Incontinence is becoming more and more prevalent across all our healthcare sectors. Commonly associated with elderly people, it is an ever-increasing problem across the entire population. It is estimated that more than 14 million people, including children of all ages, in the UK are experiencing some sort of bladder problem. Around 6.5 million people also have bowel problems (Buckley and Lapitan, 2009; Percival et al, 2021). One in 10 of the UK's population live with faecal incontinence. The statistics for incontinence are higher among older women than diseases such as breast cancer, diabetes and heart disease (Radzimińska et al, 2018).
So if it is such a significant problem for the population, why is nobody talking about it?
Normalisation of the problem
One of the biggest issues I have noticed since working in the bladder and bowel sector is that urinary incontinence is widely normalised. You can easily buy containment products off the shelf in almost any supermarket, and television advertisements promoting incontinence pads imply that urinary incontinence is completely normal. Men and women are led to believe that it is OK that they are leaking urine on exertion or at night-time, and simply buying a containment product will solve their problems. However, it is not a solution and barely even a management strategy.
Cost of products
Many people and services, such as care homes and hospitals are relying on either containment products or catheters to manage urinary incontinence. The annual continence care cost to the NHS rose from £77 million to over £200 million in just 4 years between 2006-2007 and 2010-2011, with more recent data difficult to obtain (Percival et al, 2021). It is estimated that urinary tract infections associated with catheters costs the NHS up to £99 million per year (Percival et al, 2021). With figures like these it is obvious we have a huge problem.
The Francis public inquiry (2013) recognised continence as ‘the most basic of needs’ and blamed ‘inadequate staffing levels’ and ‘lack of training in continence care’ for the shortfalls and the high number of complaints in the sector and with the impact of COVID-19 on our hospitals and care homes, these issues have become more substantial.
Education
Nevertheless, the lack of training and education does not appear to be caused by staff's unwillingness to learn. A study conducted in 2021 by Percival et al, found that staff are eager to learn and recognise how critical continence care really is. Twenty-seven participants, including nurses, healthcare assistants and consultant physicians, took part in the study, and all had similar conclusions regarding continence. A junior doctor highlighted that the unnecessary provision of catheters occurred for either service convenience or because the staff are too busy to review their use – as well as over-reliance on catheters and delays in removal being a very common situation. A ward sister also admitted to potentially causing incontinence by using pads without proper assessment of a patient's continence needs, which caused one nursing assistant to worry that they were essentially encouraging incontinence and creating obstacles to keeping people continent.
‘Men and women are led to believe that it's OK they are leaking urine on exertion or at night-time, and simply buying a containment product will solve their problems’
To summarise the report, most participants agreed that better continence care education would have a crucial impact on practice.
Training
Across the UK we have several highly qualified specialist continence care teams and we need to start using these resources by introducing training into hospital wards, GP practices and throughout the community. With the greater use of video conferencing services such as Teams and Zoom in the NHS during COVID-19, there has never been a better opportunity to provide more training. We need to make training accessible to everyone either online or face-to-face in order to improve education in continence care.
Simply educating patients on fluids, avoiding bladder irritants such as caffeinated tea and coffee, fizzy drinks, alcohol etc, can substantially improve someone's continence, reducing urgency and frequency symptoms and giving them more time to reach a toilet.
Pelvic floor exercises have proved to be an effective treatment for urinary incontinence, particularly in women, and should be recommended as a first-line conservative treatment as it significantly improves quality of life and mental, social and physical functioning (Radzimińska et al, 2018).
Bladder re-training has also been shown to be successful in some patients. Using distraction techniques on the first sensation of needing to void can allow the bladder time to stretch and reach a higher capacity.
Regular and prompted toileting regimens are good practice in care homes and wards, reducing the risks of falls from patients having to rush to the toilet.
Information on these first-line treatments should be given to all patients struggling with urinary incontinence because drastic improvements can be seen by using such techniques. Improving education for ward and care home staff will enable them to put this advice into practice and hopefully ease the pressure caused by urinary incontinence and avoid the need to rely so heavily on pads (Radzimińska et al, 2018; Incontinence Products Online, 2022).
Increasing the amount of accessible training will hopefully lead to a reduction in the reliance on catheters. Up to 25% of patients in acute care have an indwelling catheter, of which at least a quarter are unnecessary (Murphy et al, 2015; Percival et al, 2021). Improving hospital admission assessment procedures is vital to capture accurate continence needs for each individual patient, as well as systematic reviews of those patients with indwelling catheters to promote early removal and discourage discharging patients with catheters (Radzimińska et al, 2018; Percival et al, 2021; Incontinence Products Online, 2022).
We need to invest in more training and education across all care sectors. We need to use our specialist continence care teams to allow for early assessment to ensure that a patient-centred, cost-effective pathway is followed.
Hospitals should be allowed adequate time and resources to complete a continence assessment as a priority and any first-line treatment initiated, with referrals made for unresolved or more complex cases.
A higher priority
Bladder and bowel problems are very common and highly treatable. Incontinence vastly impacts on a person's mental and physical health. It is also a significant factor for admission to hospital and care homes and, because of this, continence care deserves a higher priority than it currently receives (Bladder and Bowel UK, 2021).