Excellent continence and bladder care are crucial to improve the overall quality of care patients receive. The Essence of Care best practice statements, first published in 2003 and updated in 2010, aim to share best practice among healthcare trusts to enhance overall care quality, including in continence care (NHS Modernisation Agency, 2003; Department of Health, 2010). However, continence care often falls below acceptable standards.
Nurses, regardless of their role, must have a comprehensive understanding of normal urinary system anatomy and physiology to effectively anticipate and manage potential issues and provide safe and appropriate care (Seifter et al, 2021). Urinary tract infections and incontinence are prevalent issues related to urinary elimination, emphasising the importance of promoting bladder health and continence in healthcare settings (Seifter et al, 2021). Continence care extends beyond specific nursing specialties and includes all health professionals, particularly those caring for pregnant women and older adults. Identifying risk factors and implementing strategies to promote continence can significantly impact their wellbeing. Patient engagement in continence care can lead to a more patient-centred approach, potentially improving treatment adherence and overall satisfaction (Seifter et al, 2021).
There are several ethical considerations in the care of older adults with urinary incontinence, as highlighted in the International Continence Society white paper (Suskind et al, 2022). This white paper provides a framework for health professionals to navigate ethical dilemmas in the care of older adults with urinary incontinence to ensure that best practices are upheld and to promote dignity and respect in patient care. This ethical framework is essential in guiding healthcare providers in delivering care that aligns with the values and preferences of older adults experiencing urinary incontinence (Suskind et al, 2022). In older adults, urinary incontinence significantly contributes to the risk of falls due to urgency and nocturia (Reis da Silva, 2023a; 2024a). Effective falls assessment and prevention strategies must incorporate continence management to reduce fall risks (Koloms et al, 2022; Reis da Silva, 2023a; 2024b).
Addressing incontinence helps maintain independence and dignity, which are essential for successful ageing at home (Reis da Silva, 2023b). Incontinence management is also a vital aspect of palliative care, ensuring comfort and dignity for patients nearing the end of life (Jackson, 2022). Cancer treatments, especially those involving the pelvic region, can exacerbate urinary incontinence in older patients (Liberman et al, 2014). Urinary incontinence can lead to social isolation and loneliness in older adults due to embarrassment and fear of accidents (Stickley et al, 2017). Incontinence problems in older adults may be a symptom of cognitive decline and depression (Park et al, 2022).
Overview: anatomy and physiology of the urinary system
The urinary system is a complex network of organs responsible for maintaining homeostasis by regulating fluid balance, electrolyte levels, and waste excretion. It consists of the kidneys, ureters, bladder and urethra, which work together to filter blood, produce urine, and eliminate waste from the body. The kidneys produce renin, an enzyme involved in blood pressure regulation, and erythropoietin, a hormone that stimulates red blood cell production (Seifter et al, 2021) (Figure 1).
The kidneys consist of approximately one million nephrons, which facilitate filtration and reabsorption processes essential for maintaining bodily functions. The glomerular filtration rate (GFR) is a critical indicator of kidney function, representing the volume of plasma filtered through the glomerulus per minute. Monitoring urine output serves as a guide to assess whether the kidneys are receiving adequate blood volume and pressure (Delanaye et al, 2024).
The lower urinary tract, consisting of the ureters, bladder, and urethra, plays a vital role in transporting and storing urine before excretion. The bladder contracts to expel urine through the urethra; the urethra serves as the passage for urine from the bladder to the exterior. The urinary system's defence mechanisms against infections include regular urine flow, urine acidity, and the length of the urethra, which inhibit bacterial infiltration and growth (Seifter et al, 2021). Understanding the intricate processes involved in urine production and the anatomy of the lower urinary tract is essential so that health professionals can provide optimal care and support for individuals with urinary system-related conditions.
Nurses may care for patients with different types of incontinence, as shown in Table 1.
