Quite clearly, and for good reason, 2020 has been the year that the full focus of the world's attention and resources has been on the global coronavirus pandemic (COVID-19).
Initial public health advice from the UK Government in March of this year was to ‘stay home, protect the NHS’. This advice, aiming to reduce avoidable transmission of the virus, also had an unfortunate unintended consequence. Anecdotal evidence from patients suggests the message was interpreted to mean they should try not to ‘trouble their GP’ for any reason, and certainly not for something as ‘trivial’ as their continence problems.
As the year has progressed, the Government's message has changed to assert that, indeed, UK citizens should report red flag symptoms such as blood in the urine, weight loss, altered bowel habit etc. But as far as specialist secondary care referrals are concerned, older people in particular are still largely reluctant to seek help for problems such as urinary frequency, urgency, bothersome nocturia, urine leakage, voiding difficulties and symptoms of urinary discomfort or infection.
As COVID-19 and cancer services have assumed priority in the NHS strategic response, for continence nurses, the fact that our service provision has been commensurately deprioritised is very difficult to swallow. Continence management specialists have worked incredibly hard to try to ensure their patient group retain access to a quality service, despite dwindling resources. For patients and nurses alike, staff shortages, redeployment, lockdown, furlough and shielding have contributed further to the miserable and mounting problem of unmet need in people with continence problems. These contemporary influences only compound the age-old, well-documented psychological, sociological and financial effects of incontinence: embarrassment, shame, loss of self-esteem, social isolation and the impact of the financial cost of containment products (to the individual and to the NHS) to name but a few. Community continence nurses, now so thin on the ground, are struggling to perform their essential contribution in preventing avoidable hospital admissions. Examples where their role is particularly effective is in identifying and managing patients with urinary retention, voiding difficulty due to constipation, moisture-associated skin damage, urinary infections and patients at risk of urosepsis.
What can nurses do?
Indisputably, all staff who have worked within and around heath and social care provision (including all support services, such as administrative, portering, domestic and catering staff) have done an incredible job this year to try to keep providing quality care for all patients. Just because we are in the grip of a global pandemic, it is painfully obvious to us as nurses that other diseases have not miraculously gone away. It could indeed be argued, however, that public health measures taken to mitigate the spread of SARS-CoV-2 have also had the result of drastically reducing access to healthcare provision for many of the most vulnerable people in our communities. These vulnerable groups include older people, people with physical and learning differences, people with long-term illnesses, people with communication, mental health and mobility difficulties, new mothers, children and people with a range of neurodiversities. Unfortunately, the incidence of continence issues is disproportionately higher for people in these groups. Therefore it is easy to see where special effort must be made to reach out to, and support, precisely these vulnerable people in order to prevent the avoidable misery of unmanaged incontinence and reduce the risk of unnecessary hospital admissions.
Community continence professionals cannot do it alone. It is crucial that we all get the message out to the individuals in our care that much can be done to improve or eliminate suffering from incontinence. Yes, we are still experiencing restrictions to surgical services in secondary care, so that waiting lists for treatments, such as Botox intravesical therapy, remain unacceptably lengthy for now, but so much can be tried before a referral to secondary care is necessary. It could well be that, with the correct advice and community management, bladder symptoms may become sufficiently well-managed that referral can be avoided altogether.
A simple overview of common continence problems with easily accessible self-help and primary care management solutions is offered here. Table 1 provides information on overactive bladder, Table 2 on urinary stress incontinence and Table 3 on recurrent urinary infection, all of which are more common in women.
| Definition |
| Urinary frequency: over 7 times a day and more than 1 at night (nocturia) |
| Risk factors |
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| Management |
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| Supporting information on management of overactive bladder is available from Bladder and Bowel UK, the British Association of Urological Nurses and the British Association of Urological Surgeons. Once these treatment modalities have been exhausted the patient should be encouraged to ask for secondary care referral and management. However, it cannot be over-stated what an improvement the simple measures above may make to overactive bladder symptoms |
| Definition |
| Urine leaks in the absence of bladder muscle contraction. Happens when coughing, sneezing and/or abdominal straining. May leak passively simply when mobilising |
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Risk factors
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| Management |
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| Referral |
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| Once a woman has made a concerted effort to practise pelvic floor exercises but has seen little improvement she may be referred to the pelvic floor women's health physiotherapy team who can provide an extra level of assessment and support which could obviate the requirement for surgery. A range of treatment options are available to women once conservative efforts have proved unsuccessful. Any patient keen to pursue anti-incontinence surgery will have their case considered by the local Trust's pelvic floor multidisciplinary team. Here, specialists in urology, gynaecology, anorectal, physiotherapy and continence, evaluate all diagnostic information in discussion with the patient to decide upon a safe and effective plan of action in line with the patient's own priorities (British Association of Urological Surgeons, 2020). It is important to inform patients that wherever possible these surgeries are still taking place although waiting lists may be longer than usual |
| Definition |
