Category: Advancing Modules

Match the type of urinary or bowel dysfunction with the assessment questions.

• Functional incontinence (urinary and/or faecal) is often the result of an unsuitable environment for the type and level of disability the person experiences following a stroke
• Environmental assessment with individually tailored adaptations is a key component of a comprehensive bladder and bowel rehabilitation programme
• Individual tailoring of an environment includes considering privacy and maintenance of dignity for elimination activities. Ostaszkiewicz J.(2017). Reframing continence care in care-dependence. Geriatric Nursing, 38: 520-526. Ostaszkiewicz J. (2018). A conceptual model of the risk of elder abuseposed by incontinence and care dependence. International Journal of Older People Nursing, 13(2): e12182
• Environmental adaptation may involve structural modifications eg putting in a downstairs toilet facility, fitting of grab bars
• Environmental adaptation also includes provision of equipment eg commodes, urinals, toilet frames
• Successful environmental adaptation is an important aspect of bladder and bowel rehabilitation and  requires a multidisciplinary approach

• Use of containment products does not actively support recovery of bladder/bowel function.
• Containment products should only be used as a last resort when all other bladder/bowel rehabilitation has failed.

Assessing for a product is not a bladder/bowel assessment. It is only a part of a wider comprehensive assessment.  Products can improve a patient’s quality of life, protect dignity and encourage functional and social independence when recovery of bladder/bowel function is not possible.

The main types of containment are:

• • Absorbent pads
  • Sheath catheters
  • Indwelling urethral/suprapubic catheters only where clinically indicated (RCP 2016, Australian Stroke Foundation 2017).

Factors to be considered for choice of containment:

• Level of disability: some products are easier to use than others
• Physical and cognitive function
• Type and severity of incontinence
• Gender
• Skin integrity
• Availability of care
• Likely duration of use

It is vital that before supplying a patient with a containment product, clear instructions about the correct use, fitting, storage and disposal of the product are given.

Most common side effects include:

• Dry mouth (Most common)
• Dry eyes
• Blurred vision
• Constipation
• Dizziness
• GI disturbances e.g. Nausea, Dyspepsia, Abdominal pain
• UTI / cystitis
• Insomnia

Specific side-effects of mirabegron include:

• UTI,
• nausea
• cardiac problems – tachycardia / palpitations

NB: Prescriber should be aware of contra indications and note that Antimuscarinic drugs should be used with caution in older people (especially if frail).

Antimuscarinic medication for an overactive bladder:

• Vesicare (Solifenacin) 5mg / 10mg once daily
• Detrusitol XL (Tolterodine) 4mg once daily
• Lyrinel XL (Oxybutinin) 5mg / 10mg once daily
• Kentera Patch (Oxybutinin transdermal) applied every 3-4 days
• Toviaz (Fesoterodine) 4mg and 8mg once daily
• Regurin (Trospium chloride) 20mg BD
• Emselix (Darifenicin) 7.4 / 15mg once daily

Beta-3 adrenergic receptor agonist medication:

• Mirabegron (Betmiga) 25mg / 50mg once daily

 

• Antimuscarinic agents and beta3-receptor agonists act to relax the detrusor muscle of the bladder wall.
• Most patients will report a reduction to their symptoms within the first 2 to 4 weeks of use.
• The need for continuing drug therapy should be reviewed after 3 to 6 months. If taken long term, they should be reviewed yearly.
• Must not be given when person has incomplete emptying or urinary retention as it may make this worse.
• Consult your local formulary for choice of drug.

Scheduled voiding
Prompted voiding	This teaches people to initiate voiding through positive reinforcement of appropriate requests to use the toilet. It involves approaching people regularly while awake (according to individualised schedules or every two hours) to ask if they need to go to the toilet and whether they are wet or dry. Praise is given if the person reports correctly or uses the toilet appropriately. This is a behavioural modification approach to bladder rehabilitation. It is most suitable for people with cognitive impairment who are also mobile.
Habit training	This identifies the persons usual patterns of voiding using a fluid balance chart and bladder diary over at least 3 consecutive 24 hour periods. Once the pattern is established, a schedule for toilet use is introduced that pre-empts the usual time for voiding by 10-15 minutes to avert an episode of incontinence. This is an bladder rehabilitation intervention.
Timed voiding	This is also known as routine or regular toileting. It involves helping the person to use the toilet at fixed time intervals such as 2 hourly. This is not a bladder rehabilitation intervention to promote recovery of bladder function. Timed voiding is used to manage urinary incontinence and aims to ‘keep people dry’.