Continence Management
Script
Note: This script may vary from the recording.
Slide 2 Segment 1 Index
Slide 3 Definition
Continence is the voluntary control of passing urine or faeces. It can also be applied to ejaculation of sperm so essentially it is the ability the body to voluntarily restrain passing body fluid.
Being continent or in-continent is important to our self esteem and our dignity. It is something that we learn from a young age. Loosing control of ones bodily functions can be very demoralizing and degrading for a person.
Slide 4 Things to know about incontinence
Being incontinent is not a disease but rather a sign of other problems. However the cause can be the result of a disease. As we will see later on when we discuss reasons and causes for continence problems.
Slide 5 Organs involved
There are two organs involved in incontinence and they are the bladder bowels and
Slide 6 What causes urine incontinence
Urine Incontinence This is caused through problems that occur with the muscles and nerves in the bladder.
Slide 7 The urinary system
You will see on this slide how the urine is manufactured in the kidneys and travels down to the bladder where it is excreted via the urethra. The kidneys are responsible for the body’s water balance, regulating blood pressure and blood electrolytes and help regulating the body’s acid base balance. It also helps with the production of Vitamin D as well as the excretion of wastes products and toxins from drugs and chemicals we ingest.
As people get older, their kidneys do not function so well and are not able to concentrate the urine. This means older people appear to pass more urine at night. While is may appear that they are passing more urine, in fact they are not. It is the inability to concentrate urine that makes it seem like they pass more urine
Slide 8 The bladder structure
The bladder is a small bag made up of smooth muscle that holds the urine. A normal bladder can hold 550 – 600mls but it is usually when the capacity reaches 300-350 mls that you get the urge of wanting to empty the bladder.
Slide 8 The Bladder
This slide shows what a normal bladder looks like with 600 mls in it. You can also see the smooth muscle I mentioned in the previous slide. Essentially it is a small bag that expands and contracts to hold and discharge urine.
Slide 10 Functions of the Bladder
So the bladder has two main functions. That is to store urine, until it reaches a point in which the bladder needs to empty and to expel or discharge urine. It is as simple as that.
Slide 11 How the bladder works?
So how does the bladder work?
Once the bladder reaches the level of feeling full, say around 300-350 mls the nerve impulses are stimulated and a message is sent to the brain that it wants to empty or discharge the contents of the bladder.
Once you get to the toilet you then have the control to relax the external sphincter or the opening at the bottom of the bladder. The muscles the wall of the bladder then receive the message to contract or get tighter and force the urine out of the bladder through the urethra, the external opening. All of this most people have control over. When a person has not or restricted control over this process they become incontinent.
Slide 12 Normal bladder control
For most all of us the production of urine is involuntary. That means it is going to form regardless of what we do.
As humans we have the ability to know when our bladder is full as I mentioned in the previous slide. You will all have experienced this as most of us have control over when and where we pass urine. This is monitored or controlled by the messages sent to the brain by the nerves in our bladder as I said before. So it stands to reason that if a person has a condition that interferes with the message getting to the brain, they are going to have problems knowing when or maybe even where to pass urine.
Side 13 Urethra
The urine is expelled from the bladder through a small tube called the urethra. It connects the bladder to genitals or the external meatus as it is called.
In the female the urethra is very short around 3.8 cm or 1 ½ inches and finishes just above the vaginal opening. You will see this when we discuss the female anatomy.
In a male however it is much longer as it has to travel down the length of the penis. On average the urethra is around 20 cm long or 8 inches from the opening in the bladder to the end of the penis in a male.
Slide 14 Types of incontinence
It is estimated that 1 in 10 people over the age of 65 will have some continence problems. There are many forms of incontinence and not everyone has the same type. Incontinence problems are classified into 6 different types
Urge Incontinence:
This is when the urge to pass urine is strong and often sudden. People with this problem find they have to suddenly get up and go to the toilet. You may even hear it referred to an overactive bladder. This is caused by a problem with the muscles and nerves in the bladder.
Most people make it to the toilet in time but some people have trouble and start to pass some or all of the contents of their bladder into their pants or pads before they get to the toilet.
For some people his can happen regardless to how much urine is in the bladder. For others it may happen intermittently for example if a person has a urinary infection they may have this urge to pass urine all the time which is extremely uncomfortable. It is one of the first signs of a Urinary Tract Infection or a UTI as it is often referred to. It is a clue for you when looking after people. If a person in your care keeps running to the toilet or tells you they keep wanting to go to the toilet when they don’t usually have a problem then there is a possibility they may have a urinary infection. For men with an enlarged prostate they too can want to pass urine frequently because the enlarge prostate prevent them from fully emptying their bladder. We will talk more about this further in the slide.
Stress Incontinence:
This is the most common form of incontinence. It most frequently occurs when people laugh, cough. This may be something that happens to you or you may see some of your friends rush off to the toilet you are laughing and having fun. It also happens during exercise, sneezing lifting heavy objects or any type of activity that puts pressure on the bladder. People who are more at risk of stress incontinence are
· Being female although it does happen in men. This is mainly due to our anatomy – how our urinary system and all supporting structures are designed.