| Recurrent urinary tract infection (UTI) in adults is defined as repeated UTI with a frequency of two or more UTIs in the past 6 months or three or more UTIs in the past 12 months (National Institute for Health and Care Excellence (NICE), 2018a). Care should be taken to ensure these represent individual infections and not persistence of an organism refractory to treatment. Recurrent urinary tract infection is automatically classed as complex and therefore the standard 3-day treatment for uncomplicated UTI is not appropriate |
| Risk factors |
| Incomplete bladder emptying, menopause and post-menopause, hygiene, intermittent self-catheterisation (ISC), constipation, new sexual partners, dehydration, certain sexual practices |
| Management |
| The patient should be encouraged to drink 2 L of fluid daily, mainly water, to prevent recurrence of UTIs. An active UTI in a patient with frequent UTIs always requires a urine culture so that the causative organism may be identified and treated effectively. Recurrent UTIs carry the risk of antibiotic resistance, therefore it is important that 3-day course of an empirical treatment is avoided. The utility of topical oestrogen therapy in mitigating recurrence of UTIs is well proven (Perrotta et al, 2010). Once antimicrobial sensitivities have been established, the patient should receive a course of appropriate antibiotic treatment as per local prescribing guidance (3-day empiric regimen is not recommended in this case) (NICE, 2018b). Prophylactic antibiotics are discouraged but there are instances when there appears to be no alternative and, as ever, benefit should outweigh risk. Self-start antibiotics are sometimes recommended such as nitrofurantoin or trimethoprim (NICE, 2018a). Useful non-microbial adjuncts include Hiprex (methenamine hippurate), D-mannose and intravesical bladder treatments such as sodium hyaluronate or chondroitin sulphate proprietary preparations. Treat any reversible pathology resulting in voiding difficulty, including constipation. ISC may be advised. Advise patients to avoid using soaps or washing hair in the bath, wearing tight clothing around the pelvis including thong underwear and to void pre- and post-sexual intercourse. Pouring a jug of warm water across the genitalia into the toilet after intercourse will clear away potential pathogens. The current trend to remove all pubic hair may be contributing to increased problems with UTIs as it provides a physical barrier against friction but also contributes to the formation of a healthy microbiome |
| Referral |
| Refer to local specialist secondary care advice for information on when onward referral for investigation is appropriate |
It is hoped that this information may assist anyone caring for persons with common continence issues provide some relief and clear information on what can be done—whether that is alone in home lockdown, with the support of the community continence team, with primary care prescribing or (at the appropriate time in the patient pathway) secondary care intervention which is—absolutely—available to them.
Male urinary stress incontinence commonly occurs after surgical interventions within the pelvis, such as radical prostatectomy. Men and women of all ages will benefit from pelvic floor exercises. In many cases stress incontinence in men following surgery will resolve spontaneously. If it has not resolved after 12 months then the man could consider pursuing anti-incontinence surgery via his GP. For those not wishing to go down this route, there is an enormous range of containment devices, including sheaths and novel collection devices, which may prove to be a comfortable and convenient management solution.
If a man is experiencing urine leaks it is important to exclude overflow incontinence by means of examination and bladder ultrasound. Continence team nurses are ideally placed to evaluate any patient who may be at risk of significant post-voiding urinary retention and institute intermittent self-catheterisation should this be necessary.
Botox intravesical therapy may be useful for both men and women; however, for men it is important to exclude overactive bladder as secondary to outflow obstruction. This would be identified by urodynamic studies. Any outflow obstruction should be improved before considering Botox. In many cases, overactive bladder will resolve once the obstruction is removed post-transurethral resection of the prostate (TURP). For a man who has no difficulty with his flow, a trial of an anticholinergic or mirabegron may afford significant relief from overactive bladder symptoms once diet and fluid modification has been tried.
‘We should ensure that the physical, social, emotional and financial impact of incontinence problems do not become overlooked in a world where coronavirus is taking centre stage'
Urinary tract infection is less common in men and may be related to problems such as bladder outlet obstruction (from an enlarged prostate or stricture) or voiding difficulty. GP assessment should be sought when men experience UTI, and here again the community continence nurses can assess voiding function with bladder scanning and teaching self-catheterisation where appropriate. Referral for investigation is necessary for any man where the cause of infection is not immediately obvious.
Conclusion
We must ensure that the message is clear at every opportunity: continence problems matter and seeking help for them is worthwhile and entirely valid. Secondly, our community continence teams perform a vital service in providing a lifeline to people at some of the most vulnerable times in their lives. They can make the difference between someone being able to leave the house or not, look forward to or dreading a rare social event and, crucially, prevent someone's continence problems worsening to the extent they require hospital admission (with all the risk, expense and demand on resources that entails). As discussed, it is important that referral to secondary care takes place at the right time for any patient once community management options have been actively tried and failed. Hospital care is open—not only for the those with COVID-19—and, equally, every effort is being made to mitigate the risk of viral exposure should hospital treatment be indicated for definitive continence management. Until that point is reached, however, much can be done to promote continence and urinary health. Very simple measures such as diet and fluid modification should never be overlooked and can make a significant improvement in urinary symptoms with minimal intervention from healthcare professionals.
Now, more than ever, we should ensure that the isolation, embarrassment, loss of self-esteem, and the physical, social, emotional and financial impact of incontinence problems do not become overlooked in a world where coronavirus is taking centre stage. Whether or not you directly nurse patients with incontinence, you can make a huge difference to those in your care by simply having a conversation and encouraging the person not to suffer in silence.