Continence is a skill we all expect to achieve in childhood. It is reliant on intact nerve pathways between the brain, spinal cord and bladder to send and receive appropriate messages resulting in effective and acceptable bladder emptying. Normal bladder filling and storage involves the bladder stretching to accommodate a reasonable volume of urine (it is generally accepted that a normal bladder capacity in an adult is 400–600 ml), and the detrusor muscle is at rest until the bladder capacity for the individual is reached. Thereafter, a series of nerve impulses communicate between the bladder and brain to start the emptying phase. During the filling and storage phase the urethra and sphincters must remain closed and the pelvic floor contracted to ensure no leakage occurs. This continues even when intra-abdominal pressure is raised during coughing, sneezing, laughing and physical activity. During the emptying phase, the detrusor contracts, the urethra and sphincters open and the pelvic floor relaxes; then, the intravesical pressure increases to effectively empty the bladder contents.
Normal physiology
Urine can only be effectively stored in the bladder if the urethral pressure remains higher than the internal bladder pressure. A sustained substantive contraction of the pelvic floor, urethral wall and external sphincter increases and maintains a higher urethral pressure in comparison with the intravesical pressure in order to maintain continence. A compliant bladder is when the detrusor muscle actively relaxes during the filling stage of the micturition cycle, allowing the bladder to stretch without allowing the internal pressure to increase. The parasympathetic nervous system inhibits detrusor contraction until the individual is ready to pass urine. Increased abdominal pressure during coughing, laughing or sneezing is equally distributed to the urethra and bladder in a healthy person, to ensure that pressures are maintained, and the pelvic floor supports the bladder, effectively preventing leakage.
During the filling stage of the micturition cycle, receptors within the detrusor are stimulated to send messages to the sacral spinal cord via afferent neuronal pathways. Efferent motor nerves then transmit signals back to the detrusor muscle, initiating relaxation while maintaining a contracted external sphincter. This mechanism allows stretching and filling of the bladder. This is all controlled from the pontine micturition centre (PMC) located in the frontal lobe of the brain. The first sensation of needing to pass urine usually occurs in adults at approximately 200–300 ml, but the desire to urinate can be deactivated by the PMC until a socially acceptable time and place is found. The sensation intensifies as the bladder fills, until the voiding phase, where the receptors at the S2–S4 level of the spine are activated, initiating sphincter relaxation and bladder contraction in synergy to expel urine. This mechanism is susceptible to muscle fatigue and cannot be sustained indefinitely. Any urine remaining when the mechanism reverses is retained in the bladder until the next time urination is initiated.
Psychological and social considerations
Aside from the normal anatomy and physiology of micturition, there is also an element of learned behaviour associated with maintaining continence, dictated by social rules. In Westernised societies, formal toilet training sets out these rules, encouraging us to believe toileting is a private function taking place behind a closed locked door (Holroyd, 2015). This message has been reinforced by the latest best-practice guidance Managing Bladder and Bowel Issues in Nurseries, Schools and Colleges (Bladder and Bowel UK (BBUK) and the Children's Bowel and Bladder Charity (ERIC), 2019). However, embarrassment about a normal essential bodily function is perceived as an unnatural response (Booth, 2013), as everyone has a need to empty waste products, and it is not a unique function for just a few.
Incontinence is defined as any involuntary loss of urine or the inability to control the bowels (International Continence Society (ICS), 2013). It can affect anyone at any time, and much has been written about the devastating psychological, social and financial implications for affected individuals and their families (Lukacz et al, 2011; Wan et al, 2014; Holroyd, 2015). It is recognised that many will not seek help due to embarrassment and social stigma (Ng et al, 2014). Incontinence is not generally a life-threatening condition, but there is no doubt it can have a significant and distressing effect on the physical and social quality of life of those affected. Isolation, anxiety, depression and embarrassment are commonly reported by people who have a bladder or bowel issue (Wan et al, 2014).
It is estimated that approximately 14 million people in the UK have a bladder issue, with a further 4.5 million experiencing problems with their bowels (Bladder and Bowel Foundation (BBF), 2014). When taken in context against the total UK population (Office for National Statistics, 2011), this equates to one in four people having a bladder condition and one in 10 experiencing a bowel issue.
Although incontinence crosses all boundaries of age, gender and culture, it is recognised that its prevalence increases with age (DuBeau et al, 2009; Thirugnanasothy, 2010; Day et al, 2014), and, as the global population increases and people live longer, it is an issue that will continue to pose challenges (Offermans et al, 2009; Dongjuan and Kane, 2013). However, although there is a higher risk of developing incontinence with increasing age, it should be stated that older age does not inevitably lead to incontinence (McGrother and Donaldson, 2005; Dongjuan and Kane, 2013; Goodman et al, 2013; Day et al, 2014).
Stroke and urinary incontinence
Stroke is defined as a group of pathological conditions characterised by sudden non-convulsive loss of neurological function caused by ischaemia in the brain or intracerebral or subarachnoid haemorrhage (Sacco et al, 2013). Some 15 million people worldwide suffer from a stroke every year (World Heart Federation, 2016). Urinary incontinence is a common symptom seen in the immediate post-stroke phase (Kohler et al, 2017), with the prevalence in the most acute phase reported to be around 53% (Lawrence et al, 2001; Kolominsky-Rabas et al, 2003; Williams et al, 2012). Approximately 25% of stroke patients continue to experience urinary incontinence at discharge, with around 15% reporting persisting symptoms 1 year after the stroke (Barrett, 2002). Further, the likelihood of urinary incontinence is higher in more severe strokes (Burney et al, 1996). The presence of incontinence following a stroke has been linked with reduced independence, increased disability and increased risk of mortality (Patel et al, 2001; Meijer et al, 2003; Kolominsky-Rabas et al, 2003; Pizzi et al, 2014).
