours of use without maintenance or changing. 

Positives: cotton pants, reusable.

Negatives: requires flaccid penis to dangle over testicles and reasonable dexterity for fitting.

Cotton boxer brief

Penile compression device

A penile compression device (commonly called a clamp) is a small reusable device that is available in several different designs. They all work by compressing or squeezing the penis, either by acting as a clamp that is closed over the penis, as a strap that goes around the penis or occasionally an inflatable cuff.

Positives: clamps work well for active men who want a discreet product. The man must have normal feeling in his penis and be able to remember to release the device regularly (around two hourly).  

Negatives: Clamps can be uncomfortable to wear and can reduce blood flow in the penis and some men find they are unable to tolerate them.

Penile clamp

Penile clamp

Female continence devices

Internal vaginal / Intravaginal devices

These are placed inside the vagina to support the bladder neck thereby reducing/preventing stress incontinence. Some devices are also believed to compress the urethra which also helps to reduce stress incontinence. 

Positives: Devices are purpose-made, from a range of materials including polyurethane foam and silicone and are usually only available in one size. They can be either disposable or reusable. 

Negatives: Some patients report discomfort and pain, vaginal soreness or irritation, bleeding and urinary tract infection with some types of devices. Some women find fitting the devices problematic, especially those with altered vaginal anatomy secondary to childbirth or surgery. Women still have to wear a pad as they may find that their incontinence improves but continue to suffer from some urinary leakage.

Intravaginal device 3Intravaginal device 2

  

Female External Catheter

This is a non-invasive urine management device. The flexible and contoured catheter is positioned between the labia and gluteal muscles, remaining completely external it is connected to a low-pressure and continuous suction vacuum system, pulling urine away from the body into a collection canister.  

Positives: reduces the need for indwelling catheterisation and therefore minimises the risk of CAUTI’s.  Can be used as an alternative to absorbent pads.

Negatives: patient must be in a bed or chair whilst product is in use.

Female external catheter


Bowel Management

Anal plugs prevent the uncontrolled loss of solid stool. Because of its small size, the anal plug can easily fit into your pocket or handbag. It cannot be seen by others as it is worn inside the body. By protecting against leakage, the anal plug gives the person confidence to participate in activities where you need to feel secure, such as swimming. Unpleasant odours are also avoided as the plug retains stool in the bowels. 

Anal plugs

Sphincteroplasty 

A sphincteroplasty is an operation to repair damaged sphincter muscles. The surgeon removes some of the muscle tissue and the muscle edges are overlapped and sewn back together. This provides extra support to the muscles, which makes them stronger. 

Sacral nerve stimulation 

Sacral nerve stimulation is a treatment used for people with weakened sphincter muscles. Electrodes are inserted under the skin in the lower back and connected to a pulse generator. The generator releases pulses of electricity that stimulate the sacral nerves, which causes the sphincter and pelvic floor muscles to work more effectively. 

Tibial nerve stimulation 

Tibial nerve stimulation is a fairly new treatment for bowel incontinence. A fine needle is inserted into the tibial nerve just above the ankle and an electrode is placed on the foot. A mild electric current is passed through the needle to stimulate the tibial nerve. 

It’s not known exactly how this treatment works, but it is thought to work in a similar way to sacral nerve stimulation. 

Further resources

NICE. Percutaneous posterior tibial nerve stimulation for overactive bladder syndrome (2010)

Disease specific

People living with dementia may be aware of the need to go to the toilet but may not be able to express this need. There could be a noticeable change in behaviour, such as agitation or restlessness. They may have forgotten where the toilet is or be in unfamiliar surroundings. 

Often signage on toilet doors can be confusing, especially for people with dementia. Complicated or modern icons might be used, which some people may find difficult to recognise as the place where they can go to the toilet. 

Further RCN resources are available:

Neurogenic bladder dysfunction 

This refers to urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination.

Detrusor underactivity

Detrusor underactivity is where the bladder muscle is underactive and does not contract properly to effectively pass urine and empty. The bladder will stretch and potentially retain large volumes of urine.

It is caused by damage to the nerves supplying the bladder or to the lower spinal cord. It is usually experienced by people with a spinal injury and neurological conditions, such as multiple sclerosis and diabetic neuropathy.

Symptoms of detrusor hypoactivity include:

  • a lack of bladder sensation
  • an ability to go long periods of time without passing urine
  • overflow incontinence – if the bladder is overfull and can’t fully empty.

In both types of voiding difficulties people may experience frequent urinary tract infections.

Further resources

RCN Neuroscience Forum

How does Spinal Cord Injury (SCI) affect Bowel function?

Damage to the spinal cord has a profound impact on all bodily systems including the function of the large bowel and on maintenance of faecal continence.

The effect of SCI on bowel function is individualised and dependant on many factors including:

  • neurological deficit – i.e. level of injury and completeness of injury
  • psychological factors associated with adjustment to SCI
  • body image
  • environmental factors
  • care support available.

For all SCI individuals, the enteric nervous system remains functionally intact. Therefore, peristalsis continues, but as there is little or no co-ordination from the brain and spinal cord, peristalsis is less effective, and colonic transit time is extended. This leads to a drier stool and an increased likelihood of constipation.

