Incontinence is a common global condition, which can affect entire cohorts of the population across all age profiles and adversely alter all aspects of a person's quality of life (Terzoni et al, 2011; Milsom et al, 2013; Sanses et al, 2017). Urinary incontinence is described as involuntary leakage of urine in an inappropriate place, which has social and hygienic consequences (Abrams et al, 2010). Urinary incontinence is one of the most common reasons why an individual may have to move from their home to be admitted into a residential setting (Royal College of Physicians, 2015; Wagg, 2015). The distressing symptoms of incontinence often prevent individuals from self-caring, subsequently increasing the need for family/professional carers' involvement (Murphy, 2019). Although the risk of incontinence increases with age, it is not an inevitable part of ageing (Schluter et al, 2017). Ur inary incontinence impacts on the utilisation of healthcare resources (NHS England, 2018). If incontinence management is ineffective, the financial costs will be exaggerated from increased co-morbidities and raised mortality rates, to environmental implications of disposing used incontinence wear products (Royal College of Physicians, 2011). The clinical symptoms of incontinence cannot be underrated or underestimated due to variations in clinical presentations (Smith, 2020). Urinary incontinence can be challenging to assess, address and overcome for individuals; however, this article will provide a framework for nurses on how to holistically assess an individual with urinary incontinence.
Prevalence and implications of urinary incontinence
As life expectancy has increased, so too has the need for full-time care places in residential settings (Huber, 2009). It has been extensively reported that the population will continuously age, leading to a demographic of older individuals with multi-morbidities (United Nations, 2019). Globally, incontinence symptoms are estimated to affect up to 400 million people. Despite this staggeringly high prevalence rate, the implications of incontinence remains a taboo subject in society and for those affected, and can be a low priority for some health professionals, policy makers and governments (Milsom et al, 2013). The prevalence rates and causative factors vary for all individuals based on age profile, gender and living environments as urinary incontinence is a multifaceted, complex condition, compounded by signs and symptoms experienced (Jung et al, 2015). International prevalence rates for older adults with incontinence who live in their own homes can range from 15–35% (Jeong et al, 2012; Stickley et al, 2017). A systematic review, which examined studies in English, Dutch and German, identified 43%–77% of nursing home residents had a prevalence of urinary incontinence (Offermans et al, 2009). In Ireland, these figures are even higher. A point prevalence study identified that 86% of residents in care homes were incontinent (Wall et al, 2021). Comparable prevalence rates have been observed between women and men in two large Swedish studies; these results reported that women had a much higher prevalence than men (Malmsten et al, 2010; Milsom et al, 2013). Factors such as pelvic floor dysfunction due to childbirth, menopause and uterine prolapse could be some of the reasons why women are at a greater risk of developing urinary incontinence (Lucas et al, 2012).
Continence assessment should involve the following
- History: medical, surgical, obstetrical, gynaecological
- Medication prescribed and over-the-counter medication
- Urinalysis as a screening tool
- Mobility status
- Manual dexterity
- Cognitive status
- Communication ability
- Environmental factors may contribute to incontinence; therefore, assessment should also be undertaken of the following: clear signage where toilet are located; privacy in toileting area; toilet area is well lit, clean and free from hazards; floor surfaces that are level, non-slip, and non-shine; sufficient space in toilet area to accommodate wheelchairs and walking aids
- A completed bladder continence chart for 3 days
- Bladder scan undertaken if deemed required for patients with clinical symptoms such as incomplete emptying
- Physical examination by competent, skillful nurses.
Adapted from: Health (2009); Staskin et al (2013); NICE (2014; 2015); Yates (2016)
Incontinence symptoms can disrupt an individual's holistic wellbeing, resulting in destructive implications (Stickley et al, 2017). There are countless physical challenges and complexities associated with incontinence such as reduced ability to exercise, sleep deviation, and incontinence-associated dermatitis, as well as increased risk of falls and fractures (Gibson and Wagg, 2015). An initial indicator of frailty in an older person's profile is the presence of urinary incontinence symptoms (Ellis et al, 2011). Additionally, incontinence has been associated with increased risk to an individual's mental health and wellbeing, including social isolation, anxiety disorders and even depression (Felde et al, 2017; Kwak et al, 2016). The psychological feelings that can be experienced when wetting episodes occurs include guilt, shame and embar rassment (Taylor and Cahill, 2018). Nurses need to empower the individual with the principles of patient-centered care, which are compassion, empathy and proactive care, thereby encouraging a positive approach to surmounting incontinence symptoms (Taylor and Cahill, 2018). Unfortunately, there is a misinterpretation that incontinence is an inevitable part of older people's lives; however this concept needs to be questioned, challenged and confronted by the individual with incontinence symptoms, as well as their carers, health professionals and society (de Gagne et al, 2025)
Continence assessment
For individuals to effectively survive, solve and overcome urinary incontinence symptoms, a continence assessment must be undertaken; this process will involve the collection of critical clinical evidence to enhance quality health outcomes (Ellis et al, 2017). Continence assessment is an essential nursing process that should be carried out collaboratively with all individuals who experience incontinence symptoms (Yates, 2018). The assessment is a catalyst to assist with the implementation of continence promotion approaches that are proactive and practical, rather than reactive and dependent on disposable continence wear products (Orrell et al, 2013). It is a multi-dimensional, systematic, clinical investigation, which requires the involvement of a competent nurse who has evidence-based continence knowledge to undertake this core clinical assessment (McClurg et al 2013; Rantell et al, 2016; Ellis et al, 2017). Professional competency is crucial when undertaking a continence assessment; therefore, all nurses must be mindful of preserving an individual's dignity, show respect and ensure privacy during this process (Nazarko, 2019). A continence assessment not only establishes a full history of bladder and bowel dysfunction, but also discovers the duration of the problem, presentation of symptoms, the impact on quality of life, and the identification of previous management care plans, which are also essential elements (Yates, 2018).