| Type of incontinence | Causes |
|---|---|
| Stress incontinence – leaking when coughing, laughing, sneezing or during physical activity (increases intra-abdominal pressure) | More common in women and is often associated with damage to the pelvic floor during childbirth. Symptoms of stress incontinence worsen with age and are aggravated by obesity. Stress incontinence rarely occurs in men, but may occur following prostate surgery |
| Urge incontinence (overactive bladder/detrusor instability) – rushing to the toilet, frequency, leaking urine | More common in women, again in part caused by anatomical changes related to childbirth, but also because of the shorter urethra and weaker pelvic floor, compared with men. Also caused by some neurological conditions. Most common type of incontinence in older people |
| Voiding difficulties (inefficiency) – incomplete bladder emptying, hesitancy | Commonly occurs in neurological conditions such as stroke, multiple sclerosis, etc. Occurs in women with a prolapse and men with benign prostatic enlargement (BPE) |
| Overflow incontinence – involuntary leak of urine from an over-distended bladder | Occurs in both men and women (less common). Causes include obstruction of the urethra or bladder outlet, eg BPE. Can occur in women with pelvic prolapse or as a complication of surgery to correct the prolapse. Can be caused by an underactive detrusor muscle that is associated with conditions such as multiple sclerosis and strokes or as a side-effect of some medicines |
| Reflex incontinence – incontinence without warning | Can be caused by urethral strictures (narrowing) or an enlarged prostate |
| Functional incontinence – as an impairment of physical or mental ability | Causes include spina bifida and muscular dystrophy |
| Mixed with both urge and stress | Common in post-menopausal women |
Adapted from: Osman and Chapple, 2017
Nursing interventions
Assistance with micturition
To assist individuals with urinary elimination, nursing interventions play a crucial role in ensuring their comfort, privacy and safety throughout the process (Liberman et al, 2014). Adequate hydration is essential to support urinary function, especially in hospitalised individuals who may experience fluid loss due to various factors such as sweating, vomiting or diarrhoea (Reis da Silva, 2024a). Patients who are weakened by their condition or treatment may require assistance in meeting their elimination needs, necessitating nursing support to maintain their dignity and ensure their safety. When individuals prefer using the toilet over other options such as urinals, bedpans or commodes, nursing staff should escort or assist them to the toilet to assess their mobility and provide necessary support (Wallace et al, 2023; Reis da Silva, 2023c). For those unable to access the toilet, the provision of urinals, bedpans or commodes should be prompt and efficient to minimise any potential embarrassment.
Patients' privacy, dignity and cultural requirements (such as the need for same-sex care providers) should be respected to ensure a comfortable and considerate environment for the individual (Wallace et al, 2023). This underscores the importance of nurses being self-aware and emotionally intelligent (Reis da Silva, 2022). Nurses must be acutely aware of their own emotions and the potential impact on patient care, enabling them to respond with sensitivity and empathy. Emotional intelligence in nursing fosters the ability to recognise and respect patients' feelings of vulnerability and embarrassment, and to maintain their dignity through respectful and culturally sensitive care practices. This not only enhances the quality of care but also builds trust and rapport between patients and nurses (Reis da Silva, 2022).
Use of urinals, bedpans and commodes
The use of urinals, bedpans and commodes requires sensitivity and attentiveness from nurses to maintain the individual's comfort and dignity (Wallace et al, 2023). For males using urinals, assistance may be needed to ensure proper positioning and support during urination, with attention to cultural practices such as post-void genital hygiene. For example, if the service user is Muslim; a jug of water for washing should be provided if the person is confined to bed (Wallace et al, 2023). Similarly, the use of ‘slipper’ bedpans for women offers comfort and ease of use, particularly for immobile individuals who require additional assistance.
Maintaining hygiene and cleanliness during urinary elimination is crucial to prevent infections and promote comfort (Wallace et al, 2023). Proper disposal of used toilet tissues or wet wipes, avoidance of leaving incontinence pads under individuals after use, and ensuring thorough cleaning and drying of the perianal area are essential nursing practices to prevent complications such as skin soreness, infections and pressure ulcers (Mitchell and Hill, 2020). Providing handwashing facilities and assisting individuals with personal hygiene contribute to their overall wellbeing and comfort during the elimination process (Mitchell and Hill, 2020).
For most people, voiding when lying flat is extremely difficult. If the person can use a commode, this can often assist with passing urine and can offer a sense of normality and independence in passing urine (Holroyd, 2018). Nurses should ensure the cleanliness and safety of the commode, provide necessary supplies such as toilet tissue, and maintain a clear and obstruction-free environment to support the individual's comfort, convenience and safety (Holroyd, 2018; Reis da Silva, 2023c). In all instances the call bell must be left within easy reach of the person.
Monitoring fluid balance and recording voided volumes accurately are essential tasks for nurses to track urinary output and ensure proper hydration (Reis da Silva, 2024a). If a fluid balance chart is being kept, it is important not to assess the volume of urine at the bedside, but to make a note of the volume in the sluice room before discarding. The nurse must dispose of gloves and wash their hands before recording the voided volume on the person's chart.
