Continence Care Explained

Incontinence is the unintentional passing of urine from the bladder or faeces from the bowel. Continence issues are common and it is estimated that 14 million people in the UK experience some level of incontinence. Incontinence can occur for many reasons, including injuries, physical issues, medical conditions, neurological difficulties and advanced age. Incontinence can be a short-term issue, for example, during pregnancy or due to a bladder or bowel infection or irritation, or it can be a long-term issue, with some people managing incontinence issues for the rest of their life.

Continence care is the management and support provided to individuals who experience difficulties with bladder or bowel control (incontinence). It encompasses a range of medical, physical, practical and emotional advice and interventions designed to help people maintain dignity, comfort and quality of life while managing incontinence.

The key aspects of continence care are:

Assessment and diagnosis

The first step in continence care is identifying the type of incontinence. It is then important to determine the underlying cause or causes, such as medical conditions, medications, ageing, pregnancy or neurological disorders.

Management strategies

Once the individual has received a diagnosis and the underlying cause has been identified, incontinence management strategies can be implemented, such as:

• Lifestyle modifications: Changes in diet, fluid intake and exercise routines.
• Pelvic floor exercises: Strengthening the pelvic muscles to improve bladder and bowel control
• Bladder training: Encouraging scheduled voiding to improve control.
• Medications: Prescribed medication can be used to treat underlying conditions or to control symptoms.

Use of aids and devices

Many people with incontinence find aids and devices to be extremely effective. For example:

• Absorbent products, such as pads, pants or adult nappies.
• Catheters and penile sheaths can be effective for people with more severe incontinence.
• Specially adapted clothing.
• Assistive devices, such as commodes or urinals.
• Bed and chair protection.

Specialised care plans

Tailored care plans are created for individuals based on their specific needs. This can include long-term strategies for chronic incontinence. A care plan can help individuals to manage their incontinence, teach them proper personal care and can help healthcare professionals to monitor their incontinence and recognise any worsening symptoms.

Education and support

This includes teaching patients and caregivers about managing symptoms, maintaining hygiene and reducing the risk of infections like urinary tract infections (UTIs). Support also includes emotional and psychological support to address any feelings of embarrassment or isolation.

Surgical options

Depending on the type of incontinence the individual is experiencing, any other medical issues and their personal circumstances, surgery may be recommended. This could include a sling procedure or the repair of pelvic floor muscles.

Continence care can be provided by a variety of healthcare professionals, including general practitioners, nurses, urologists, gynaecologists, care workers and physiotherapists, often as part of a multidisciplinary team. The goal is to help individuals achieve the highest possible level of independence and well-being.

Continence care differs from person to person, depending on their individual needs. Each care plan must be created by a relevant professional or professionals and all care should be person-centred. It is also important to be aware that continence care isn’t limited to supporting the individual’s physical needs. Continence issues can also affect a person’s mental and emotional well-being and healthcare professionals and caregivers should consider this when providing continence care.

Types of Continence

There are multiple different types of incontinence, with different underlying causes, different symptoms and different treatments. By understanding these different types of continence and incontinence, healthcare providers can better assess and manage the specific needs of individuals and tailor treatment and care plans to improve their quality of life.

People can have one form of incontinence or can have double incompetence, meaning they have both urinary and bowel incontinence. Incontinence issues can vary in severity, including when are how the incontinence occurs.

Urinary Incontinence

Someone with urinary incontinence will be unable to control the flow of urine from their bladder. A loss of bladder control can lead to the involuntary leakage of urine. Some people may experience small amounts of urine leaking frequently, whereas others may empty their whole bladder at one time. There are several different types of urinary incontinence, including:

Stress incontinence

Leakage occurs during physical activities that put pressure on the bladder, such as coughing, sneezing, laughing or exercising. It is typically associated with weak pelvic muscles that are unable to support the pelvic organs.

Urge incontinence

A sudden, intense urge to urinate, followed by involuntary leakage or urination. It is often linked to overactive bladder (OAB), weak pelvic muscles, nerve damage and diabetes.

Overflow incontinence

An inability to fully empty the bladder which causes frequent or continuous dribbling of urine.