In the majority of cases, the descending input from the brain to the colon and ano-rectum is lost. These changes result in the loss of sensation of the need for defaecation, loss of voluntary control of defaecation and loss of the brain’s influence over reflex activity.

Sensory and motor control of the ano-rectum is lost leaving the individual unable to feel the need to evacuate the bowel or to control the process of defaecation.

Without intervention, the SCI individual will be incontinent of faeces and chronically constipated.

This will lead to secondary complications such as

  • overflow diarrhoea and faecal impaction
  • loss of appetite
  • increased risk of pressure ulcers and moisture lesions
  • abdominal pain and increased spasm
  • autonomic dysreflexia (this is a risk for individuals with spinal cord lesions at T6 or above)
  • damage to the colorectal structures – common problems include mega colon, haemorrhoids, anal fissure and rectal prolapse
  • abdominal distension leading to respiratory difficulty
  • bladder dysfunction
  • faecal vomiting
  • perforated bowel.

The function of the lower bowel must be effectively managed to allow the SCI individual to maintain continence and to minimise associated health problems.

Types of SCI bowel Dysfunction

Reflex bowel

Reflex bowel occurs in injuries where the nerves in the reflex arc from the cord to the colon and anorectum are not damaged. This usually occurs in individuals who have an injury above T12.

Because the reflex arc is not damaged, there is reflex activity which can be utilised for effective bowel emptying using digital rectal stimulation (DRS) and rectal stimulants (suppositories or micro enemas)

Areflexic bowel

Injuries which result in damage to the reflex arc between the spinal cord and the colon and ano-rectum result in an areflexic bowel (this is sometimes referred to as “flaccid”).

These are usually injuries to the first lumbar vertebra (LI) and below.

This results in slow stool propulsion through the descending and sigmoid colon and a high risk of faecal incontinence through the lax anal sphincter and pelvic floor. The management for this type of bowel is based on a Digital Removal of Faeces (DRF), therefore a slightly firmer stool which is easier to remove digitally is advised (Bristol Scale 3).

Incomplete neurogenic bowel dysfunction

Some individuals with incomplete lesions may have a degree of preserved sensation or residual voluntary control.

They may or may not have:

  • an efficient defecation reflex
  • sensation or even pain
  • awareness of ‘full’ & ‘empty’
  • voluntary defecation inhibition. 

However, this may not be sufficient to enable reliable bowel control.

Conus and Cauda Equina Injuries

Individuals with Conus Medullaris Injuries or injuries to the spinal nerves forming the Cauda Equina will usually experience Lower Motor Neurone bowel function because these reflex centres are located in the conus.

Further resources

An overview of conventional SCI Bowel Management

conventional bowel management

For more information please see Royal College of Nursing (2019) Bowel Care. Management of lower bowel dysfunction, including digital rectal examination and digital removal of faeces, London: RCN.

Taken from: Bowel Management for Individuals with an Established Spinal Cord Injury (SCI) An Introductory Document for Healthcare Practitioners in the Hospital Setting
Lisa Lewis RGN & Paul Harrison, RGN, 2018

Case studies

Old lady looking out of window

 

Case Study 1 - Lily Jones

Names used are fictitious

“Patient, Lily Jones, 78 is referred to the district nurses with worsening urinary incontinence.  She has recently moved into a residential home after the death of her husband who was her main carer. She has rheumatoid arthritis, with pain in most joints and chronic back pain and is using opiate based medication. She is constipated. She has been doubly incontinent at times. Her urine is stinging when she goes. She has been avoiding drinking as she has been struggling to get to the toilet independently and her clothes and furniture have been getting wet.”  

What further information would you need to assess if Lily has a UTI? 

You will need to find out the following:

  • does she have a temperature? 
  • is she needing to pass urine urgently or more frequently than usual? 
  • does she have pain or a burning sensation when passing urine? 
  • does she have any blood in her urine? 
  • does she have any pain in lower abdomen? 
  • is she feeling tired and unwell? 
  • is there new onset or worsening incontinence? 
  • does she have increased voiding at night? 

You find out:

  • Lily’s temperature is 37.6 
  • she has increased urinary frequency and urgency 
  • she has pain in her lower abdomen 
  • she has been feeling tired 
  • she needs to get up 5 times at night instead of twice.  

Does Lily have an upper or lower urinary tract infection?

Lily has a lower urinary tract infection.  

What else could you do for Lily to improve her continence and reduce the risk of her getting a UTI again in the future? 

Please note: this is not an exhaustive list.

  • once UTI has been treated with antibiotics, arrange for a continence assessment to be done 
  • support Lilly to improve her constipation by reviewing her dietary and fluid intake (see fluid matrix chart in hydration section) 
  • review the need for laxatives as appropriate 
  • review her pain management to see if an alternative to an opiate based painkiller could be found.  
  • consider a referral to a physio to see if her mobility can be improved 
  • consider the need for psychological support for her low mood due to her recent bereavement and loss of her home. This may be impacting on her motivation and appetite
  • ensure she has easy access to a toilet or commode.