Multiple problems can occur in micturition (see Table 2).
| Problem | Definitions, possible causes and effects |
|---|---|
| Dribbling | Occurs with bladder outflow obstruction such as in benign prostatic enlargement (BPE) in men or damage to the pelvic floor (common in women after childbirth) |
| Dysuria | Pain on passing urine. Often a feature of a urinary tract infection (UTI) |
| Enuresis | Inability to control urination |
| Frequency | The need to pass urine more often than is usual or acceptable for the person. Usually small amounts of urine are passed. Often associated with UTIs but can be due to anxiety, bladder outflow obstruction or bladder irritability caused by an infection or injury |
| Hesitancy | A delay in starting to pass urine. This could be a result of bladder outflow obstruction, hypersensitivity or instability |
| Incomplete emptying | Indicates a failure of the bladder to empty completely; results in acute urinary retention |
| Poor urinary flow | May be due to bladder outflow obstruction such as in BPE |
| Retention | Inability to pass urine due to obstruction or bladder failure such as in BPE |
| Strangury | Frequent painful desire to void small amounts of urine, due to muscle spasms associated with irritation or inflammation caused by a UTI |
| Urgency | Strong desire to pass urine, which, if not acted upon immediately, may lead to urge incontinence. Associated with detrusor instability or UTI |
Adapted from: Osman and Chapple, 2017
Promoting continence
Urinary incontinence is a global health concern. It is particularly prevalent in women, with a UK study revealing a prevalence of 40% (Cooper et al, 2015). Effective management of urinary incontinence requires skilled practitioners to listen carefully to discern the hospital patient's or community client's needs. Continence affects physical health, psychosocial functioning, everyday activities, and the quality of life of those with symptoms of overactive bladder and urine incontinence (Wallace et al, 2023). A combination of continence aid products, skin-care routines, and toileting equipment can help individuals cope with their condition.
In hospitals, nursing models should consider elimination when assessing individuals. Nurses should respond promptly to requests for commodes, urinals, or bedpans and consider environmental conditions such as the proximity and accessibility of toilet facilities (Reis da Silva, 2023a; 2023c). Adaptations to clothing, such as wraparound skirts or Velcro fastenings, can also help maintain continence. Nurses should also consider the effects of medication on elimination because many drugs can affect urinary volume and frequency. Box 1 provides a list of causes of urinary incontinence symptoms.
Causes of urinary incontinence symptoms
Adapted from: Aoki et al, 2017; Osman and Chapple, 2017
The National Institute for Health and Care Excellence (NICE) website provides guidance, quality standards and advice on urinary incontinence (https://tinyurl.com/2t8jucrt).
Paediatric normal voiding habits
Normal daytime control of bladder function matures in children between the ages of two and three, whereas night-time control is normally achieved between the ages of three and seven years. Bedwetting can be a continuing problem for some children (Bolat et al, 2014). NICE provides guidance on bedwetting in under-19s (NICE, 2010). The volume of urine voided increases with age, reaching around 400 ml every 4–6 hours in adults (Bolat et al, 2014). Fluid intake and kidney function influence voiding patterns, with individuals experiencing issues often reducing fluid intake, which can lead to urinary tract infections (UTIs). Understanding voiding patterns is crucial for diagnosing and managing urinary issues in children (Bolat et al, 2014). Uroflowmetry, a method used to measure urine flow rate, is a valuable tool for assessing voiding function (Kitamura et al, 2014). Interventions such as urotherapy and biofeedback can help correct dysfunctional voiding in children. Urotherapy and electromyography are also valuable in evaluating children with lower urinary tract dysfunction.
Examining voiding patterns is essential in assessing children with primary refractory nocturnal enuresis and vesicoureteral reflux (Sharifiaghdas et al, 2023). In paediatric kidney recipients, screening lower urinary tract function is crucial for postoperative care and monitoring (Altunkol et al, 2018).
Achieving urinary continence during childhood
Continence in children is a complex process involving socialisation and nervous system maturation (Bolat et al, 2014). Key factors include awareness of the need to void and the ability to postpone urine release. Introducing children to the potty in established routines can aid in learning, with positive reinforcement playing a crucial role. Boys need to learn to stand while urinating, and all children need to understand privacy norms and master toilet usage. Accidents are common until around the age of five, often due to distractions, unfamiliarity with toilet locations, or life changes (Bolat et al, 2014). Enuresis, characterised by regular urine leakage, can present challenges for children and their families. Factors influencing its prevalence include psychological issues, family dynamics, sleep patterns, UTIs, developmental delays, and genetic predispositions. Treatment approaches for enuresis include behavioural therapies, pharmacological interventions, and addressing underlying medical conditions (De Wall et al, 2021). Educational programmes targeting parents and caregivers have been effective in enhancing knowledge and practices related to managing enuresis in children (Sikchi et al, 2023).