The continence assessment is an intricate collection of information, which initially involves the inclusion of an individual's medical, surgical, obstetrical and gynaecological history (Staskin et al, 2013; National Institute for Health and Care Excellence (NICE), 2013; 2021). To ensure a comprehensive continence assessment, a multidisciplinary approach should be used, thereby assessing all medical conditions and circumstances of the patient (McDaniel et al, 2020). This process involves a clinical review of current medication and would include prescribed and over-the-counter drug usage. Clinically, there must be awareness of what medication can cause, worsen or contradictory improve incontinence symptoms (Bishara et al, 2017). As a screening mechanism, a urinalysis could be used by way of a multidimensional holistic continence assessment (Yates, 2018). Staskin et al (2013) identified that urinalysis is not a diagnostic test but a screening tool undertaken during a continence assessment. It can be used to rule out abnormalities such as haematuria or ketones, which may be associated with vomiting or diabetes. For individuals who present with incomplete urinary emptying, a bladder scan could be suggested; this is a non-invasive procedure, which allows an estimation of post-void residual compared to the direct invasive process of urethral catheterisation (NICE, 2013; Christianson et al, 2021). Individuals who experience neurological conditions such as stroke, diabetes, spinal injuries or clincial conditions such as obstruction of the urethra due to enlarged prostate or prolapse, are at a greater risk of inadequate bladder emptying (NICE, 2013; Yates, 2018; 2019a). Evaluation should occur of the individuals' mobility, manual dexterity, cognitive functional ability, body mass index and social circumstances—these are vital components within the assessment process (Staskin et al, 2013; Health Service Executive, 2016). Physical examination should take place with specific inspection of the perineum, rectum and abdominal area; however, nurses must have specialised knowledge, clinical skill and competency in the area of continence physical examinations before embarking on this specialised investigation (NICE, 2013; 2021). The nurse undertaking a continence assessment should have evidence–based knowledge, skills and be guided by national and international continence care guidelines and standards (McClurg et al, 2013; Rantell et al, 2016). Hunter and Wagg (2018) identified that nurses have an essential role in undertaking continence assessment, which result in implementing evidence-based continence promotion strategies and practical management treatments interventions. However, nurses face countless challenges before they can take on a continence assessment; these include planning their work schedules, which could be overburdened within their clinical roles. Consequently, continence might be viewed as a low priority compared to other clinical interventions, thus developing a culture of reliance on supplying disposable continence wear products (Hunter and Wagg, 2018).
It is imperative that all nurses are aware of the need to clearly communicate, cooperatively commit and explicitly engage in a comprehensive assessment for individuals with incontinence, as a culture of acceptance to incontinence should never be adopted (Yoo and Spencer, 2018). Engagement of nurses in precise communication is essential (e.g. asking open–ended questions), hence providing an opportunity for open dialogue within a therapeutic patient-centred relationship (Bradway and Cacchione, 2010). Individuals' with incontinence can express feelings of embarrassment, shamefulness and humiliation, so it is important that an effective continence assessment needs to be undertaken in a sensitive, empathic manner before the introduction of any treatment interventions (Bardsley, 2016). A continence assessment will enhance patient–centred care and quality health outcomes; assessment is mandatory before any diagnosis occurs, or before implementing targeted treatment interventions with clinical evaluation (Booth, 2013).