Functional incontinence

Loss of control due to physical or cognitive impairments that prevent them from reaching the bathroom in time (e.g., arthritis or dementia). For example, they may not be able to recognise when they need to go to the toilet, use the toilet independently, identify what a toilet is or manage their personal or physical needs. However, unlike other types of incontinence, the bladder and pelvic muscles are typically healthy.

Mixed incontinence

People with mixed incontinence experience more than one type of incontinence, most commonly a combination of stress and urge incontinence symptoms.

Bowel Incontinence

Also known as faecal incontinence, someone with bowel incontinence may be unable to control the passing of faeces. They may experience a loss of control over their bowel movements, which can lead to passing sold stood, liquid stool, intestinal mucus and gas. The main types of bowel incontinence are:

Passive incontinence

Being unaware of the need to pass stool can result in accidental leakage. People with passive incontinence may not even experience the sensation that they have soiled themselves.

Urge incontinence

Urge incontinence is an inability to hold stool long enough to reach the toilet after the urge to defecate is felt. People with urge incontinence may experience a sudden need to go to the toilet but are unable to make it to the toilet on time.

Overflow incontinence

Often caused by severe constipation, where stool builds up and causes leakage around the blockage.

Sleep Incontinence

Being able to control your bladder and bowel function during sleep is known as sleep continence. However, some people are able to manage their bladder and bowel function when awake but lose control during sleep. Types of sleep incontinence include:

• Nocturnal enuresis (bedwetting): Involuntary urination during sleep, commonly seen in children but also affecting some adults.
• Nighttime bowel incontinence: Rare but can occur with severe bowel control issues or neurological disorders.

Temporary Incontinence

A short-term loss of control of bladder or bowel function can occur due to specific factors, such as urinary tract infections (UTIs), medications, severe diarrhoea or postpartum recovery. Temporary incontinence can mimic stress, urge or overflow incontinence but it usually resolves once the underlying issue is treated.

Continence Care in Nursing Homes

Effective continence care in nursing homes involves providing comprehensive support and management for residents who experience difficulties with bladder and bowel control. The goal is to improve residents’ comfort, dignity and quality of life while preventing complications such as infections, skin breakdown or social isolation. Nursing homes implement continence care as part of a holistic, person-centred approach to meet the individual needs of each resident.

The key components of continence care in nursing homes are:

Initial assessment and care planning

A comprehensive evaluation of the resident’s continence needs is required upon admission to the nursing home. The assessment should include:

• Medical history: Such as any chronic illness, medications, surgeries and any neurological difficulties.
• Physical difficulties: Such as pelvic floor strength, ability to get to the toilet independently and walking difficulties.
• Behavioural patterns: Such as frequency of urination and bowel movements.

The initial assessment stage helps the care home to develop an individualised care plan that addresses the underlying causes, symptoms and resident preferences.

Daily management strategies

Daily management strategies can include:

• Scheduled toileting: Encouraging regular bathroom visits to reduce the risk of accidents.
• Prompted voiding: Care staff reminding or assisting residents to use the toilet at regular intervals.
• Bladder and bowel training: Implementing techniques to strengthen continence control, such as pelvic floor exercises or bladder retraining.
• Dietary adjustments: This can include encouraging hydration to prevent urinary tract infections (UTIs) and constipation and providing high-fibre meals to promote regular bowel movements.
• Hygiene and skin care: Skin care can include ensuring proper cleaning and drying of the perineal area to prevent skin breakdown or infections and using barrier creams to protect sensitive skin.

Specialised interventions

Specialised interventions can address underlying medical conditions, such as UTIs, diabetes or Parkinson’s disease. Medication may be helpful for managing overactive bladder or bowel dysfunction and nursing home staff may collaborate with specialists such as urologists, gastroenterologists or physiotherapists, when necessary.

Addressing mobility and accessibility issues

Care home staff must make sure that the bathroom is easily accessible for residents with accessibility issues. This could include installing grab bars, raised toilet seats or non-slip mats and keeping the pathway to the bathroom well-lit and free of obstacles. If required, care home staff must also provide mobility aids, such as walkers or wheelchairs.