Adult normal voiding habits
Voiding habits in adults and older adults are crucial for maintaining urinary health and overall wellbeing. As individuals age, changes in voiding patterns can occur, necessitating a deeper understanding of these processes by nurses. Prompted voiding, a technique where individuals are reminded and encouraged to void at regular intervals, has been beneficial in reversing urinary incontinence in older adults (Martín-Losada et al, 2021). In institutionalised older adults with urinary incontinence, individually tailored ultrasound-assisted prompted voiding has been identified as a valuable strategy. Continence care strategies, such as bladder training, habit retraining, timed voiding, and prompted voiding, have been emphasised in managing urinary incontinence among institutionalised older adults (Iwatsubo et al, 2014).
Nocturia, a common issue affecting older adults, is influenced by lifestyle habits and underlying health conditions (Nguyen et al, 2022). Evaluation of voiding habits is essential for diagnosing and managing various urinary conditions, and lifestyle habits, such as physical activity levels and dietary patterns, can influence urinary health outcomes (Agarwal et al, 2022). Further research and comprehensive assessments of voiding patterns are needed to enhance understanding of urinary health in adults and older adults.
Women may experience urinary incontinence after childbirth and after the menopause. NICE has issued a quality standard on urinary incontinence in women (NICE, 2021a).
Men may experience lower urinary tract symptoms, including urinary incontinence (NICE, 2015).
Pelvic floor exercises
NICE provides guidance on pelvic floor dysfunction (NICE, 2021b).
Pelvic floor exercises, also known as Kegel exercises, are crucial for rehabilitating pelvic floor muscles after injury, childbirth, or surgeries for prostate problems or cervical cancer (Griffiths et al, 2015). These exercises strengthen the muscles surrounding the urinary sphincters, aiding in bladder control and continence. Pelvic floor exercises are effective in treating women with postpartum stress incontinence, and children with non-neurogenic lower urinary tract symptoms (Griffiths et al, 2015). Pelvic floor muscle training, including Kegel exercises, has been shown to improve various types of urinary incontinence in both men and women. Studies have also found positive effects in children with functional constipation (Kamatchi et al, 2022) and in managing chronic pelvic pain syndrome in men (Masterson et al, 2017). A holistic approach combining physical therapy, Kegel exercises, myofascial treatments, biofeedback, behavioural modifications, and acupuncture have been recommended for managing chronic pelvic pain in both men and women (Mina et al, 2021).
Pelvic floor muscle training has also been shown to improve pelvic organ prolapse (Anderson et al, 2015). Studies have shown that Kegel exercises and general fitness exercises have been effective in managing urinary incontinence (Vijayakumar et al, 2023), and yoga has been linked to strengthening pelvic region muscles (Joshi et al, 2020).
Types of urinary incontinence and management
Urinary incontinence is a prevalent condition that can significantly impact an individual's quality of life, leading to feelings of isolation, loneliness and disruptions to daily activities (Griffiths et al, 2015). The effects of incontinence can be particularly challenging for individuals from some ethnic backgrounds, where factors such as culture, religious practices, language barriers and poverty can affect access to healthcare services, especially among immigrant populations (Sollini et al, 2023). To address these disparities, it is recommended that local health services raise awareness and enhance continence services in areas with high immigrant populations to ensure equitable access to health care.
Management of urinary incontinence aims to promote continence through non-surgical interventions whenever possible (Griffiths et al, 2015). Behavioural programmes play a crucial role in assisting individuals in achieving continence, starting with lifestyle modifications such as reducing dietary irritants such as caffeine and gradually increasing water intake (Griffiths et al, 2015). Encouraging individuals to maintain adequate fluid intake to avoid producing concentrated urine that may predispose to UTIs is essential (Griffiths et al, 2015). Additionally, strategies such as pelvic floor exercises, keeping voiding diaries, and urinating before bedtime are simple yet effective interventions in managing incontinence (Griffiths et al, 2015).
The International Continence Society categorises urinary incontinence into three main types based on symptoms: stress, urge, and mixed urinary incontinence (Kamal Helmy et al, 2022; Suskind et al, 2022). Understanding the type of incontinence is crucial for devising appropriate management strategies tailored to individuals' needs (Kamal Helmy et al, 2022). Different treatment options, including bladder retraining, biofeedback, electrical stimulation, and medications such as trospium chloride and solifenacin succinate, are available for managing urinary incontinence (Griffiths et al, 2015). Surgical interventions may also be considered in cases where conservative measures are ineffective (Griffiths et al, 2015). It is important to note that the choice of treatment should be individualised based on the patient's specific type of incontinence, severity of symptoms, and personal preferences. A thorough assessment by a health professional is essential to determine the most appropriate management strategy (Nightingale, 2020). Ongoing education and support for patients is crucial to ensure adherence to treatment plans and optimise outcomes (Nightingale, 2020).