A continence assessment is deemed incomplete if baseline continence charts are not undertaken; this is a practical aspect of an assessment. However, it provides observable objectivity, which can assist with diagnosis of symptoms, treatment interventions and managing strategies (NICE, 2013; Colley, 2015). The aim of a baseline continence chart is to accurately ascertain fluid intake, the type consumed and voiding patterns. Wetting episodes are observed for three 24-hour periods so that fluid intake and voiding pattern can be documented over this 72-hours period (Staskin et al, 2013; Yates, 2018). The baseline continence chart provides important information; therefore, nurses must ensure that all stakeholders—individuals, carers, family members and other professionals—are educated on the benefits of using the chart (Colley, 2015).
Multidisciplinary approach to continence assessment
It is essential at all health professionals are aware of the risks and consequences of bladder control problems. Incontinence issues can be multifarious, requiring diverse, wide-ranging interventions from a dynamic multidisciplinary team of professionals (Yates, 2019b).
A multidisciplinary team approach is fundamental to providing excellent continence service and can ensure quality health outcomes (Ogbeide, 2014). Newman et al (2017) advocated that individuals with incontinence require the intervention of a multidisciplinary team of professionals to deliver an all–inclusive service, thus providing a comprehensive continence care model. The participation of doctors, specialised continence nurses, physiotherapists and occupational therapists are invaluable in the continence assessment, promotion and management process. Geriatric doctors have a pivotal role is continence service provision by screening, examining, diagnosing and referring individuals, where required, to relevant allied health professionals (Spencer et al, 2017). The expertise of an occupational therapist may be required in assessing for correctness of toilet height, reliance of hand rails, suitability of floor surfaces in addition to sufficient space in toilet area to accommodate wheelchairs (Yates, 2016). Occupational therapists are also fundamental team members in continence promotion treatments by providing effective therapeutic interventions, improving access, availability to equipment and empowering individuals to self-manage (Cunningham and Valasek, 2019). Physiotherapists are specialists within the musculoskeletal aspects of mobility and the pelvic floor area, as well as the pelvic floor dysfunctional repair; their professional role is to promote continence, prevention and control of incontinence symptoms (Spencer et al, 2017). Nurses' play a vital role in identifying and supporting those experiencing urinary incontinence (Hunter and Wagg, 2018). Nurses are frequently the first point of contact for the individuals with incontinence, and consequently, in continence promotion and its management. Management is a basic remit of the nursing profession (Borglin et al, 2020).
Treatment interventions
Lifestyle interventions, treatment plans and management strategies must be implemented in totality for all individuals with incontinence following a proactive continence assessment (Buckley and Lapitan, 2009; Jung et al, 2015). Once an assessment is successfully completed, the fundamental first line of treatment for continence promotion should be the introduction of lifestyle interventions, which include adequate fluid intake, smoking cessation programmes, weight reduction regimes, pelvic floor exercises for men and women, and bladder behavioural retaining programmes (Abrams et al, 2017; Yates, 2017). Incontinence symptoms can be prevented from progressing into a chronic condition through simple treatment interventions such as ensuring quantifiable hydration, prevention of constipation, and prompted/timed voiding (Tak et al, 2012; Vinsnes et al, 2012; Roe et al, 2013). The individual's living environment may need to be adapted to enhance continence promotion; for example, clear signage where the toilets are located, a well-lit toilet area, toilet space should be clean, free from clutter, hazards, preserving privacy is essential to assist with voiding of urine and defaecation of bowel motion (Staskin et al, 2013; Yates, 2016).
Conditions that make individuals more at risk of urinary incontinence
- Poor or inadequate fluid intake/dehydration
- Chronic constipation/faecal impaction
- Mobility problems
- Manual dexterity difficulties
- People with cardiac complications/heart failure
- People with urinary tract infections
- People with musculoskeletal problems, such as arthritis
- Women who had a hysterectomy
- Men with prostate problems
- People with neurological problems.
Adapted from the NHS England (2015); Yates (2016)
The nurses that undertake continence assessment may clinically prescribe continence wear products, if required, following clinical appraisal (Medicines and Health Regulatory Agency (MHRA), 2014). An absorbent continence wear product can be defined as the ‘most commonly used product for absorbing and containing both light and moderate/heavy leakage’ (Continence Product Advisor, 2023). Disposable continence wear products are classified as medical devices and therefore, safety, suitability and fitness for purpose principles are essential to ensure that quality care is delivered to the user of these products (Health and Safety Executive, 2019). Nurses are professionally accountable for accurately documenting why continence wear products are prescribed, safety of usage, adhering to the criteria for correct fitting, ensuring products are non-maleficent and are reliable (MRHA, 2014). The prescribing of continence wear products as an initial intervention is not evidence-based best practice; unfortunately, there is reliance by some nurses to sanction continence wear as first line management intervention (Zürcher et al, 2011; HSE, 2019; NHS England, 2021). The results of a national audit reported that older people received continence care that was focused mainly on the use of containment products (Wagg at al, 2008). Positive proactive continence promotion treatment options are essential to prevent the risks of falls, reduce incidence of incontinence associated dermatitis, pressure sores development, prevent social isolation and reduce depression rates (Taylor and Cahill, 2017).
