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The importance of being
continent
Linda Appiah-Kubi Geriatrician
Elaine Scanlon Continence Nurse Consultant
Control of Voiding
Image Adapted from Landon Centre for Ageing Module on Urinary incontinence, Wiggins SA
Control of Voiding
Image Adapted from Landon Centre for Ageing Module on Urinary incontinence, Wiggins SA
Control of Voiding
Image Adapted from Landon Centre for Ageing Module on Urinary incontinence, Wiggins SA
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Control of Voiding
Image Adapted from Landon Centre for Ageing Module on Urinary incontinence, Wiggins SA
Voiding
Filling
Increased sympathetic tone
in bladder neck, relaxation of
detrusor
Inhibition of parasympathetic
tone
Somatic innervation
- maintains pelvic oor tone
- and striated periurethral
muscle tone
Voiding
Decreased sympathetic
and somatic muscle tone
relaxation of urethral
sphincter
Increased
parasympathetic tone
bladder contraction
What is normal Bladder
Voiding
maximum of once overnight
four to six times daily
with average urine volume is 300 to 350 mls each void
No difculty in starting
Stream is continuous and strong
No straining during voiding
and
No urine dribbling after voiding
Bladder feels completely empty following voiding
No urgency
No leakage even with rise in abdominal pressure
e.g. coughing, sneezing
No dysuria
Getliffe and Dolman. (2003).
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What is normal - Bowels
from 3 times per day to once every 3 days
soft and formed
No straining to empty
No bowel urgency
No pain present on defaecation
Not taking longer than 1 minute
Voiding
Recognise need to void
At appropriate bladder volume
Time to access appropriate place to void
Complete voiding
Manage toilet hygiene
What is
Urinary incontinence
is the complaint of any involuntary leakage of urine
The Standardisation Subcommittee of The International Continence Society, Neurology and Urodynamics. (1998).
Faecal incontinence
An involuntary loss of anal sphincter control leading to
unwanted release of liquid or solid faeces (not atus) at an
inappropriate time or in an inappropriate place
Western Health Continence Clinical Guidelines. (2010).

Why is this important?
May signify underlying illness eg.
UTIs
Constipation
Cognitive impairment
Other
Risk factor for falls
Impaired skin integrity infections
Sleep deprivation
Distressing to patient +/-carer
Affects discharge planning, premature placement etc.
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How common is incontinence?
How often do people
(voluntarily) talk about it?
Stats
Urinary incontinence affects
up to 37% of Australian women
up to 13% of Australian men AIHW 2006
65% of women and 30% of men sitting in a GP waiting room
report some type of urinary incontinence, yet
only 31% of these people report having sought help from a
health professional. Byles & Chiarelli, 2003
70% of people with urinary leakage do not seek advice and
treatment for their problem. Millard, 1998
Urine Incontinence
Women
30% (60 years+)
42% (75 years+)
Men
20% (60 years+)
44% (75 years+)
Faecal Incontinence
Women 12.9%
Men 20%
Department of Health. (2009). Best care for older people everywhere The toolkit .
AIHW 2006
Stats
In one study, over a three month period, 50% of women aged
45-59 years of age experienced some degree of mild, moderate
or severe urinary incontinence. Millard, 1998#
Faecal incontinence is one of the three major causes (along with
decreased mobility and dementia) for admittance to a residential
aged care facility

77% of nursing home residents in Australia are affected by
incontinence
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Is incontinence a normal part of ageing?
Is incontinence a normal part of ageing?
NO
- But age-related changes may predispose
or aggravate incontinence
- Age-related diseases may also
exacerbate incontinence
Risk Factors
Age
Multiparity
Comorbidities
eg. cerebrobvascular disease, neurological/spinal,
autonomic neuropathy, constipation
Cognitive impairment
Functional impairment
Gait abnormality
Diuretics
Obesity
Pelvic surgery
Delirium/confusional states #
Infection-urinary (symptomatic) #
Atrophic urethritis/vaginitis #
Pharmaceuticals #
Psychological, especially depression #
Excessive excretion (i.e., Heart failure, hyperglycemia,
hypercalcaemia, alcohol, caffeine, diuretics ) #
Restricted mobility #
Stool impaction
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Spinal Pathology
Neurogenic detrusor overactivity
Detrusor sphincter dyssynergia (supra-sacral lesions)
Leads to raised detrusor pressures
Detrusor underactivity and impaired bladder sensation
(usually sacral lesions)
Poorly sustained detrusor contractions
Or combinations of these
Risk of raised upper urinary tract pressures,
dilatation and renal impairment
Types of Urinary Incontinence
Stress
Urine leakage with increased abdominal pressure
Urge
Strong sudden desire to pass urine and involuntary urine
loss
Mixed
Most common in women
Overow
Usually small volume leak with poor urinary stream,
hesitancy, frequency, nocturia
Functional
Physical or psychological factors inuencing voiding
Questions
Do you sometimes leak before you get to
the toilet?