Behavioural and environmental adjustments

Care home staff can help residents to minimise triggers for accidents, such as delaying trips to the bathroom or drinking excessive fluids at bedtime. Residents can also be encouraged to wear clothing that is easy to remove (e.g., elastic waistbands or Velcro fastenings).

Resident dignity and privacy

An important part of continence care is maintaining the resident’s dignity by ensuring private and discreet continence care. Additionally, the care plan should encourage residents’ independence whenever possible and allow them to take part in their own care.

Provide emotional support

Care home staff should acknowledge the emotional impact of incontinence, such as embarrassment or frustration. They should provide reassurance to residents, avoid stigmatising the condition and avoid embarrassing the residents. Care homes could offer support groups or counselling for any residents who are struggling mentally or emotionally.

Staff training and education

It is essential to ensure that nursing home staff are trained to recognise and manage incontinence effectively. Care homes should educate staff on sensitive communication, infection prevention and proper use of continence products. Training can also help to promote awareness of behavioural or environmental factors that may contribute to continence issues (e.g., dementia or immobility).

Monitoring and ongoing evaluation

Care home staff should regularly review the resident’s care plan to assess its effectiveness and make necessary adjustments. It is also important to monitor for complications, including infections, skin irritation or prolonged exposure to moisture. Consistently monitoring allows care home staff to identify any changes in the resident’s continence status and address any new issues or make any necessary changes promptly.

By providing personalised continence care, nursing homes can create a supportive environment that addresses both the physical and emotional needs of their residents. Continence care in nursing homes has multiple goals:

• Improve residents’ physical comfort and prevent secondary complications.
• Preserve dignity and promote independence whenever possible.
• Provide emotional and psychological support to help reduce feelings of embarrassment or anxiety.
• Ensure a clean, healthy and safe environment for all residents.

Managing Incontinence in the Elderly

Incontinence is increasingly common in older age, particularly in people over the age of 80. Although incontinence is not a normal part of ageing, both urinary and bowel incontinence are more prevalent with age due to physiological changes, underlying health conditions and functional limitations. NHS England’s Excellence in Continence Care statistics show 15% of adults aged 85 years and over who still live in their own homes have faecal incontinence, with these figures being even higher in those living in residential and nursing homes.

Ageing is a significant risk factor for incontinence for multiple reasons, such as:

• Decreased bladder capacity.
• Decreased bladder elasticity.
• Reduced sensation of a full bladder or rectum.
• Increased risk of neurological disorders, such as Parkinson’s disease, multiple sclerosis (MS) or dementia that can impair communication between the brain and bladder or bowel.
• Increased risk of diabetes that can lead to nerve damage and an overactive bladder.
• Mobility issues, such as a physical disability or arthritis can impair a person’s ability to reach the toilet on time.
• Cognitive decline can cause individuals to struggle to identify when they need the toilet or forget to use the toilet.
• More likely to be taking medications that can increase the risk of incontinence, such as diuretics or anticholinergics.
• Increased risk of pelvic floor disorders, for example, prolapsed bladder, womb or rectum in women and enlarged prostate in men.

Managing incontinence in the elderly requires a comprehensive, compassionate and individualised approach that addresses both the physical and emotional aspects of the condition. Continence issues can be very distressing for older people and managing incontinence is critically important as it can impact their physical health, emotional well-being and overall quality of life. Effective management not only improves dignity and comfort but also prevents physical complications.

Effective management of incontinence in elderly people is important for several reasons, including:

Preventing physical health complications

Prolonged exposure to urine or faeces can cause skin irritation, rashes and infections. Moisture can also weaken the skin, increasing the risk of pressure ulcers (bedsores), particularly in bedridden or immobile individuals. Incontinence also increases the likelihood of bacterial infections, such as urinary tract infections (UTIs) due to constant exposure to urine or faecal matter.

Improving emotional well-being and dignity

Incontinence can cause embarrassment, shame and anxiety about social interactions, leading to social withdrawal and isolation. Chronic incontinence can lead to feelings of helplessness or a loss of independence, which can contribute to depression and decreased mental health. Managing incontinence with discretion and care ensures elderly people feel respected and valued.