Old man looking out of window

Case study 2 - James Morrison

Names used are fictitious

James Morrison is an 89-year-old gentleman with a history of dementia and benign prostatic hyperplasia. You are visiting his wife for a wound dressing and she explains he has been feeling unwell.  

He has been vomiting, is off his legs, is not eating and struggling to keep fluids down. He is normally fully mobile but is in bed and his wife says he seems more confused than normal.  

What further information would you need to assess James? 

You will need to assess the following (please note: this is not an exhaustive list):

  • baseline observations to include  
  • pulse 
  • respiration 
  • oxygen saturations
  • temperature 
  • blood pressure
  • does he have any back pain / muscle aches? 

You discover:

  • he is complaining of back pain 
  • he has a temperature 38.3 
  • his BP is 90 / 54 pulse 134 
  • he has not passed urine since last night.

What life threatening conditions would you be concerned about?  

James could have a possible upper urinary tract infection and/or sepsis.

What further action would you take?  

Ring 999.

Project group

Ali Wileman - RCN Bladder and Bowel Forum Chair. Continence Service Lead, Southern Health NHS Foundation Trust

Anna Hancock - Clinical Nurse Specialist for Continence Care

Fiona Le Ber RGN BSc (Hons) - Queen’s Nurse. Clinical Nurse Specialist for Continence and Stoma Care

Isobel Wilkerson RN, MSc - QN Quality Improvement Development Lead/ Nursing Support (OPAC)

Jane Fenton - Teaching Fellow [Bladder & Bowel Care], Keele University

Karen Irwin - Service Manager / Specialist Nurse

Lisa Lewis - Community Liaison Sister Spinal Cord Injuries Centre

Liz Howard - Thornton RGN, BSc (Hons) Dip DN. Clinical Nurse Specialist – Bladder & Bowel (Retired 2020)

Margaret Ojo - RCN Project Co-ordinator

Ofrah Muflahi - RCN Professional Lead- Nursing Support Workers & Long-Term Conditions

Suzanne Ryder - Service Lead South Manchester Bladder & Bowel Service, Professional Lead for MLCO Bladder & Bowel Services

Webpage updates

Claire Constable - Digital Resources Coordinator, RCN

Jay Musson - Digital Resources Coordinator, RCN

Anne Carroll - Continence Nurse Specialist, West Hertfordshire Hospitals NHS Trust

Debbie Quinn - Chair of Neuroscience Forum, Queens Nurse

Gail Goddard - BSc RN SPDN SCPT Queens Nurse, District Nurse Team manager

Janice Reid - Teaching Fellow in Adult Nursing/Course Leader Bladder & Bowel modules, University of Ulster

Lisa Jones - Staff Nurse Continence Service, NHS FIFE

Natalie Pugh – Continence Practitioner, Continence Service, Southern Health NHS Foundation Trust

Dr. Nikki Cotterill PhD BSc(Hons) RN - Associate Professor in Continence Care and Florence Nightingale Foundation Leadership Scholar 2019, Centre for Health and Clinical Research, UWE
Continence Lead, Bristol Urological Institute, NBT and BABCON HIT Director, Bristol Health Partners, Visiting Fellow – Universities of Southampton and Bristol

Marisa Webber - District Nurse, Wales

Rose Gallagher MBE - RCN Professional Lead for Infection Prevention and Control/AMR

Sue Morris - Ward Manager/ Senior Sister, Portsmouth Hospitals University NHS Trust

Victoria Coghlan -  Advanced Nurse Practitioner Bladder & Bowel Service

Amanda Cheesley - Original Professional lead for the RCN Bladder and Bowel Forum

Anne Carroll – Continence Nurse Specialist, West Hertfordshire Hospitals NHS Trust

Belinda Wolfendale – College Nurse, Scope

Esther Monk – Nurse, Leonard Cheshire Disability

Jeanifer Orina – Supervised Practice Nurse/ Registered Nurse, Belmont House Care Home

Karen Tomlin – Clinical Lead- Planned Care, Northamptonshire Healthcare NHS Foundation Trust

Lynn Briggs – Urodynamics Specialist Nurse, Harrogate District Hospital

Pippa Hutchings – ANP, Princess of Wales Hospital

Sue Morris (remote reviewer) – Ward Manager/ Senior Sister, Portsmouth Hospitals NHS Trust

Glossary of terms

Antimuscarinic - used to block the activity of the muscarinic acetylcholine receptor, reducing the symptoms of bladder spasm

Aphasia - Difficulty to understand or communicate language, which can be caused by damage to the brain

Autonomic dysreflexia - a potentially life-threatening medical emergency that affects people with spinal cord injuries at the T6 level or higher

Costovertebral tenderness - pain that results from touching the region inside of the costovertebral angle

Delirium - abrupt change in the brain that causes mental confusion and emotional disruption. Making it difficult to think, remember, sleep, pay attention, and more

Dysphasia - Problem swallowing

Dysuria - painful urination

Haematuria - blood in urine

Hydro Nephrosis - swollen kidneys, could be caused by a blockage

Micturition - Passing urine

Pyelonephritis - Infection of the kidneys

Page last updated - 27/07/2021