Do you wake up twice or more during
the night to go to the toilet?
Do you have to rush to use the toilet?
Questions
Do you sometimes leak when
you lift something heavy, exercise or play sport?
you change from a seated or lying position to a standing
position?
Do you strain to empty to bowel?
Do you sometimes soil your underwear?
Do you sometimes feel you have not completely emptied
your bladder?
Are you frequently nervous because you think you might lose
control of your bladder or bowel?
Do you plan your daily routine around where the nearest
toilet is?
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Other questions
Onset, Duration, Patterns
Parity, delivery complications
PMH esp diabetes, prostate, neurological, cognitive,
abdo/pelvic surgery
Medications, smoking (cough), alcohol, caffeine
Continence chart:- including types of uids, caffeine,
volumes voided, pads used and associated triggers/
symptoms
Examination
General
cognition / confusion / delirium
signs of CCF (oedema),
signs of other relevant comorbidities
signs of infection?
Blood! (urine, pr, fresh or altered)
Abdo
distension
masses
back pain/renal angle tenderness
catheter?
Investigations and Assessment
MSU MC+S
Random/fasting glucose
PVR
Bladder Diary
Frequency Volume chart
Bowel Chart (consider Bristol Stool Chart)
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Further Investigations
U+E, Calcium
Renal tract US (?upper tract abnormality)
Uroowmetry
Urodynamics
What is a normal PVR?
Varies significantly
between individuals
over the course of the day in one person
Scandinavian study of 75 year old community adults with
no voiding symptoms found a wide range of PVR
Men 10 400ml; Women 0 180ml
Thees and Dreblow 1999, Kolman et al 1999, Fitzgerald et al 2001, Hershekovitz
et al 2003, Mochtar et al 2006, Bonne et al 1996
Post Void Residual Management
0 - 200ml Likely no intervention needed
200 - 400ml Abnormal but can be monitored
>400ml despite
trying to void
Abnormal, likely needs
intervention (IDC)
Post Void Residual Management
0 - 200ml Likely no intervention needed
200 - 400ml Abnormal but can be monitored
>400ml despite
trying to void
Abnormal, likely needs
intervention (IDC)
B
U
T review
history and predisposing factors
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General Advice for Patients$
Ask For Help# Bring the toilet closer to the patient
Timed toileting and verbal prompting
Develop picture dictionary
Recognise patient cues when they want to toilet
Good toileting position
Promote a good bowel regime
and document bowel pattern
Bedside commode and/or
non-spill urinal for patients
Night time commodes or urinals
Management
Correct precipitating/predisposing causes
Pelvic oor exercises/physiotherapy
Oestrogen cream for vaginal atrophy
Pessaries
Antimuscarinics for detrusor overactivity
Intermittent self catheterisation
Continence Aids
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Continence product selection - consider
Promotes patient to toilet independently
Volume lost in incontinent episode
Day/night pattern of urinary incontinence
Ease of use and disposal
Patient preference
Cost
Also
Relationships and sex
Home life, ADLs#
Work
Social outings
Exercise and sport
Travel
Funding for continence aids
Medications for Detrusor Overactivity
Drug Selectivity Route
Oxybutynin M1, M3 Oral/patch/elixir
Tolterodine Non-selective Oral
Solifenacin Predom M3 Oral
Propiverine Non-selective Oral
Trospium Non-selective alpha
adrenergic agonist
and antimuscarinic
Oral
Darifenacin Predom M3 Oral
Antimuscarinic Drugs caution in cognitive impairment and impaired detrusor
contractility, warn about side effects. Avoid tricyclics in older patients.
Munuluri et al 2007
Summary
Urinary incontinence is common,
particularly in women
Many people experience it but dont seek
help unless asked
Incontinence can worsen quality of life,
length of stay and discharge outcomes
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Further Reading
http://www.continence.org.au/
Continence Foundation of Australia
http://www.toiletmap.gov.au/
National Public Toilet Map
http://www.bladderbowel.gov.au/
Government website
Medscape http://emedicine.medscape.com/
Urinary Incontinence
Neurourol Urodyn. 2002;21(2):167-78.The standardisation of terminology of lower urinary tract
function: report from the Standardisation Sub-committee of the International Continence Society.
Abrams et al The Standardisation Sub-committee of the International Continence Society.
Int J Clin Pract. 2009;63(4):568-573. Prevalence of Urinary and Faecal Incontinence and Nocturnal
Enuresis and Attitudes to Treatment and Help-seeking Amongst a Community-based
Representative Sample of Adults in the United Kingdom. B. S. Buckley; M. C. M. Lapitan
The Obstetrician & Gynaecologist 2007;9:1:9-14 Anticholinergic drugs for overactive bladder: a
review of the literature and practical guide. N Munjuluri, WWong, and WYoong,