Comprehensive management of urinary incontinence requires a multidisciplinary approach involving continence nurse specialists, doctors, physiotherapists, and pharmacists (Griffiths et al, 2015). An accurate diagnosis of the type of incontinence is essential for developing personalised management plans for individuals (Griffiths et al, 2015). Continence nurse specialists play a key role in co-ordinating care, establishing long-term relationships with patients, and ensuring the effective implementation of management strategies (Griffiths et al, 2015).
Research by Gibson et al (2021) emphasises the importance of evidence-based management strategies for urinary incontinence in frail older individuals, highlighting the need for ongoing advancements in the field to address the unique challenges faced by this population. Similarly, studies have underscored the significance of appropriate management approaches for childhood urinary incontinence, emphasising the role of urotherapy and anticholinergics in addressing this condition (Caldwell et al, 2019; Kamatchi et al, 2022).
Continence aids
Continence aids play a crucial role in managing the condition and improving the quality of life for affected individuals. Continence aids range from protective pads to more specialised devices such as urinary sheaths, catheters and urological stomas (Yahya et al, 2017). Continence aids can be broadly categorised into containment devices and diversion devices. Containment devices, such as absorbent pads, are designed to absorb urine and prevent leakage from soiling clothing or bedding. In contrast, diversion devices, such as urinary catheters and external collection devices, are used to divert urine away from the body and are often employed in cases of severe incontinence or when patients are unable to void naturally (Koloms et al, 2022).
When using continence pads, it is essential to prioritise skin care to prevent irritation and damage, particularly in sensitive areas such as the perianal region, thighs, and legs (Mitchell and Hill, 2020). Proper hygiene practices and seeking advice from specialists such as tissue viability nurses are crucial in maintaining skin integrity and preventing complications associated with prolonged pad use.
Urinary sheaths, also known as external catheters or condom catheters, offer an alternative for men who prefer a device attached to a drainage bag to promote continence without the need for pads (Park et al, 2015) (see Figure 2). Urinal funnels attached to drainage bags are available for women. The selection and fitting of continence aids, including urinary sheaths, are critical to ensure comfort, effectiveness, and prevention of leakage or skin irritation (Park et al, 2015). Manufacturers provide guidance on choosing the correct size and type of sheath based on individual needs, with considerations for natural movement and secure attachment to prevent leaks (Park et al, 2015). However, challenges such as leakage, detachment, or skin irritation due to adhesive use can arise, highlighting the importance of proper fitting and monitoring for optimal aid functionality (Park et al, 2015).
In the context of care facilities and hospitals, the use of continence aids such as wearable absorbent pads and urinary catheters is common, but studies have indicated potential over-reliance on these aids for older adults, emphasising the need for appropriate assessment and management strategies (McGurk et al, 2023). Continence aid use should be regularly evaluated to ensure appropriateness and prevent prolonged reliance beyond necessary periods. Moreover, the implementation of technological solutions, such as sensor technology in continence care products, has shown promise in enhancing effectiveness and automating care processes (Jeong and Park, 2019).
Personalised care plans, incorporating continence aids, toileting programmes, and regular monitoring and reviewing, are essential for individuals with urinary incontinence, particularly those in residential care settings or hospitals (McCann et al, 2022). Continence care involves a multidisciplinary approach, with health professionals, including occupational therapists, and continence nurse specialists, playing key roles in assessing, managing, and supporting individuals with incontinence (McCann et al, 2022). By addressing individual needs, promoting autonomy, and using evidence-based interventions, the quality of continence care can be significantly improved for those living with urinary incontinence.
Conclusion
Continence and bladder care are crucial aspects of healthcare that require a multidisciplinary approach and a deep understanding of anatomy, physiology, and best practices. Health professionals can enhance the quality of life and wellbeing of individuals experiencing continence issues by promoting continence, addressing incontinence effectively, and upholding ethical standards. Nursing interventions, including helping patients with micturition and recommending and explaining the performance of Kegel exercises where appropriate, are essential for supporting individuals with urinary elimination needs. Providing continence aids helps patients achieve comfort and dignity. Urinary incontinence is a complex condition that requires a holistic approach, including behavioural interventions, pelvic floor exercises, and tailored treatment strategies. Addressing cultural and linguistic barriers to healthcare access and promoting multidisciplinary care led by continence nurse specialists can improve individuals' quality of life.