Person-centered care
Dignity, respect, care, compassion and commitment are crucial, concepts for health professionals to bestow on individuals who experience incontinence, to ensure quality health outcomes (Zirak et al, 2017). Clear, concise communication, consultation and collaboration between the individual with incontinence and the nurse facilitates a comprehensive assessment, thus preventing unnecessary prescriptions for disposable continence wear products. Contrary to this, collaborative approach instigates proactive continence promotion strategies (Stewart, 2018). Individuals who suffer from incontinence may have reduced quality of life; furthermore nurses may spend significant amount of time caring for a person with incontinence and performing intimate personal care (Del Prato, 2022). By applying the principles of person-centredness, improvement to the quality of life can and do occur (Grabowski et al, 2014; Zimmerman et al, 2014). Comparably, nurses will develop enriched professional characteristics by implementing, person-centered care principles and will subsequently be equipped to deliver enhanced patient care and excellent healthcare service provision (Kwame and Petrucka, 2021).
In Ireland, the principles of patient-centered care is embedded within policies, patient safety guidelines, and quality, health and safety documents and by implementing healthcare statutory regulations (Gavin and Brady, 2013; HSE, 2014; Health Information and Quality Authority, 2016). The WHO (2015) outlined that patient-centeredness care concentrates on the conceptualisation of the individuals' wishes, desires, wants and most of all, distinguishes the uniqueness of each patient beyond the presenting medical condition. Alexiou et al's (2021) study identified that implementing a person-centeredness approach for individuals with urinary incontinence assisted nurses in comprehensively completing excellence within the continence assessment process, thus enriching individuals' quality of life despite nurses facing resource challenges and organisational complexities. Through the application of person-centered care, patients move from being passive recipients of care to active participants who become self-empowered persons with individualised wishes, beliefs, values, which are implemented in their own specific care (Ekman et al, 2011). There are several national and international evidence-based guidelines regarding urinary incontinence assessment and management; however, some guidelines do not focus on person-centered care, which is fundamental for quality of care (NICE, 2013; HSE, 2019; Alexiou et al, 2021). Wijk et al's (2018) study indicated that by introducing person-centeredness principles, nurses are professionally empowered to undertake all-encompassing continence assessments, which improve quality of life for individuals with incontinence. Person-centeredness continence management programs have shown to improve the quality of life of patients by enhancing individualised continence care (Borglin, 2020). Involvement of individuals in their own customised continence care is essential to identify people's aspirations, anticipations and needs so that the principles of patient-centeredness care are thoroughly fulfilled (Nazarko, 2015).
Conclusion
Urinary incontinence is a common condition and prevalence rates increase as people age (McGrother et al, 2003; DuBeau et al, 2009). Urinary incontinence not only has devastating consequences for an individual's physical, psychological, emotional health and well-being, but also affects their family members, who can become confined within a caring role. Financially, the economic burden is enormous to society, from supplying disposable continence wear products to the environmental implications of disposing used products. A continence assessment and baseline continence charting are essential processes to determine the extent of incontinence issues, which will involve a detailed history of duration of presenting symptoms, previous interventions and a bladder record chart for 3 days and nights. Continence products should not be the first line of intervention for individuals with incontinence. Proactive person-centeredness therapeutic care approaches should be introduced in collaboration with the multidisciplinary team of professionals, each with their own exceptional expertise and experience. It is apparent that by carrying out a continence assessment in conjunction with baseline continence charting, the devastating, distressing, disturbing symptoms of incontinence can be overcome.
Key points
- Urinary incontinence can have devastating implications on the individuals who experience bladder dysfunction, affecting their personal, physical, psychosocial health and wellbeing. Unfortunately, it also adversely impacts on their families, carers and society, in general
- For individuals who experience incontinence, a continence assessment must be undertaken to collect critical clinical evidence and enhance quality outcomes. A continence assessment is a catalyst to assist with the implementation of continence promotion approaches, which are proactive and practical, rather than reactive, with a dependence on disposable continence wear products
- The involvement of a multidisciplinary team of professionals is essential to collaborate with the nurses when assessing, promoting and managing urinary incontinence for individuals with bladder dysfunction
- A person-centeredness continence assessment, baseline continence chart should be completed for all individuals who experience incontinence urinary symptoms, to ensure quality health outcomes.
CPD reflective questions
- How does urinary incontinence impact on the individual, their family and caregivers?
- Drawing on your clinical experience and education, what principles, processes and practices should you, the nurse, undertake when completing a continence assessment, baseline continence chart?
- Why is the multidisciplinary approach essential in the area of continence assessment?
- List three treatment interventions for urinary incontinence that nurses can implement to proactively promote continence?