· Childbirth is another very common reason because the pressure of the baby on the pelvic floor and childbirth itself weakens the pelvic floor muscles. Women are encouraged to do exercises after the baby to strengthen these muscles and bring them back to normal. The pelvic floor is just a term used to describe all the muscles that sit in the pelvic area of the body. It does not mean a person has to get on the floor to do the exercises.
· Chronic coughing for people chronic bronchitis and asthma or even smokers the continuous coughing puts stress on the pelvic muscles which will eventually make them weak so that every time they cough a little bit of urine escapes.
· Getting older – while age itself is not a cause of continence problems the fact is an increase in risk factors. These include loss of estrogen after menopause in women, development of physical and mental disabilities, some medications people take, decreased sensation in the bladder, decreased capacity of the bladder, and a loss of muscle tone do all contribute to continence problems
· Obesity – in a number of studies of severely obese women over 60% complained of stress incontinence
· Smoking – Cigarette smokes is known as a bladder irritant meaning that the bladder can become inflamed and sore.
Overflow Incontinence
This happens when there is a problem with the bladder capacity or a person has been unable to go to the toilet for some reason. The pressure builds up in the bladder and the bladder struggles to hold the amount of urine produced causing some of the urine to leak out as it cannot hold on to the excess urine.
Mixed Incontinence
This is most commonly a combination of both urge and stress incontinence but it can be a combination of any types of incontinence. You may well know of people with a combination or you may even suffer from it yourself?
Functional Incontinence
This when a person has a medical condition that prevents them from getting to the toilet in time to urinate. They may be unable to undo their pants in time due to arthritis or they may have Parkinson’s disease which makes it difficult to not only get in the door to the toilet but also to get their pants down. The more agitated and fearful of wetting themselves can make the tremors worse which make it even more difficult for them to get to the toilet. A person with dementia may know they want to go to the toilet but have forgotten what a toilet looks like. This may cause them to urinate in inappropriate places.
Total incontinence
This is when the bladder cannot hold urine and leaks all the time. This is where a person has no voluntary control over the sphincter that allows urine out through urethral sphincter because of damage causing loss or weakness of the muscles and nerves. It is common in people with spinal cord injury. It can happen in women after childbirth and in men with prostate problems. For this condition devices or pads are used which we will talk about in later slides.
Slide 15 Summary
So let’s summarize continence
l Incontinence is caused by problems with the muscles and nerves in the bladder
l The function of the bladder is to store and expel urine
l When the bladder reaches around 300 – 350 mils the a person will get the urge to go to the toilet
l There are many different types of continence problems and you cant treat all people the same
So to understand continence it is really helpful to understand how the body works. Knowing this will make it easier for you to understand the person in your care and indeed yourself, so the appropriate care or intervention is given to the person.
Segment 2 Slide 1
Female and Male Incontinence
Slide 2 Female anatomy
Firstly lets look at the female.
As you can see from this slide of a female anatomy, the ureter, vagina, bowel and anus are all very close together. Their proximity or closeness of the organs contributes to urinary problems in women.
As mentioned early one of the common causes urinary problems in women is caused through pregnancy and childbirth. It is easy to see how the extreme pressure that gets put on the pelvic floor, or the lower part of the body can cause damage to the muscles and ligaments. This is why stress and urge incontinence so prevalent in women.
Urine leakage in women is very common. In fact it is twice as more common in women than in men.
Slide 3 Causes of urinary problems in women
Structure and anatomy is the major contributing factor as mentioned earlier.
The most common is pregnancy and childbirth.
Prolapses can occur which means that a part of the anatomy of the body has slipped from its normal position. It can refer to the uterus, the bladder, anus or sometimes even the rectum. These are all caused through weakness to the supportive structures. This is why it is important to do pelvic floor exercise after birth to help prevent continence problems in later life. In younger women with severe continence problems these prolapses are repaired through surgery however surgery is rarely performed on older women.
Menopause is another factor. This is due to the reduction in estrogen hormones that not only affect the vaginal wall it affects the urethra as well.
Constipation – continual straining affects the pelvic floor muscles and ligaments
Chronic Coughing – as mentioned before
Urinary Tract Infections
Birth defects Sometimes the urethra becomes narrow and what is called a stricture develops which means the outlet becomes narrow in one part of the urethra which prevent urine from flowing.
Neurological injury or diseases like Multiple Sclerosis, Parkinson's disease, spinal cord injury, stroke, spinabifida, and hydrocephalus. These all affect the bladder in some form.
Side effects of medications or complications of surgery
Diabetes – Women with diabetes have a 70% increase of risk of continence problems contributed by increased thirst, increased bloods sugar levels irritate the bladder, nerve damage leading to loss of bladder sensation.
Obesity – the increased fat and the effect of gravity puts excess pressure on the pelvic floor.
Dehydration – can cause the onset of incontinence
Or Physical problems associated with aging many of which have already been mentioned.
Male Incontinence
Slide 4 Male Anatomy
While incontinence is not so prevalent in men, it does still occur and it does increase with age.
If you look at the anatomy of the male, it is easy to see the urethra; the tube that passes the urine from the bladder is a lot longer than in women. You will also see the distance between the urethra and the anus is far greater in males than females. This renders them at a lesser risk of urinary tract infections. However the major problem for men comes from the prostate gland which you can see just below the neck of the bladder.