Improving quality of life

Effective continence care allows many elderly individuals to remain independent for longer and minimises their reliance on caregivers. Addressing incontinence enables individuals to participate in social activities without fear of accidents, which helps to improve their overall quality of life.

Reducing the burden on the caregiver

Incontinence care can be physically and emotionally taxing for caregivers. Proper management strategies (e.g., effective use of continence products, scheduling and training) can reduce the time and effort caregivers spend on cleaning, toileting and managing accidents. Managing incontinence allows interactions to focus more on companionship and support rather than on the challenges of caregiving.

Reducing healthcare costs

Poorly managed incontinence can lead to expensive medical complications, such as hospitalisations for UTIs, pressure ulcers or falls. Early intervention and management reduce the need for emergency care or invasive treatments.

Addressing underlying conditions

Incontinence can be a symptom of treatable medical conditions, such as infections, constipation or medication side effects. Proper management ensures these underlying issues are identified and addressed and helps to improve overall health outcomes.

Supporting holistic care in elderly populations

Managing incontinence is a critical part of comprehensive geriatric care, addressing not just physical symptoms but also emotional, social and environmental factors. It integrates with other aspects of elderly care, such as mobility support, cognitive health and nutritional planning to ensure more holistic, person-centred care.

Promoting safety and reducing accidents

Incontinence often results in urgency or nighttime bathroom trips, which increases the risk of slips and falls. Proactive strategies, such as bedside commodes or grab bars, minimise hazards and improve safety.

Incontinence management is far more than a hygiene issue, it is essential to maintaining health, dignity and independence for the elderly. Addressing it effectively ensures a holistic approach to elderly care and helps to improve physical, emotional and social well-being while reducing the burden on caregivers and healthcare systems.

Continence Care Guidelines and Regulations

There are several guidelines and regulations surrounding continence care in the UK, including:

National Institute for Health and Care Excellence (NICE) Guidelines

The NICE guidelines provide evidence-based recommendations for the assessment, management and treatment of incontinence:

Urinary Incontinence and Pelvic Organ Prolapse in Women: Management (NICE Guidelines [NG123])

The NG123 guideline makes recommendations to the NHS and clinicians on how to treat and care for women with urinary incontinence. It covers the assessment and management of urinary incontinence and pelvic organ prolapse in females over the age of 18 and highlights the importance of specialist services and multidisciplinary care. The guideline covers the comprehensive assessment of urinary incontinence. It recommends the use of non-invasive treatments first, such as pelvic floor exercises and bladder training, as well as medications and surgical options for refractory cases, such as pelvic organ prolapse. NG123 also emphasises multidisciplinary care and conservative treatments.

Lower Urinary Tract Symptoms in Men: Management (NICE Guideline [CG97])

The CG97 guidelines cover the assessment and management of symptoms of lower urinary tract symptoms (LUTS) in males over the age of 18. The guideline aims to improve the quality of life for men with urinary incontinence. It covers assessment, care, lifestyle interventions, medications and surgical options. CG97 also highlights the importance of person-centred care.

Faecal Incontinence in Adults: Management (NICE Guideline [CG49])

The CG49 guidelines cover the assessment and management of faecal incontinence in adults over the age of 18. It includes the steps for assessment, including physical examination and identifying underlying causes and management strategies including dietary advice, bowel training, medications and specialist interventions. CG49 aims to improve the physical health, mental health and quality of life for adults with faecal continence issues.

Care Quality Commission (CQC) Standards

The CQC standards regulate and inspect health and social care services in England, including continence care in nursing homes, hospitals and community settings. Key expectations include:

• Providing person-centred continence care that respects dignity and privacy.
• Conducting thorough assessments of residents’ continence needs upon admission and reviewing care plans regularly.
• Ensuring staff are trained to deliver high-quality continence care.
• Using appropriate continence aids and maintaining hygiene to prevent complications like skin breakdown.

Bladder and Bowel UK

Bladder and Bowel UK is a charity that supports professionals who work in bladder and bowel health. They offer guidance and resources, including specialist training and advice for healthcare providers and caregivers, professional resources for developing effective continence management plans and advocacy for improving access to continence services.