Many stroke patients have described significant issues with communicating continence needs while in the rehabilitation phase (Brady et al, 2016). Some of this can be attributed to communication difficulties associated with stroke, but given that the general public is less than accepting of the topic of incontinence, many patients are just too embarrassed to talk about the loss of bladder control. One study reported that many stroke survivors tried to manage their own incontinence as they felt that healthcare staff were not interested in, or unaware of, how to deal with the complexity of post-stroke incontinence (Kohler et al, 2017).
Management of post-stroke incontinence
In the immediate post-stroke phase, it is more common to see device-based management of incontinence, including the use of indwelling catheters or external collection devices, such as urinary sheaths or pads (Guo and Kang, 2018). The risks of indwelling urinary catheters have been widely reported (Chenoweth and Saint, 2013), with evidence suggesting the incidence of catheter-associated urinary tract infection (CaUTI) to be 20% of all healthcare-acquired infections (HCAIs). The clinical indications for catheter use should be clearly identified and documented within patient records, and patients using them should be closely monitored, with an early removal of catheter planned in order to reduce the risk of infection and urosepsis.
Intermittent catheterisation is defined as drainage or aspiration of the bladder or urinary reservoir using a hollow tube/catheter that is subsequently removed (Abrams et al, 2002; Vahr et al, 2013). The intermittent catheter is removed once the bladder has been drained adequately, thereby eliminating the issue of biofilm formation commonly found with the balloon retention catheter. The procedure can be undertaken by the patient or, if the individual is unable to do it, by a nominated person (relative, carer or professional). The technique can be adapted to suit many situations or scenarios. Use of intermittent catheters is a viable option for some stroke patients in the early rehabilitation phase, and it will reduce the risk of infection compared with that of indwelling catheters. Staff can support patients who frequently need intermittent catheterisation, and many patients may be able to independently take on the task of intermittent self-catheterisation as their mobility, dexterity and cognitive function improve.
Use of pads can be uncomfortable for many, as people then believe they have reverted to early childhood, and a loss of dignity is perceived at having to wear a containment pad (Agnew and Booth, 2013; Booth, 2013). Any containment pads used need to have the appropriate absorbency for the amount of effluent. This requires a careful assessment, as too high or too low an absorbency can lead to skin damage.
Urinary sheaths (also referred to as male external catheters, condom catheters or penile sheaths) have been available from the early 1980s as a specific device aimed at collecting urine. Developments in their design and manufacturing over the past 30 years have vastly improved the efficacy of these devices, and there are many manufacturers who now offer one-piece systems made of latex or silicone, which offer a greater flexibility and choice for male users (Pemberton et al, 2006). Nonetheless, sheaths for the male patient are still, in the author's opinion, an under-utilised option as they can be tricky to get right the first time, needing time and patience to achieve success (Booth and Lee, 2005; Potter, 2007; Smart, 2014).
Hand-held urinals may be introduced once the patient's manual dexterity is sufficient to position and hold the device in place. However, cognitive and/or physical function may affect the individual's ability to recognise the appropriate signals for voiding, and healthcare staff should offer support in the early rehabilitation phase. Encouraging the individual to regain control of their bladder through the use of appropriate devices will aid recovery and improve feelings of self-worth.
Other management options for post-stroke incontinence include standard behavioural modifications, including bladder retraining, prompted toileting, double voiding techniques and fluid/diet management (Nilsen et al, 2018). Pelvic floor muscle exercises and medication for treating bladder irritability or overactivity may also be of use (Guo et al, 2014; John et al, 2018).
The post-hospitalised phase of recovery should be considered when suggesting treatment or management options for incontinence, as much has been recorded about the strain that incontinence places on family caregivers once the patient is discharged (Tseng et al, 2015). The introduction of any device or behaviour modifications should be based on individual needs, as the abilities of each patient change at different rates during recovery. The management method for post-stroke incontinence needs to suit the stage of rehabilitation, taking into account cognitive and physical limitations.
Conclusion
Incontinence is a common condition following stroke, occurring in over 50% of patients. Careful assessment and management of incontinence from the earliest opportunity is a key component for rehabilitation and improved quality of life. The timing of appropriate interventions is also essential for successful rehabilitation and can lead to a reduction in the psychological issues associated with both stroke and incontinence. Recognition of need and regular reassessment to ensure the most effective treatment is offered must be considered by health professionals to improve patient experience.
KEY POINTS
- Stroke affects some 15 million people worldwide every year
- Incontinence affects over 50% of stroke victims, with many still experiencing this distressing symptom after discharge
- Incontinence can be humiliating and increases the risk of depression and social isolation
- Stroke victims struggle to communicate their continence needs to healthcare staff
CPD REFLECTIVE QUESTIONS
- What is your first-line choice for treating incontinence in stroke patients?
- How can you improve communication with stroke patients with regard to continence needs?
- What can you do in practice to break down the social barriers associated with talking about bladder control?