Incontinence: Background

Recommendations

Identify and Treat the Cause
1 Take a careful history from the person identified to have urinary and/or fecal incontinence. Level of Evidence
Not Assessed


Address Patient-centered Concerns
2 Consider the potentially serious adverse effects that urinary and fecal incontinence have on a patient’s quality of life. Level of Evidence
Not Assessed
3 Provide information and advice on treatment options available in both primary and secondary care. Level of Evidence
Not Assessed


Provide Local Care
4 Thoroughly assess patients with urinary incontinence, including a directed history, physical examination, laboratory testing, and urodynamic studies if appropriate. Level of Evidence
Not Assessed
5 Thoroughly assess patients with fecal incontinence, including a directed history, physical examination, neurologic examination, and specialized investigations as appropriate. Level of Evidence
Not Assessed
6 Determine and implement an appropriate treatment approach based on the cause and type of incontinence. Level of Evidence
Not Assessed
7 Monitor incontinence treatment results and adjust the therapeutic approach as necessary. Level of Evidence
Not Assessed
8 Recommend containment products and reassess their suitability. Consider absorbent products as: - a coping strategy pending definitive treatment - an adjunct to other ongoing therapy - long term management of urinary incontinence only after other treatment options have been explored Level of Evidence
Not Assessed
9 Ensure that skin integrity is restored and maintained in patients with incontinence through the use of skin barriers and protectants and appropriate containment devices. Level of Evidence
Not Assessed


Provide Organizational Support
10 Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information. Level of Evidence
Not Assessed


Background

Fecal or urinary incontinence and double incontinence, though common problems in the aging population, are not restricted to the elderly. The overall prevalence of these problems is unknown, but increasing prevalence is noted with age. Social discomfort among patients with incontinence is significant and can lead to fear of social contact, isolation, psychological distress among patients and caregivers, and unnecessary institutionalization. As a result, quality of the life is a key issue directing incontinence treatment.

Urinary incontinence is widespread in geriatric individuals and is estimated to affect 15% to 30% of those living in the community and 50% of nursing home residents. Women may be affected twice as often as men. The estimated cost of managing urinary incontinence in American nursing homes is more than $3 billion. The cause may be related to various causes, summarized in the acronym DIAPPERS: delirium, infection, atrophic vaginitis, psychological, pharmaceutical, endocrine (diabetes), restricted mobility, and stool impaction. Many causes of urinary incontinence are reversible, and thorough assessment is required for accurate diagnosis. Depending on the cause, treatment options include medical therapy with anticholinergic agents or hormones, biofeedback, and surgery.

Fecal incontinence is estimated to occur in 2% of the population, and prevalence may increase to 60% in the elderly, especially hospitalized patients and nursing home residents. Risk factors include female gender, multiparity, and advancing age. Some estimates indicate that fecal incontinence is more common in women than men. Intact pelvic floor muscles, neurologic integrity and normal sensation are critical to maintaining continence. Fecal incontinence is associated with diarrhea, constipation, fecal impaction, and laxative use; hyperosmotic enteral feeding; neurologic problems associated with stroke, diabetes, and multiple sclerosis; pelvic, neurologic, surgical and obstetric injury; drug side effects; and collagen vascular disease. Thorough assessment and diagnostic evaluation may identify the cause, type of incontinence, and appropriate treatment. Management may include the use of bulking agents, dietary management, biofeedback, and surgery for refractory cases. Bowel habit training may be useful in disabled patients and those with advanced dementia.

Double incontinence may be equally prevalent in men and women living in the community. As well, patients with spinal cord injury will generally experience both urinary and fecal incontence.

Incontinent dermatitis due to chemical irritation by urine and/or feces may lead to skin breakdown and local bacterial infection. Routine use of skin barriers and protectants, along with appropriate containment systems, can prevent and treat incontinent dermatitis.

References

Essential Publications
1 Incontinence-associated dermatitis Quality Indicator
 Type: Systematic review
Gray M, Bliss DZ, Doughty DB, Ermer-Seltun J, Kennedy-Evans KL, Palmer MH. Incontinence-associated dermatitis: A consensus. JWOCN 2007;34(1):45-54, quiz 55-6.
The purpose of this review was to examine incontinence-associated dermatitis (IAD) and strategies for assessing, preventing, and treating it. Very little evidence was found concerning IAD. More research is needed to evaluate the efficacy of various treatments for IAD.
2 Perineal dermatitis Quality Indicator
 Type: Retrospective Analysis
Bliss DZ, Savik K, Harms S, Fan Q, Wyman JF. Prevalence and correlates of perineal dermatitis in nursing home residents. Nursing Research 2006;55(4):243-51.
The prevalence of perineal dermatitis and factors affecting its incidence were evaluated in this study. 59,558 patient records were analyzed. The researchers found that 5.7% of the patients studied had perineal dermatitis. Perineal dermatitis was associated with impaired tissue tolerance, perineal problems such as incontinence (73% of patients with perineal dermatitis were incontinent), and altered toileting ability due to restraints.


Enablers for practice

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